Door-in-door-out times and outcomes in patients with acute ischaemic stroke transferred for endovascular therapy in the USA: a retrospective cohort study.

Abstract

Many patients with acute ischaemic stroke require interhospital transfer for endovascular therapy. We sought to determine whether door-in-door-out (DIDO) time is associated with functional outcomes. We conducted a retrospective cohort study of patients with acute ischaemic stroke and a visualised target occlusion on cerebrovascular imaging who were transferred from acute care hospitals to hospitals participating in the US nationwide Get With The Guidelines-Stroke registry for endovascular therapy evaluation between Jan 1, 2019, and Dec 31, 2023. The primary exposure was DIDO time (time from arrival to discharge from the presenting emergency department). Patients were followed up until hospital discharge. The primary outcome was ordinal modified Rankin Scale (mRS) score at hospital discharge, from which we calculated the odds of a 1-point increase (ordinal shift) in the mRS score at discharge. Secondary outcomes were mRS dichotomies (mRS score 3-6 vs 0-2 and mRS score 4-6 vs 0-3), receipt of endovascular therapy, discharge ambulatory status, and complications after reperfusion therapy. We used generalised linear mixed models with sequential adjustment for demographics, risk factors, receiving hospital, and clinical characteristics. Among 22 410 patients with acute ischaemic stroke (median age 70 years [IQR 60-80]; 11 236 [50·1%] female; 16 558 [73·9%] White, 3146 [14·0%] Black or African American, 1338 [6·0%] Hispanic) transferred for endovascular therapy evaluation, median DIDO time was 121 min (IQR 89-175). Endovascular therapy was performed in 16 976 (75·8%) patients at the receiving hospital. Compared with 90 min or less, longer DIDO times were associated with higher odds of a 1-point increase in mRS score at discharge (91-180 min: adjusted odds ratio [aOR] 1·29, 95% CI 1·20-1·37; 181-270 min: 1·49, 1·36-1·64; >270 min: 1·70, 1·53-1·89) and lower odds of endovascular therapy receipt (91-180 min: 0·71, 0·65-0·79; 181-270 min: 0·50, 0·44-0·57; >270 min: 0·35, 0·30-0·40). Results were similar for mRS dichotomies. Longer DIDO time was also associated with reduced independent ambulation and increased complications after reperfusion therapy. Longer DIDO times were strongly associated with lower rates of endovascular therapy, higher rates of complications, and worse functional outcomes. System-level strategies to minimise DIDO time are essential to optimise acute ischaemic stroke care and improve outcomes. None.