Endovascular therapy for acute ischemic stroke

295 Pages·2017·15.15 MB·English

by  Stefanie Kletke

Alberta STE Report
pre

Endovascular therapy for acute ischemic

st roke

August 2017
INSTITUTE OF HEALTH ECONOMICS
The Institute of Health Economics (IHE) is an independent, not-for-profit organization that
performs research in health economics and synthesizes evidence in health technology assessment to
assist health policy making and best medical practices.

IHE BOARD OF DIRECTORS
Chair
Dr. Lorne Tyrrell – Professor & Director, Li Ka Shing Institute of Virology, University of Alberta
Government and Public Authorities
Mr. Justin Riemer – Assistant Deputy Minister, Alberta Health
Mr. Jason Krips – Deputy Minister, Economic Development and Trade
Mr. Reg Joseph – VP Health, Alberta Innovates
Dr. Kathryn Todd – VP Research, Innovation & Analytics, Alberta Health Services
Academia
Dr. Walter Dixon – Associate VP Research, University of Alberta
Dr. Jon Meddings – Dean of Medicine, University of Calgary
Dr. Richard Fedorak – Dean of Medicine & Dentistry, University of Alberta
Dr. Ed McCauley – VP Research, University of Calgary
Dr. Neal Davies – Dean of Pharmacy & Pharmaceutical Sciences, University of Alberta
Dr. Braden Manns – Svare Chair in Health Economics and Professor, Departments of Medicine
and Community Health Sciences, University of Calgary
Dr. Constance Smith – Chair, Department of Economics, University of Alberta
Industry
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Economics
Alberta STE Report

Endovascular therapy for acute ischemic
stroke

Alberta STE Report: Policy-driven Health Technology

Assessment reports that include an analysis of the

social and system demographics, technological effectiveness, and

economic implications of a health technology.
The reports are written under contract with the
Alberta Health Technologies Decision Process and
contextualized for use in Alberta.
Acknowledgements
The Institute of Health Economics is grateful to:
• Expert Advisory Group
• Health Evidence and Policy Unit, Alberta Health
• Business Advisory Services at Alberta Health Services, Alberta Health Services
• Cardiovascular Health & Stroke – Strategic Clinical Networks, Alberta Health Services
• Clinical Analytics (DIMR) Unit, Alberta Health Services
• Clinical Neurosciences Unit, Alberta Health Services
• Community Accessible Rehabilitation (CAR) Program, Alberta Health Services
• Customer Relationship Management (CRM) and Data Access Unit, Alberta Health
• Department of Community Health Sciences, University of Calgary
• Department of Health Technology Assessment, University of Calgary
• Department of Surgery (Division of Neurosurgery), University of Saskatchewan
• Diagnostic Imaging Unit (Senior Administration), Alberta Health Services
• Dispatch Communications and Deployment Unit, Emergency Medical Services (EMS),
Alberta Health Services
• Emergency – Strategic Clinical Networks, Alberta Health Services
• Emergency Health Services Unit, Alberta Health
• Emergency Link Centre (ELC) and Operations, Shock Trauma Air Rescue Society
(STARS)
• Health Technology Assessment and Innovation Unit, Alberta Health Services
• Information Management & Technology Services, EMS, Alberta Health Services
• Intergovernmental Relations Branch, Alberta Health
• Patient/Care Based Funding, Alberta Health Services
• Poison and Drug Information Services (PADIS) & Referral, Access, Advice, Placement,
Information and Destination (RAAPID) Unit(s), Alberta Health Services
• Provincial Air Ambulance Operations & Inter-Facility Patient Transfer (IFT) Strategy
Unit, EMS, Alberta Health Services
• Quality Improvement & Clinical Research (QuICR), University of Calgary
• Strategic Capital Planning, Capital Management, Alberta Health Services
• Stroke Prevention Clinic, Calgary Stroke Program, Alberta Health Services
• System Performance and Innovation (SPI) Unit, EMS, Alberta Health Services
The views expressed in this report are of the Institute of Health Economics.
Corresponding Author
Please direct any inquiries about this report to Dr. Bing Guo, [email protected].
Endovascular therapy for acute ischemic stroke i
Funding
This report was supported by a financial contribution from Alberta Health (AH) through the
Alberta Health Technologies Decision Process, the Alberta model for health technology
assessment and policy analysis. The completed report was submitted to AH in May 2017.
The views expressed herein do not necessarily represent the official policy of Alberta Health.
Declared Competing Interest of Authors
Competing interest is considered to be financial interest or non-financial interest, either direct or
indirect, that would affect the research contained in this report or create a situation in which a
person’s judgement could be unduly influenced by a secondary interest, such as personal
advancement.
The authors of this publication claim no competing interest.
Suggested Citation (ICMJE or Vancouver Style)
Institute of Health Economics. Endovascular therapy for acute ischemic stroke. Edmonton (AB):
Institute of Health Economics; 2017.
Web Address
This publication is available for free download from the IHE website at http://www.ihe.ca.

Reproduction, redistribution, or modification of the information for any purposes is prohibited without the express
written permission of the Institute of Health Economics
Institute of Health Economics, 2017 www.ihe.ca
Endovascular therapy for acute ischemic stroke ii
Executive Summary
Background
Stroke care in Alberta is evolving to incorporate advancements in technology such as endovascular
therapy (EVT) into the current standard of care, which is typically a pharmaceutical intervention
using tissue plasminogen activator (tPA; also called alteplase). However, there are concerns
regarding the ability to provide EVT, given that the treatment can only be provided at two hospitals
in Alberta (comprehensive stroke centres, in Edmonton and Calgary), and within a narrow window
from time of stroke onset (that is, within 6 hours, the ultra-acute period of acute ischemic stroke).
Therefore, several strategies need to be in place to make EVT available to all eligible patients,
including those located in rural and other remote areas where there is no immediate access to EVT.
Accordingly, there was a need to conduct an evidence assessment contextualized to the Alberta
setting, particularly with regards to the impact of providing EVT to all eligible patients versus
maintaining the status quo.
Alberta STE Evidence Assessment
This evidence assessment was conducted under the auspices of the Alberta Health Technology
Decision Process. This process involves the use of appropriate evidence and information for
decision-making regarding the public provision of health technologies and services. These
assessments consider existing evidence and other information relevant to three areas:
• social and system demographics (S section);
• technology effects and effectiveness (T section); and
• economic analysis (E section).
Social and System Demographics
The objective of the S section of this STE report is to provide information describing the burden of
acute stroke, the current situation of stroke care in the province of Alberta, the current care
pathways associated with the administration of both EVT and tPA, and the related health outcomes
after EVT. Accessibility/acceptability, patient/public views, facilitators/barriers, social/ethical/legal
considerations, and health system capacity in Alberta with regards to providing EVT will also be
described. A brief description of policy and practice regarding EVT in other jurisdictions of Canada
will be reported.
Findings from the jurisdictional scan and resource requirements for province-wide implementation
of EVT are briefly summarized in Tables ES.1 and ES.2 below.
Endovascular therapy for acute ischemic stroke iii
TABLE ES.1: Canadian jurisdictions providing EVT (as of 31 December 2016)
Protocol for transporting patients Began providing EVT procedures
Province/Territory
who might benefit from EVT EVT per year
British Columbia No January 2016a 210b
Alberta Yesc 2010d 195e
Saskatchewan Yes 2008 50
Manitoba No 2005 Not specifiedf
Ontario Yesc February 2015g 351h
Quebec Yes Summer 2015 180i
Newfoundland and Labrador NR NR NR
Nova Scotia Yesj,k
2012 18i
Nol
New Brunswick No 2006 30-50
Prince Edward Island NR NR NR
Nunavut NR NR NR
Yukon NR NR NR
Northwest Territories NR NR NR
Source: Provinces/territories were surveyed regarding their use of EVT and associated protocols, and seven provided
answers (British Columbia, Alberta, Manitoba, Ontario, Quebec, Nova Scotia, and New Brunswick); additional
information was obtained from a report on EVT performed by the HTA Unit at the University of Calgary
a Some procedures performed earlier, in a non-programmatic way
b Since January 2016
c Interim, final under development
d The first use of a stent retriever was in 2010. However, EVT started earlier in the context of randomized controlled
trials in the mid-2000s. After the ESCAPE trial in January 2015, EVT was done consistently
e Approximately, 135 EVT procedures in Calgary and 60 in Edmonton are performed per year
f Currently, Manitoba has no volume for this procedure. EVT is provided when resources are able to patients within
the Winnipeg Regional Health Authority
g Some centres in Ontario have been performing EVT since 2005 as participants in research trials. In February 2015,
the Ontario Stroke Network established a provincial workgroup to develop an EVT implementation strategy
h In 2015/16
i In 2015
j For areas surrounding the site where EVT is provided: Halifax/Dartmouth/West Hants/Eastern Shore
k Patients with terminal cancer and living in nursing home with dementia are excluded from EVT
l For areas outside of the central part of the province, there is a protocol drafted but is not in place yet; patients are
currently transferred on a case-by-case basis from areas outside of the central part of the province
NR: no response
Endovascular therapy for acute ischemic stroke iv
TABLE ES.2: Resources necessary for implementing EVT, by care pathway stage
Additional resource
Current resource needs Capacity issues Training issues
needs
EMS
• Ground – paramedics (2 No capacity issues for EMS No training issues are No additional needs
per team) ground, fixed-wing air foreseen; all required required
• STARS – 2 pilots, 1 RN, ambulances, or STARS to protocols are being
absorb the EVT demand developed and
1 paramedic
piloted, and will be
• Fixed-wing air implemented in the
ambulance – 2 pilots, 2
near future without
paramedics or 1 EMT,
affecting the system
and 1 paramedic
• Dispatch and STARS
Emergency Link
Centre service (i.e., 4-
way communication
involves EMS
practitioner, stroke
neurologist, transport
physician, RAAPID)
• RAAPID for
communications link
Emergency department
• Emergency physician • Emergency departments are • In Edmonton, pre- In Edmonton, a
consult working at 150-180% of their hospital algorithms business plan is being
• Emergency hospital visit capacity, regardless of the are being created to put forward to hire a
(includes nursing, facility presenting conditions; capacity reduce the load at nurse (neurology/ICU
issues need to be discussed the U of A Hospital; nurse) who will help to
costs)
from a system perspective in order to reduce the burden on
• In Edmonton, there was implement this, emergency department
previously inadequate nursing EMS personnel will nurses at the U of A
support for EVT procedures at be trained for at Hospital
the U of A Hospital, meaning a least 3 months (in-
kind contribution
nurse would be taken from the
emergency department when from the EMS
needed, potentially putting program)
strain on the emergency • Education in rural
department communities
regarding protocols
and how to use
LAMS are needed
to reduce door-to-
needle times and
reduce the burden
of EVT cases for
rural emergency
departments
Endovascular therapy for acute ischemic stroke v
Additional resource
Current resource needs Capacity issues Training issues
needs
Diagnostic imaging
• CT AHS diagnostic imaging services • Professionals need • Increase funding for
• CTA head scan have the capacity to respond to to be trained to staff training, staff
the expected volume of EVT; satisfy demand costing, operational
• Radiologist however, they need to expand in • Training takes costs, and
• CT technologist some places where they do not approximately 6-8 interpretational costs
have 24/7 availability of a weeks, and is done • Anticipate that
neurologist/radiologist to interpret
on-site with a minimum 30
the images
hands-on approach technologists need to
• Personnel need to be trained
physically be at • Several costs need to
either the U of A be taken into
Hospital or Foothills consideration for on-
Medical Centre for site training: travel
at least 2 weeks to costs,
be able to perform accommodation, AHS
the procedures per diem, plus
repeatedly replacement costs to
pay personnel to
cover the person in
training
Telehealth
• Neurologist consult • No capacity issues are No training issues are Solution unknown (a
• RAAPID for expected; however, there are foreseen combination of
some issues with the current equipment, software,
communications link
technology and software, and troubleshooting
• Telestroke capability
which can limit the timely may be needed)
• Central infrastructure access to EVT in some areas
(e.g., Supernet) to allow (e.g., North Region)
transfer of images • Neurologists paid by the fee-
• Software at the for-service model have raised
receiving end to see concerns about the increased
and review images number of calls involved to
determine eligibility for EVT
tPA
• 1 vial is 100mg, $2,700 No capacity issues are expected No training issues are No additional needs are
• IV tubing, IV pump, etc. foreseen required
• Neurologist consult to
administer tPA
EVT
Angiography suite • It is anticipated that the No training issues are In Calgary, another
including imaging number of angiography suites foreseen angiography suite with
technology (biplane angio) in Edmonton will cover demand appropriate staffing is
• Calgary has 3 suites that are required
working at capacity; the
equipment has not been
renewed for at least 20 years
Endovascular therapy for acute ischemic stroke vi
Additional resource
Current resource needs Capacity issues Training issues
needs
Angiography team: • There are sufficient No training issues are In Edmonton, there are
• Neurointerventionalist neurointerventionalists to foreseen two options, either:
(physician) – currently perform EVT procedures (9 in a) Increase of 4.2 FTE
either a neurosurgeon Edmonton, 5 in Calgary) RNs to manage
or neuroradiologist • There is a shortage of both critical care needs of
• RN – angiography angiography nurses and EVT and other
scrub nurse/DI technical nurses for the medical team in patients
nurse who can manage the angiography suite OR
the angiography suite • In Edmonton, with 2 nurses b) Increase of 2.1 FTE
• RN/LPN – angiography and 2 technologists now on call RNs to manage
rotating nurse for room after hours, no further issues critical care needs of
and DI tech are anticipated for the EVT EVT patients, plus call
management of the procedure itself; however, back
there is still a shortage of care
imaging modality In Calgary:
nurses
Medical team: • It would be ideal to
• Calgary has only one on-call
• Neurologist OR increase 2.8 FTE of
team for both neurological and
anaesthetist – to nurses to have full
non-neurological interventions
manage the patient coverage for the
after hours neurology unit and
• RN – to manage the
• In Calgary, a nurse from the EVT
patient
neurology unit assists with • In addition, another
• Device and materials patient care during an EVT
nurse and tech on call
procedure; this model has
would be required
functioned very well to keep
the continuity of care of the
patients. However, this nurse
leaves the neurology unit in
order to help with the EVT
procedure, generating some
strain in the unit
Hospital admission
• Hospital bed for stroke • In Edmonton, hospital In Edmonton, to In Edmonton, if the
(includes nursing, etc.) admission services at the U of implement the pre- strategies for redirecting
• Neurologist subsequent A Hospital is at 104% of its hospital algorithm patients to other
visit (after consult for capacity, regardless of the strategy to redirect hospitals do not work,
presenting conditions; capacity patients to other an increase in inpatient
initial treatment)
issues need to be discussed hospitals, EMS beds and personnel
• Neurologist discharge
from a system perspective personnel will be would be needed (not a
visit • Strategies are being created so trained for at least 3 realistic possibility)
months (in-kind
that patients not requiring the
contribution from the
services of the U of A Hospital
can be redirected/moved to EMS program)
another hospital within 1-2
days
• In Calgary, although all the
beds in the neurology unit are
occupied and they are at 100%
or more of their capacity, they
have protocols and processes
in place to be able to absorb
the demand of new EVT
patients
Endovascular therapy for acute ischemic stroke vii