Geographical Requirements for the Applicability of the Results of the RACECAT Study to Other Stroke Networks

Abstract

Prehospital stroke triage; Reperfusion therapy

Triaje prehospitalario de ictus; Terapia de reperfusión

Triatge prehospitalari d'ictus; Teràpia de reperfusió

Background The RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) trial was the first randomized trial addressing the prehospital triage of acute stroke patients based on the distribution of thrombolysis centers and intervention centers in Catalonia, Spain. The study compared the drip‐and‐ship with the mothership paradigm in regions where a local thrombolysis center can be reached faster than the nearest intervention center (equipoise region). The present study aims to determine the population‐based applicability of the results of the RACECAT study to 4 stroke networks with a different degree of clustering of the intervention centers (clustered, dispersed). Methods and Results Stroke networks were compared with regard to transport time saved for thrombolysis (under the drip‐and‐ship approach) and transport time saved for endovascular therapy (under the mothership approach). Population‐based transport times were modeled with a local instance of an openrouteservice server using open data from OpenStreetMap.The fraction of the population in the equipoise region differed substantially between clustered networks (Catalonia, 63.4%; France North, 87.7%) and dispersed networks (Southwest Bavaria, 40.1%; Switzerland, 40.0%). Transport time savings for thrombolysis under the drip‐and‐ship approach were more marked in clustered networks (Catalonia, 29 minutes; France North, 27 minutes) than in dispersed networks (Southwest Bavaria and Switzerland, both 18 minutes). Conclusions Infrastructure differences between stroke networks may hamper the applicability of the results of the RACECAT study to other stroke networks with a different distribution of intervention centers. Stroke networks should assess the population densities and hospital type/distribution in the temporal domain before applying prehospital triage algorithms to their specific setting.

M.G. has received grants from the Swiss Academy of Medical Sciences/Bangerter‐Rhyner‐Foundation, Swiss Stroke Society, and Mittelbauvereinigung der Universität Bern as well as a congress grant from Pfizer, not related to this project. J.G. reports being global co‐principal investigator of the STAR Study, NCT01327989; consultancy Medtronic; global co‐principal investigator of SWIFT DIRECT, NCT03192332; consultancy Medtronic; principal investigator: Stroke treatment goes personalized: Gaining added diagnostic yield by computer‐assisted treatment selection (the STRAY‐CATS project), Swiss National Funds 170 060. J.K. reports grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, and Clinical Trials Unit Bern during the conduct of the study. T.R.M. reports grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss National Science Society, and Swiss Heart Foundation during the conduct of the study. U.F. reports research grants from Medtronic for the SWIFT DIRECT trial and BEYOND SWIFT registry, Swiss National Science Foundation, Swiss Heart Foundation; consulting fees from Medtronic, Stryker, and CSL Behring (fees paid to institution); membership of a Data Safety Monitoring Board for the IN EXTREMIS trial and TITAN trial and Portola (Alexion), advisory board (fees paid to institution); and vice presidency of the Swiss Neurological Society. The remaining authors have no disclosures to report.