Bringing thrombectomy to rural patients: functional outcome and cost-utility of a flying intervention team versus secondary interhospital transfer

Background Timely access to mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke remains challenging in rural regions, where secondary interhospital transfer can cause major treatment delays. Flying intervention teams (FITs), in which the neurointerventionalist travels to the patient, have been shown to reduce time to treatment in a controlled trial, but real-world clinical and health economic data are limited. Methods This retrospective cohort study used prospectively collected data from the rural TEMPiS telemedicine network in Southeast Bavaria, Germany. Consecutive patients with acute ischemic LVO stroke and an indication for MT were treated either by an on-site FIT in regional hospitals or after secondary transfer to a tertiary stroke center. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Secondary outcomes were key process times, modeled lifetime quality-adjusted life years (QALYs), and an exploratory cost-utility analysis from a health service perspective. Results A total of 492 patients were included (322 FIT, 170 secondary transfer). Baseline characteristics were comparable between groups. Decision-to-groin time was markedly shorter with FIT than with secondary transfer (median 69 vs 140 min; mean 70.93 vs 147.17 min; P<0.001). The overall ordinal 90-day mRS distribution did not differ significantly (P=0.271), whereas the pre-specified dichotomy of mRS 0–3 versus 4–6 favored FIT (OR 1.50, 95% CI 0.99 to 2.28; P=0.048). Modeled lifetime QALYs were numerically higher with FIT (2.27 vs 1.78 per patient; bootstrap mean difference 0.291, 95% CI −0.109 to 0.711). Restricted to acute inpatient costs, the incremental cost-utility ratio was €16 651 (parametric) and €28 038 (bootstrap) per QALY gained. Conclusions Within a rural telemedicine network, a FIT strategy was associated with a substantially shorter interval from treatment decision to arterial puncture and a higher probability of avoiding functionally unfavorable outcomes at 90 days. Modeled lifetime QALYs were numerically higher with FIT, but the clinical and economic findings were subject to considerable uncertainty. These results support prospective evaluation of FIT as an organizational approach to improve access to thrombectomy in rural regions.