Outcomes were not significantly different whether acute ischemic stroke patients were treated entirely at community hospitals or they were transferred to a “hub" hospital staffed by stroke specialists after tissue plasminogen activator (tPA) was administered, according to a meta-analysis described at the 2021 virtual AAN Annual Meeting.
The findings make a case for increased consideration of the so-called “drip-and-stay" model, researchers said. In this model, patients are taken to a “spoke" hospital, without a stroke specialist, for treatment with tPA and are treated there by telestroke care by stroke specialists who are physically at other centers. This differs from the traditional “drip-and-ship" model in which patients are transported to a “hub," or comprehensive stroke center, after tPA, and from the “hub" model in which patients receive all treatment at a comprehensive stroke center.
“This suggests that the drip-and-stay model is non-inferior to the current models out there and may be as safe and effective as either model," said Hena Waseem, MD, a neurologist and member of the Leadership and Preventive Medicine program at Dartmouth-Hitchcock Medical Center.
Researchers found 10 relevant studies—published 2006 to 2019—to include in the analysis that compared a drip-and-stay model to either a drip-and-ship model or a hub model. The studies included 4,164 patients.
Their analysis found no significant difference in good functional outcome—considered as a modified Rankin score of 0 or 1— between the drip-and-stay model and the combined drip-and-ship and hub groups. Drip-and-stay also met the threshold for non-inferiority compared to the other models, Dr. Waseem said.
They found no significant differences in the rate of symptomatic intracerebral hemorrhage (sICH) between the model types, and that drip-and-stay met the threshold for non-inferiority for sICH.
There was also no difference found in 90-day mortality between the groups, but non-inferiority for this couldn't be evaluated.
Researchers did find a small but statistically significant difference in length of stay; those who had the drip-and-stay approach stayed 0.18 days longer (p=0.018). But only three of the studies evaluated this, making this result difficult to interpret, Dr. Waseem said.
Drip-and-stay could become a more appealing option for stroke care, helping to ease the demand on hub facilities, possibly alleviating growing costs, and allowing patients and families to stay closer to home for care, Dr. Waseem said.
“Just the transfer costs themselves probably add up to millions of dollars around the country," she said. “With the growing popularity of telehealth, especially since COVID, these types of telehealth models are here to stay and we need to continue to study them, with more high-quality observational studies."
Ramy El Khoury, MD, founder of Neuro Care of Louisiana and stroke director of Slidell Memorial Hospital, said the data are “quite compelling based on this large volume of analysis and is looking at significant outcomes that are important in decision-making as to whether to adopt the drip-and-stay model."
A deeper look at length of stay and time to tPA treatment would be helpful in comparing the models and making plans for improvements, he said.
“More hospitals," he said, “are becoming more comfortable with drip-and-stay model, especially in the presence of neurology and vascular neurology presence, feedback and education to nursing staff."
Drs. Waseem and El Khoury had no disclosures.
AAN Abstract 30.001: Waseem H, Salih Y, Burney C, et al. Safety and efficacy of the telestroke drip-and-stay model: A systematic review and meta-analysis.