Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Price, Christopher I; White, Phil; Balami, Joyce; Bhattarai, Nawaraj; Coughlan, Diarmuid; Exley, Catherine; Flynn, Darren; Halvorsrud, Kristoffer; Lally, Joanne; McMeekin, Peter; Shaw, Lisa; Snooks, Helen; Vale, Luke; Watkins, Alan; Ford, Gary A

doi:10.3310/tzty9915

Journal article 651 views 122 downloads

Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Christopher I Price

, Phil White

, Joyce Balami

, Nawaraj Bhattarai

, Diarmuid Coughlan

, Catherine Exley

, Darren Flynn

, Kristoffer Halvorsrud

, Joanne Lally

, Peter McMeekin

, Lisa Shaw

, Helen Snooks

, Luke Vale

, Alan Watkins

, Gary A Ford

Programme Grants for Applied Research, Volume: 10, Issue: 4, Pages: 1 - 96

Swansea University Authors: Helen Snooks , Alan Watkins

PDF | Version of Record

Permission to reproduce material from a published report is covered by the creative commons licence http://creativecommons.org/licenses/by/4.0/
Download (5.21MB)

Check full text

DOI (Published version): 10.3310/tzty9915

Abstract

BackgroundIntravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.ObjectivesThe aims wer...

Full description

Published in:	Programme Grants for Applied Research
ISSN:	2050-4322 2050-4330
Published:	National Institute for Health and Care Research (NIHR) 2022
Online Access:	Check full text
URI:	https://cronfa.swan.ac.uk/Record/cronfa60478
Tags:	Add Tag No Tags, Be the first to tag this record!

first_indexed	2022-08-03T15:30:49Z
last_indexed	2023-01-13T19:20:38Z
id	cronfa60478
recordtype	SURis
fullrecord	<?xml version="1.0"?><rfc1807><datestamp>2022-08-03T16:33:07.0809406</datestamp><bib-version>v2</bib-version><id>60478</id><entry>2022-07-13</entry><title>Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT</title><swanseaauthors><author><sid>ab23c5e0111b88427a155a1f495861d9</sid><ORCID>0000-0003-0173-8843</ORCID><firstname>Helen</firstname><surname>Snooks</surname><name>Helen Snooks</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>81fc05c9333d9df41b041157437bcc2f</sid><ORCID>0000-0003-3804-1943</ORCID><firstname>Alan</firstname><surname>Watkins</surname><name>Alan Watkins</name><active>true</active><ethesisStudent>false</ethesisStudent></author></swanseaauthors><date>2022-07-13</date><deptcode>HDAT</deptcode><abstract>BackgroundIntravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.ObjectivesThe aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.DesignA mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.SettingThe paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.ParticipantsA total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.InterventionsThe paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.Main outcome measuresThe primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.Data sourcesNational registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.Review methodsSystematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsThe paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).LimitationsEvidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.ConclusionsParamedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.Future workFurther evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.</abstract><type>Journal Article</type><journal>Programme Grants for Applied Research</journal><volume>10</volume><journalNumber>4</journalNumber><paginationStart>1</paginationStart><paginationEnd>96</paginationEnd><publisher>National Institute for Health and Care Research (NIHR)</publisher><placeOfPublication/><isbnPrint/><isbnElectronic/><issnPrint>2050-4322</issnPrint><issnElectronic>2050-4330</issnElectronic><keywords/><publishedDay>1</publishedDay><publishedMonth>5</publishedMonth><publishedYear>2022</publishedYear><publishedDate>2022-05-01</publishedDate><doi>10.3310/tzty9915</doi><url/><notes/><college>COLLEGE NANME</college><department>Health Data Science</department><CollegeCode>COLLEGE CODE</CollegeCode><DepartmentCode>HDAT</DepartmentCode><institution>Swansea University</institution><apcterm/><funders>The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme</funders><projectreference/><lastEdited>2022-08-03T16:33:07.0809406</lastEdited><Created>2022-07-13T12:03:03.4443844</Created><path><level id="1">Faculty of Medicine, Health and Life Sciences</level><level id="2">Swansea University Medical School - Medicine</level></path><authors><author><firstname>Christopher I</firstname><surname>Price</surname><orcid>0000-0003-3566-3157</orcid><order>1</order></author><author><firstname>Phil</firstname><surname>White</surname><orcid>0000-0001-6007-6013</orcid><order>2</order></author><author><firstname>Joyce</firstname><surname>Balami</surname><orcid>0000-0001-9968-3179</orcid><order>3</order></author><author><firstname>Nawaraj</firstname><surname>Bhattarai</surname><orcid>0000-0002-1894-2499</orcid><order>4</order></author><author><firstname>Diarmuid</firstname><surname>Coughlan</surname><orcid>0000-0002-5348-3750</orcid><order>5</order></author><author><firstname>Catherine</firstname><surname>Exley</surname><orcid>0000-0002-3570-7503</orcid><order>6</order></author><author><firstname>Darren</firstname><surname>Flynn</surname><orcid>0000-0001-7390-632x</orcid><order>7</order></author><author><firstname>Kristoffer</firstname><surname>Halvorsrud</surname><orcid>0000-0002-8813-0939</orcid><order>8</order></author><author><firstname>Joanne</firstname><surname>Lally</surname><orcid>0000-0002-8468-1397</orcid><order>9</order></author><author><firstname>Peter</firstname><surname>McMeekin</surname><orcid>0000-0003-0946-7224</orcid><order>10</order></author><author><firstname>Lisa</firstname><surname>Shaw</surname><orcid>0000-0002-3435-9519</orcid><order>11</order></author><author><firstname>Helen</firstname><surname>Snooks</surname><orcid>0000-0003-0173-8843</orcid><order>12</order></author><author><firstname>Luke</firstname><surname>Vale</surname><orcid>0000-0001-8574-8429</orcid><order>13</order></author><author><firstname>Alan</firstname><surname>Watkins</surname><orcid>0000-0003-3804-1943</orcid><order>14</order></author><author><firstname>Gary A</firstname><surname>Ford</surname><orcid>0000-0001-8719-4968</orcid><order>15</order></author></authors><documents><document><filename>60478__24832__e044b6486fbc4d10a99713647314e0bd.pdf</filename><originalFilename>60478_VoR.pdf</originalFilename><uploaded>2022-08-03T16:31:10.1501714</uploaded><type>Output</type><contentLength>5465688</contentLength><contentType>application/pdf</contentType><version>Version of Record</version><cronfaStatus>true</cronfaStatus><documentNotes>Permission to reproduce material from a published report is covered by the creative commons licence http://creativecommons.org/licenses/by/4.0/</documentNotes><copyrightCorrect>true</copyrightCorrect><language>eng</language><licence>http://creativecommons.org/licenses/by/4.0/</licence></document></documents><OutputDurs/></rfc1807>
spelling	2022-08-03T16:33:07.0809406 v2 60478 2022-07-13 Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT ab23c5e0111b88427a155a1f495861d9 0000-0003-0173-8843 Helen Snooks Helen Snooks true false 81fc05c9333d9df41b041157437bcc2f 0000-0003-3804-1943 Alan Watkins Alan Watkins true false 2022-07-13 HDAT BackgroundIntravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.ObjectivesThe aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.DesignA mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.SettingThe paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.ParticipantsA total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.InterventionsThe paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.Main outcome measuresThe primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.Data sourcesNational registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.Review methodsSystematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsThe paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).LimitationsEvidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.ConclusionsParamedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.Future workFurther evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications. Journal Article Programme Grants for Applied Research 10 4 1 96 National Institute for Health and Care Research (NIHR) 2050-4322 2050-4330 1 5 2022 2022-05-01 10.3310/tzty9915 COLLEGE NANME Health Data Science COLLEGE CODE HDAT Swansea University The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme 2022-08-03T16:33:07.0809406 2022-07-13T12:03:03.4443844 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Medicine Christopher I Price 0000-0003-3566-3157 1 Phil White 0000-0001-6007-6013 2 Joyce Balami 0000-0001-9968-3179 3 Nawaraj Bhattarai 0000-0002-1894-2499 4 Diarmuid Coughlan 0000-0002-5348-3750 5 Catherine Exley 0000-0002-3570-7503 6 Darren Flynn 0000-0001-7390-632x 7 Kristoffer Halvorsrud 0000-0002-8813-0939 8 Joanne Lally 0000-0002-8468-1397 9 Peter McMeekin 0000-0003-0946-7224 10 Lisa Shaw 0000-0002-3435-9519 11 Helen Snooks 0000-0003-0173-8843 12 Luke Vale 0000-0001-8574-8429 13 Alan Watkins 0000-0003-3804-1943 14 Gary A Ford 0000-0001-8719-4968 15 60478__24832__e044b6486fbc4d10a99713647314e0bd.pdf 60478_VoR.pdf 2022-08-03T16:31:10.1501714 Output 5465688 application/pdf Version of Record true Permission to reproduce material from a published report is covered by the creative commons licence http://creativecommons.org/licenses/by/4.0/ true eng http://creativecommons.org/licenses/by/4.0/
title	Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT
spellingShingle	Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT Helen Snooks Alan Watkins
title_short	Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT
title_full	Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT
title_fullStr	Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT
title_full_unstemmed	Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT
title_sort	Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT
author_id_str_mv	ab23c5e0111b88427a155a1f495861d9 81fc05c9333d9df41b041157437bcc2f
author_id_fullname_str_mv	ab23c5e0111b88427a155a1f495861d9_*_Helen Snooks 81fc05c9333d9df41b041157437bcc2f_*_Alan Watkins
author	Helen Snooks Alan Watkins
author2	Christopher I Price Phil White Joyce Balami Nawaraj Bhattarai Diarmuid Coughlan Catherine Exley Darren Flynn Kristoffer Halvorsrud Joanne Lally Peter McMeekin Lisa Shaw Helen Snooks Luke Vale Alan Watkins Gary A Ford
format	Journal article
container_title	Programme Grants for Applied Research
container_volume	10
container_issue	4
container_start_page	1
publishDate	2022
institution	Swansea University
issn	2050-4322 2050-4330
doi_str_mv	10.3310/tzty9915
publisher	National Institute for Health and Care Research (NIHR)
college_str	Faculty of Medicine, Health and Life Sciences
hierarchytype
hierarchy_top_id	facultyofmedicinehealthandlifesciences
hierarchy_top_title	Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id	facultyofmedicinehealthandlifesciences
hierarchy_parent_title	Faculty of Medicine, Health and Life Sciences
department_str	Swansea University Medical School - Medicine{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}Swansea University Medical School - Medicine
document_store_str	1
active_str	0
description	BackgroundIntravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.ObjectivesThe aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.DesignA mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.SettingThe paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.ParticipantsA total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.InterventionsThe paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.Main outcome measuresThe primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.Data sourcesNational registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.Review methodsSystematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsThe paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).LimitationsEvidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.ConclusionsParamedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.Future workFurther evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.
published_date	2022-05-01T04:18:37Z
_version_	1763754238246125568
score	11.037056

Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Similar Items