PURPOSE:Evidence suggests that rural-residing adults-compared with urban-may be at greater risk of readmission and mortality. Operational leaders within the Department of Veterans Affairs (VA) Geriatric Learning Health System (GLHS) sought to understand the effects of rural residence on readmission and mortality risk for older Veterans discharged from hospital to home. METHODS:This observational cohort study included Veterans aged ≥ 65 years discharged from VA hospitals (fiscal year 2023) to home. A semi-competing risk model was fit to jointly model unplanned readmission, mortality, and mortality after readmission, with rural residence as the exposure of interest. Data were censored at 30-days, 90-days, or 1-year post discharge to examine short- and longer-term effects. Additional variables considered for the model were identified through prior literature, clinical significance and those selected by the Centers for Medicare & Medicaid Services for unplanned readmission. FINDINGS:Among 99,557 patients (120 hospitals), 28.4% were rural residents. Only 18% of rural residents lived within 30 min of a VA facility versus 80.3% of urban residents. At 30 days, compared to urban, rural-residing patients had a 5% lower risk of readmission (hazard ratio [HR] = 0.95, 95% confidence interval [CI] = [0.91-1.00]), 20% higher risk of mortality (HR = 1.20, 95% CI = [1.03-1.40]), and a similarly higher risk of mortality after readmission (HR = 1.19, 95% CI = [1.03-1.39]). CONCLUSION:Rural-residing older Veterans had lower risk of readmission but higher risk of mortality. These findings will guide future VA GLHSs: seeking modifiable factors (e.g., social drivers of health, timely services) associated with mortality risk among rural Veterans that can inform practice, policy, and quality improvement, thereby reducing disparities in outcomes.

Planning for discharge is common among nursing-home residents who enter the facility for a short-term rehabilitative stay. More challenging is community discharge among long-stay residents who have been in a nursing-home beyond the Medicare funded rehabilitation period. The current manuscript describes an analysis of interviews conducted with 42 nursing-home discharge planners in the context of a statewide policy to promote nursing-home to community discharge among long-stay residents. Identified themes from the analysis include a focus on newly admitted residents, starting early, multi-disciplinary planning, lack of available community services, financial concerns, and balancing resident safety with the desire to return home.

Objectives This study modeled 5-year care trajectories of first-time, dual-eligible older adults admitted to Minnesota nursing homes (NHs), capturing discharges to the community, NH readmissions, hospitalizations, and mortality. A secondary aim was to examine associations between care trajectories and dementia, baseline cognitive function, and demographic, clinical, and functional profiles. Design Retrospective cohort study. Setting and Participants We analyzed 9853 older adults first admitted to Minnesota NHs in 2015 and followed them for up to 60 months. Minimum Data Set were linked to Medicaid claims from the Minnesota Medicaid Management Information System. Methods Latent class growth analysis identified trajectories based on monthly NH stay, hospitalization, and community stay, with mortality treated as a discrete time survival outcome. Dementia was included as a binary covariate. Resident characteristics across trajectories were compared using bivariate analyses and multinomial logistic regression. Results The following 4 distinct trajectories were identified: (1) trajectory 1 (early mortality with continued NH use, 38%) experienced shortest survival, highest NH utilization, and peak hospitalizations in year 1; (2) trajectory 2 (steady return to long-term NH care, 11%) had longer survival and frequent hospitalizations in years 2 and 3, ultimately spending 90% of time alive in NHs by year 5; (3) trajectory 3 (transitional care with multiple moves, 22%) had better survival and longer community stays but the most transitions, with increased NH use over time; and (4) trajectory 4 (short stay then return to community, 29%) experienced best outcomes with longest survival, minimal NH readmissions, and few hospitalizations. Trajectories were significantly associated with baseline differences in cognitive function, physical dependency, and sociodemographic characteristics. Conclusions and Implications Care trajectories among dual-eligible NH residents are highly heterogeneous. Although 38% remained in NHs until death, 29% sustained community living, and 33% experienced frequent transitions. These patterns underscore the need for individualized care planning and system-level strategies to meet complex, evolving needs.

The objectives were to: 1) model the 5-year care trajectories of a cohort of first-time admissions to Minnesota nursing homes (NHs), while considering multiple outcomes of discharges to the community, NH readmission, acute hospitalizations, and mortality; and 2) determine the percentage of admissions and resident characteristics related to each trajectory. Using the Minimum Data Set and the Medicaid claims data files, we selected 11,943 residents, age 65+, admitted to Minnesota NHs in 2015 with no prior NH stays. Admissions were followed for 5 years (2015-2019) for survival and care transitions between NH, community, and acute hospitals. Latent class growth analysis was used to analyze longitudinal care trajectories. The optimal number of latent classes was four. Trajectory 1 (37%) had the shortest survival and highest initial (30-day) rate of rehospitalizations. Trajectory 2 (11%) had the second shortest survival and the highest hospitalization rate during years 4–5. These residents were initially discharged to the community but experienced a steadily increasing rate of NH readmission. Trajectory 3 (22%) demonstrated longer survival and the highest hospitalization rate during years 1-3. Trajectory 4 (30%) experienced the most successful transitions to the community and the best long-term outcomes, characterized by the fewest NH readmissions, longest survival, and lowest hospitalization rates. Our findings highlight the heterogeneity of outcomes for the NH population. The trajectories were distinguished by age, dementia, ADL dependency, and comorbid conditions. Understanding this heterogeneity is crucial for developing appropriate care models and policies to meet the needs of an increasingly diverse NH population.

BACKGROUND:Learning health systems (LHS) improve patient and provider experiences, population health, and health system performance. LHS leaders develop LHS' social and scientific infrastructures and align the LHS with host organization's priorities. Although researchers have examined data infrastructure and Learning Community configurations, few studies have evaluated discrete strategies leaders deploy to construct a LHS. OBJECTIVES:We described methods used to establish the Department of Veterans Affairs (VA) Geriatric LHS (GLHS) supporting older Veterans transitioning from hospital to home and examined strategies GLHS leaders used to conduct LHS activities. DESIGN:Qualitative methods were employed to review notes from all meetings and post-meeting debriefs from encounters with operational partners, Learning Community members, and Quantitative and Qualitative Data Core subcommittees. Member checking with Learning Community and Data Core representatives led to iterative refinement of findings. A seven-question survey examined Learning Community member satisfaction with the GLHS. RESULTS:Ten of 16 Learning Community members (62.5%) completed surveys, indicating that the GLHS met Learning Community members' needs. The four key GLHS structural elements were (1) the imperative of maintaining an Idea Repository, (2) the value of notetaking and formal debriefs, (3) the cadence of meetings, and (4) the role of the newsletter to promote engagement. Five themes described core activities/perspectives GLHS operational leaders used: (1) listening to the Learning Community; (2) modifying analyses in response to Learning Community input; (3) including diverse perspectives; (4) managing organizational complexity; and (5) serving the healthcare system. CONCLUSIONS:The GLHS illustrates the importance of active listening, collaborative engagement, and responsive adaptation to advance LHS objectives. LHS leadership strategies such as an Idea Repository and iterative feedback mechanisms fostered stakeholder participation and informed data-driven improvements.

Introduction Whether obtaining the more intensive goal systolic blood pressure (SBP) of <130 mm Hg, rather than a less intensive SBP goal of <140 mm Hg poststroke/transient ischaemic attack (TIA) is associated with incremental mortality and recurrent vascular event benefit is largely unexplored using real-world data. Lowering SBP excessively may result in poorer outcomes.Methods This is a retrospective cohort study of 26 368 Veterans presenting to a Veterans Administration Medical Center (VAMC) with a stroke/TIA between October 2015 and July 2018. Patients were excluded from the study if they had missing or extreme BP values, receiving dialysis or palliative care, left against medical advice had a cancer diagnosis, were cared for in a VAMC enrolled in a stroke/TIA quality improvement initiative, died or had a cerebrovascular or cardiovascular event within 90 days after their index stroke/TIA. The analytical sample included 12 337 patients. Average SBP during 90 days after discharge was assessed in categories (≤105 mm Hg, 106–115 mm Hg, 116–130 mm Hg, 131–140 mm Hg and >140 mm Hg). Separate multivariable Cox proportional hazard regressions were used to examine the relationship between average SBP groups and time to: (1) mortality and (2) any recurrent vascular event, from 90 days to up to 365 days after discharge from the index emergency department visit or inpatient admission.Results Compared with those with SBP>140 mm Hg, patients with SBP between 116 and 130 mm Hg had a significantly lower risk of recurrent stroke/TIA (HR 0.77, 95% CI 0.60 to 0.99) but not cardiovascular events. Patients with SBP lower than 105 mm Hg, compared with those with >140 mm Hg demonstrated a statistically significant higher risk of death (HR 2.07, 95% CI 1.43 to 3.00), but no statistical differences were found in other SBP groups.Discussion Data support a more intensive SBP goal to prevent recurrent cerebrovascular events among stroke/TIA patients by 90 days poststroke/TIA compared with less intensive goal. Very low SBPs were associated with increased mortality risk.

Abstract Stroke is a major cause of mortality and disability in old age worldwide, often requiring ongoing formal long-term care (LTC). Only a handful of studies examining longitudinal patterns of institutional and community based LTC beyond the immediate post-stroke period. In order to better understand the impact of LTC use by stroke survivors, we compared findings from studies of LTC trajectories among people discharged from the hospital after a stroke in Sweden and the United States. The Swedish study modeled LTC trajectories over a three-year period for a nationally representative cohort of 31,560 stroke survivors age 70 and older during 2015 to 2017, while the US study modeled LTC trajectories over 12 months among a sample of 3,811 Veterans discharged from Veterans Administration (VA) hospitals after stroke during 2007. Approximately half of the sample in each study was alive and without a history of LTC use at one year. Use of LTC in both studies was associated with LTC use prior to stroke, advanced age, number of comorbid conditions including dementia, and frailty/dependency. In the Swedish study, transitions into formal LTC tended to be unidirectional - few people entering formal LTC ever returned to no care, and few people entering care homes ever transitioned back to home care. In the VA study, frequent transitions occurred between nursing homes and home-based LTC, as well as out of the LTC system entirely. We discuss how differences in LTC policies, particularly the role of the nursing home, affect LTC trajectories in the two countries.

The objectives were to 1) systematically evaluate the Minnesota Long-Stay Resident Quality of Life (QoL) Survey based on validity, reliability, parsimony, relevance, and ability to discriminate facility performance; and 2) arrive at a new version of the survey and composite scoring approach. Data consisted of Minnesota nursing home resident QoL surveys, conducted through annual face-to-face interviews in 2017 (10,007 residents, 355 facilities), 2018 (9,884 residents, 352 facilities), and 2019 (9,896 residents, 347 facilities). Validity was evaluated using exploratory and confirmatory factor analyses. Reliability was assessed by Cronbach’s alpha values. Parsimony and relevance were assessed using content validity, construct validity, correlation, frequency of endorsement, and percentage missing. The ability to discriminate facility performance was assessed by examining the distributions of facility QoL scores. The current domain structure has unbalanced items ranging from 4 to 9 across the eight domains; 28 items fit as well or better empirically under an alternative domain structure; and four items are redundant and could be dropped from the survey without loss of information. The current facility QoL scores do not discriminate well in facility performance because of the lack of item balance and a ceiling effect. The proposed revisions result in a shorter, more balanced, more discriminating, and more valid QoL survey, while maintaining a high level of reliability. The revised survey allows the Minnesota Department of Human Services, and others who might adopt the survey, to better assess nursing facility performance on aspects of QoL that are meaningful to residents.

Stroke is a major cause of mortality and adult-onset disability, in the United States and worldwide, that often requires ongoing formal long-term care (LTC).1 The study by Meyer and colleagues,2 a nationwide study of stroke survivors in Sweden, is one of a handful of studies examining long-term patterns of institutional and community-based LTC, as well as mortality beyond the immediate poststroke period. It addresses many of the same issues as our US study, "Care Trajectories of Veterans in the 12 Months After Hospitalization for Acute Ischemic Stroke."3 This commentary draws on findings from both studies to highlight what we have learned about poststroke care trajectories and to identify key issues for further study.

Given the differential impacts of COVID-19 on racial and ethnic groups, it is unclear how racial/ethnic status and frailty combine to influence pandemic-related healthcare disruptions. This study aimed to test the double jeopardy hypothesis: racial/ethnic minority older adults suffer a double disadvantage in access to health care during the pandemic due to the interactive effects of frailty and race. This study uses the linked National Health and Aging Trends Study (NHATS) and COVID-19 public use data files. A multivariate logistic regression model was performed. Overall, approximately two out of five (41%) older adults reported postponing care due to the pandemic. The likelihood of putting off care increased slightly by frailty status. We found no significant difference between Whites and non-Whites in putting off care. However, the simple comparison masked significant variation across frailty status. Robust non-White older people were less likely to put off care than robust Whites (robust non-Whites: 29% vs. robust Whites: 39%); in contrast, frail non-White older people were more likely to put off care (frail non-Whites: 55% vs. frail Whites: 42%). Being frail and non-White creates double jeopardy, which has a negative impact on access to healthcare. Timely access to care is essential for frail older people, particularly non-Whites, because of their complex health conditions accentuated by health and social disparities.

OBJECTIVE:To study factors associated with systolic blood pressure(SBP) control for patients post-discharge from an ischemic stroke or transient ischemic attack(TIA) during the early months of the COVID-19 pandemic compared to pre-pandemic periods within the Veterans Health Administration(VHA).MATERIALS AND METHODS:We analyzed retrospective data from patients discharged from Emergency Departments or inpatient admissions after an ischemic stroke or TIA. Cohorts consisted of 2,816 patients during March-September 2020 and 11,900 during the same months in 2017-2019. Outcomes included primary care or neurology clinic visits, recorded blood pressure readings and average blood pressure control in the 90-days post-discharge. Random effect logit models were used to compare clinical characteristics of the cohorts and relationships between patient characteristics and outcomes.RESULTS:The majority (73%) of patients with recorded readings during the COVID-19 period had a mean post-discharge SBP within goal (<140 mmHg); this was slightly lower than the pre-COVID-19 period (78%; p=0.001). Only 38% of the COVID-19 cohort had a recorded SBP in the 90-days post-discharge compared with 83% of patients during the pre-pandemic period (p=0.001). During the pandemic period, 29% did not have follow-up primary care or neurologist visits, and 33% had a phone or video visit without a recorded SBP reading.CONCLUSIONS:Patients with an acute cerebrovascular event during the initial COVID-19 period were less likely to have outpatient visits or blood pressure measurements than during the pre-pandemic period; patients with uncontrolled SBP should be targeted for follow-up hypertension management.

Background COVID-19 put older individuals at high risk for morbidity and mortality, isolation, reduced coping, and lower satisfaction with life. Many older adults experienced social isolation, fear, and anxiety. We hypothesized that successful coping with these stressors would maintain or improve satisfaction with life, a crucial psychological outcome during the pandemic. Our study investigated relationships between older people’s coping and life satisfaction during the pandemic and their optimism, sense of mastery, closeness with spouse, family, and friends, and vulnerabilities from frailty, comorbid diseases, memory problems, and dependencies in instrumental activities of daily living (IADL). Methods The study was based on a special COVID-19 sample of 1351 community-dwelling older adults who participated in the 2020 Health and Retirement Survey. A comprehensive structural equation modeling was used to test direct and indirect effects, with life satisfaction as the main outcome and coping as a mediator between the other variables and coping. Results Most survey respondents were female and between the ages of 65–74 years. They averaged 1.7 chronic conditions, one in seven was frail, about one-third rated their memory as fair or poor, and about one in seven reported one or more difficulties in IADL. As hypothesized—older people with increased sense of mastery and optimism were better able to cope and had greater life satisfaction. In addition, close relationships with friends and with other family members besides the spouse/partner or children contributed to more successful coping, while the interpersonal closeness of all types contributed directly to greater life satisfaction. Finally, older people with more IADL limitations reported greater difficulty coping and lower life satisfaction, and those older people who were frail or had multiple comorbid diseases reported lower life satisfaction. Conclusions Optimism, sense of mastery and closeness with family/friends promotes coping and life satisfaction, whereas frailty and comorbidities make coping more challenging and lead to lower life satisfaction particularly during a pandemic. Our study improves on prior research because of its nationally representative sample and formal specification and testing of a comprehensive theoretical framework.

Background Healthcare quality measurement systems, which use aggregated patient-level quality measures to assess organisational performance, have been introduced widely. Yet, their usefulness in practice has received scant attention. Using Minnesota nursing home quality indicators (QIs) as a case example, we demonstrate an approach for systematically evaluating QIs in practice based on: (a) parsimony and relevance, (b) usability in discriminating between facilities, (c) actionability and (d) construct validity. Methods We analysed 19 risk-adjusted, facility-level QIs over the 2012-2019 period. Parsimony and relevance of QIs were evaluated using scatter plots, Pearson correlations, literature review and expert opinions. Discrimination between facilities was assessed by examining facility QI distributions and the impact of the distributions on scoring. Actionability of QIs was assessed through QI trends over time. Construct validity was assessed through exploratory factor analysis of domain structure for grouping the QIs. Results Correlation analysis and qualitative assessment led to redefining one QI, adding one improvement-focused QI, and combining two highly correlated QIs to improve parsimony and clinical relevance. Ten of the QIs displayed normal distributions which discriminated well between the best and worst performers. The other nine QIs displayed poor discrimination; they had skewed distributions with ceiling or floor effects. We recommended scoring approaches tailored to these distributions. One QI displaying substantial improvement over time was recommended for retirement (physical restraint use). Based on factor analysis, we grouped the 18 final QIs into four domains: incontinence (4 QIs), physical functioning (4 QIs), psychosocial care (4 QIs) and care for specific conditions (6 QIs). Conclusion We demonstrated a systematic approach for evaluating QIs in practice by arriving at parsimonious and relevant QIs, tailored scoring to different QI distributions and a meaningful domain structure. This approach could be applied in evaluating quality measures in other health or long-term care settings.

The publisher regrets that the following affiliations were incorrect at the time the article was published; however these have now been corrected. Affiliation "a" should read "Indianapolis IN" instead of "Washington DC". Affiliation "b" should read "West Lafayette IN" and not "West Lafayette, Indianapolis, IN". The publisher would like to apologise for any inconvenience caused. Blood Pressure Trajectories and Outcomes for Veterans Presenting at VA Medical Centers with a Stroke or Transient Ischemic AttackThe American Journal of MedicineVol. 135Issue 7PreviewBlood pressure control has been shown to reduce risk of vascular events and mortality after an ischemic stroke or transient ischemic attack (TIA). Yet, questions remain about effectiveness, timing, and targeted blood pressure reduction. Full-Text PDF Open Access

Abstract Covid-19 put older individuals at high risk for increased morbidity and mortality, isolation, reduced coping and life satisfaction. Optimism, sense of mastery and closeness with family and friends can enhance coping and life satisfaction among older adults. No such studies were found during the pandemic. Our study examined the associations between optimism, sense of mastery, closeness with spouse, family, and friends, physical and psychological functioning and its effects on coping and life satisfaction. A national representative sample of 1,890 community dwelling older adults was obtained from the 2020 Health and Retirement Study COVID-19 data during March 2020-June 2021. A structural equation modeling approach used to test the associations and their direct and indirect effects on life satisfaction. Coping was seen as a mediator affecting these relationships and their effects on life satisfaction. Optimism (β = .318, p < .001), mastery (β = .195, p < .001) closeness with spouse/partner (β = .199, p < .001), closeness with children ((β = .075, p < .010), friends (β = .086, p < .001), had significant positive direct and indirect effects on life satisfaction. Frailty (β = -.137, p < .001), comorbidities (β = -.057, p < .050), and IADL limitations (β = -.118, p < .001) had negative direct effects on life satisfaction. Optimism, sense of mastery and closeness with family/friends promotes coping and life satisfaction whereas frailty and comorbidities negatively influence coping and life satisfaction of the older adults. Community interventions should target coping strategies that enhances optimism, mastery, and interpersonal closeness among older adults during pandemic.

BACKGROUND: Blood pressure control has been shown to reduce risk of vascular events and mortality after an ischemic stroke or transient ischemic attack (TIA). Yet, questions remain about effectiveness, timing, and targeted blood pressure reduction. METHODS: We analyzed data from a retrospective cohort of 18,837 veterans cared for 12 months prior and up to 12 months after an emergency department visit or inpatient admission for stroke or TIA. Latent class growth analysis was used to classify patients into systolic blood pressure trajectories. With Cox proportional hazard models, we examined relationships between blood pressure trajectories, intensification of antihypertensive medication, and stroke (fatal or non-fatal) and all-cause mortality in 12 months following the index event. RESULTS: The cohort was classified into 4 systolic blood pressure trajectories: 19% with a low systolic blood pressure trajectory (mean systolic blood pressure = 116mmHg); 65% with a medium systolic blood pressure trajectory (mean systolic blood pressure = 136 mm Hg); 15% with a high systolic blood pressure trajectory (mean systolic blood pressure = 158 mm Hg), and 1% with a very high trajectory (mean systolic blood pressure = 183 mm Hg). After the stroke or TIA, individuals in the high and very high systolic blood pressure trajectories experienced a substantial decrease in systolic blood pressure that coincided with intensification of antihypertensive medication. Patients with very low and very high systolic blood pressure trajectories had a significantly greater (P<. 05) hazard of mortality, while medication intensification was related significantly (P<. 05) to lower hazard of mortality. CONCLUSIONS: These findings point to the importance of monitoring blood pressure over multiple time points and of instituting enhanced hypertension management after stroke or TIA, particularly for individuals with high or very high blood pressure trajectories. (c) 2022 The Authors. Published by Elsevier Inc.

Background and Objectives Minnesota's implementation of a new nursing home value-based reimbursement (VBR) system in 2016 presented an opportunity to compare the response of nursing homes (NHs) to financial incentives to improve their quality and efficiency. The state substantially increased reimbursement for care-related costs and tied this rate increase to a composite quality score. Coinciding with rate increases of the new VBR system was an increase in ownership changes, with new owners being primarily for-profit entities from outside of Minnesota, including several private equity firms. Our objective was to examine NHs that underwent a change in ownership to determine their cost and quality response to the change. Research Design and Methods Our sample consists of 342 Minnesota NHs that submitted Medicaid cost reports each year from 2013 to 2019. A time differential two-way fixed-effects difference-in-difference model is used to assess changes in quality metrics by comparing measures in years prior to and years following the sale for NHs that changed ownership versus NHs with consistent ownership. Nursing home characteristics, revenue, and spending patterns are examined to understand differences in performance. Results Those NHs with ownership change experienced a decline in quality scores with notable changes to expenditure patterns. They performed worse on Minnesota Department of Health inspection scores and had nonsignificant declines in measures of quality of life and clinical care. They had declining staff dental and medical benefits and occupancy rates, greater revenue growth from Medicare Part B, and larger increases in administrative management fees. Discussion and Implications Minnesota like many other states has given wide latitude for nursing home ownership changes, without specific oversight for the quality of care and expenditure patterns of new owners. Recommendations include strict guidelines for the transparency of ownership structures, quality performance targets, rigorous financial auditing, and enhanced regulatory oversight.

Abstract The COVID-19 pandemic has had a disproportionate impact, in terms of mortality, on people who live in Long-Term Care Facilities (LTCFs). This study involved compiling data on number of deaths of people who live in LTCFs and analyzing the extent to which differences between countries could be attributed to measures taken to control the spread of COVID-19 to LTCFs or to other factors. The study found that differences in how the data is collected make international comparisons difficult but that there is a clear correlation between number of COVID-19 deaths of residents in LTCFs and number of COVID-19 deaths of people living in the community. The study also found that countries that experienced a particularly high number of deaths in LTCFs during the first COVID-19 wave tended to have lower relative mortality in LTCFs in the subsequent waves, which potentially could be attributed to learning from the initial shock.

HomeStrokeVol. 52, No. 2Cost-Effectiveness of Mechanical Thrombectomy for Treatment of Stroke Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBCost-Effectiveness of Mechanical Thrombectomy for Treatment of StrokeFrom Modeling to Real-World Implementation Greg Arling, PhD and Mikael Mazighi, MD, PhD Greg ArlingGreg Arling Correspondence to: Greg Arling, PhD, School of Nursing, Purdue University, West Lafayette, IN 47907. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8563-9433 School of Nursing, Purdue University, West Lafayette, IN (G.A.). and Mikael MazighiMikael Mazighi Department of Neurology, Lariboisière Hospital, Research and Training Center for Cerebrovascular Disease, Fondation Rothschild Hospital, Université de Paris, France (M.M.). Originally published11 Jan 2021https://doi.org/10.1161/STROKEAHA.120.032112Stroke. 2021;52:674–676This article is a commentary on the followingCost-Effectiveness of Mechanical Thrombectomy for Treatment of Nonminor Ischemic Stroke Across EuropeOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 11, 2021: Ahead of Print See related article, p 674The article by Candio et al1 is of great interest because it makes a strong case for cost-effectiveness of mechanical thrombectomy (MT), a significant advancement in stroke care that is yet to be widely implemented. A large gap exists between patients who could benefit from MT and those who receive it. Recent studies found that only about 3% of patients with acute ischemic stroke in Europe and in the United States received MT, compared with the 17% of patients who might have been eligible.2–4 Demonstrating the cost-effectiveness of MT and better yet, its potential for cost savings, should motivate European countries to invest resources to promote greater adoption of MT in treatment of the 1.2 million cases of incident stroke annually in Europe.5Contributions of the StudyThe article reports on a highly ambitious study that models access to and use of MT among patients with ischemic stroke in 32 European countries over a 5-year time horizon from a societal perspective. Estimates of cost-effectiveness and cost savings are based on comparison between 2 treatment approaches: eligible patients receive full access to and use of MT or they receive continuation of standard care. The study draws upon multiple indicators that are of keen interest to public policy makers and other stakeholders: health care cost, informal and social cost, and lost productivity cost; functional outcomes, mortality, quality of life; and quality-adjusted life-years. The study also integrates multiple data sources, including results of clinical trials, population-based cohort studies of patients with stroke, general population surveys, and country-specific economic and health care cost data. The modeling approach is solid. It relies on Markov-simulation with a probabilistic sensitivity analysis to produce informative probability estimates associated with different modeling assumptions.Findings from the study are compelling. MT is found not only to be cost-effective in all but one of the 32 countries, it is projected to achieve cost savings in 21 of them. Cost-effectiveness is achieved, according to the model, by off-setting the incremental cost of MT with savings in future health care costs, lowering the burden on the informal care system, and reducing losses in economic productivity. The major driver of cost savings is less disability and higher levels of functional independence with MT compared with standard care. Each of these outcomes is highly valued from a societal perspective.Concerns About the Study and FindingsNonetheless, the study is not without weaknesses, both methodological and from the perspective of practical application. Results of a statistical model, particularly one that forecasts future events, are heavily influenced by the data sources that go into estimating the model parameters. Several parameters, including number of eligible stroke cases, unit costs for health and social care, days of informal care, and employment rates, are informed by country-specific data. However, estimates of functional improvement (modified Rankin Scale score) from MT compared with standard care were based on a meta-analysis of 1287 patients pooled from 5 clinical trials conducted under controlled conditions.6 Other key model parameters, including mortality, utilities, and health and social care resource use, are drawn largely from a single study, OXVASC (Oxford Vascular Study), in the United Kingdom.7 Treatment protocols and unit costs for staff, pharmaceuticals, and medical devices come from OXVASC and a single Italian study.8 Parameters from these studies may not be generalizable across the 32 European countries.For example, the total costs and quality-adjusted life-years estimated from the simulation are based on the assumption that all eligible patients would receive either MT+ intravenous thrombolysis or intravenous thrombolysis alone (depending on the MT or standard care scenario) and that it would be delivered with the same level of effectiveness in each country. In theory, this may be true, but in practice, one could anticipate wide variation in availability of MT or intravenous thrombolysis and the quality of its administration depending on the health care resources of different countries. Moreover, many financial assumptions about costs are based on UK population tariffs. Given differences in health care systems across Europe, such assumptions may not be valid.Moreover, the comparison of the MT intervention to standard care is not as simple as the study would imply. Capturing the heterogeneity inherent to the physician practice and patient characteristics is quite a challenge. The MT intervention is not well codified. Although the European guidelines suggest preferential use of one first-line device (ie, stentriever),9 some interventionalists may use 2 devices at the same time (eg, stentriever and aspiration catheters) with the aim to achieve higher rates of first-pass-effect, which is associated with better functional outcomes (reduced times for onset to reperfusion are linked to functional independence). Therefore, costs may not only vary based on the difficulty of the intervention (in complicated cases, several devices may be used) but also based on the interventionalists technical strategy. In this situation, the device-related costs may double. Providing the intervention outside working hours, which represents a significant proportion of patients, brings additional costs. Depending on the site, the pluri-disciplinary team on call may include different specialists (eg, anesthesiologist in addition to the neurointerventionist and vascular neurologist), which are additional staff costs to consider. Last but not least, a drip and ship approach may have increased cost relative to an additional stop (including ambulance, brain imaging, physicians), as compared to a mothership strategy. In this perspective, MT costs may rise for patients living in rural areas, where the probability of a drip and ship approach is higher due to the remoteness of MT facilities.These examples of the stroke management complexity stress the fact that MT is part of a stroke care pathway including the admission in a stroke unit, which by itself reduces disability and mortality irrespectively of the intervention.10 Standards of care have evolved since 2002 to 2012, the period of the OXVASC. Stroke pathways have improved significantly with more patients treated and faster, independence of their eligibility for or receipt of MT. The faster the treatment is initiated, the better is the outcome with a direct impact on costs. However, even in resource-rich countries, patients with stroke may not have full access to stroke centers or other settings where MT could be delivered. The number of patients receiving MT is expected to grow in the future, but the relative cost-effectiveness of MT could vary considerably dependent on patient's specificities and MT center organization.Looking to the FutureFuture research should address challenges in implementing comprehensive stroke care and ensuring its effectiveness. First, researchers should approach MT not as a separate intervention but as part of a comprehensive system of care for acute ischemic stroke. Second, researchers should obtain more refined estimates of the numbers and types of patients who would be eligible and could benefit from MT, and identify the gap between who could benefit from MT and who is receiving it. We need a better understanding of barriers to MT access and stroke care in general. With this information, policies can be developed to remove barriers to timely and effective care: reducing delays in symptom recognition and time to treatment; expanding stroke care access in rural or remote locations, and remove disparities in access by sex, age, racial/immigrant/ethnicity status, socio-economic status, and health care insurance coverage.Third, research should help improve stroke care effectiveness. Key performance indicators can be targeted: time from symptom onset to reperfusion; door-to-imaging time; imaging to groin puncture time; groin puncture to clot/first device deployment; degree of reperfusion; modified Rankin Scale score at 3 months; and procedure-related complication rate. These performance indicators should be reported as part of on-going audits.9 MT access should be integrated within health care networks in collaboration with emergency medical services to maximize access to MT and minimize delays.ConclusionsAs the statistician George Box is credited with saying: "All models are wrong, but some are useful." On balance, this simulation study has more right than wrong, and its findings are useful. Study findings make a credible case for the cost-effectiveness of MT as a component of comprehensive stroke care. However, we need increased understanding of ways to expand access to care and to improve stroke care effectiveness.Sources of FundingNone.Disclosures Dr Mazighi reports personal fees from Boehringer Ingelheim, personal fees from Air Liquide, personal fees from Amgen, and personal fees from Acticor Biotech outside the submitted work. The other author reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 676.Correspondence to: Greg Arling, PhD, School of Nursing, Purdue University, West Lafayette, IN 47907. Email [email protected]eduReferences1. Candio P, Violato M, Leal J, Luengo-Fernandez R. Cost-effectiveness of mechanical thrombectomy for nonminor ischemic stroke across Europe.Stroke. 2021; 52:664–673. doi: 10.1161/STROKEAHA.120.031027LinkGoogle Scholar2. Kuhrij LS, Wouters MW, van den Berg-Vos RM, de Leeuw FE, Nederkoorn PJ. 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Stroke. 2021;52:664-673 February 2021Vol 52, Issue 2Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.120.032112PMID: 33423515 Originally publishedJanuary 11, 2021 Keywordsischemic strokeEditorialsprobabilitymortalitythrombectomyquality of lifePDF download Advertisement SubjectsCerebrovascular Disease/StrokeCost-EffectivenessTreatment