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Rationale and design for studying organisation of care for intra-arterial thrombectomy in the Netherlands: simulation modelling study
  1. Maarten M H Lahr1,
  2. Willemijn J Maas1,2,
  3. Durk-Jouke van der Zee3,
  4. Maarten Uyttenboogaart2,4,
  5. Erik Buskens1,3
  1. 1 Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
  2. 2 Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
  3. 3 Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
  4. 4 Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
  1. Correspondence to Dr Maarten M H Lahr; m.m.h.lahr{at}


Introduction The introduction of intra-arterial thrombectomy (IAT) challenges acute stroke care organisations to provide fast access to acute stroke therapies. Parameters of pathway performance include distances to primary and comprehensive stroke centres (CSCs), time to treatment and availability of ambulance services. Further expansion of IAT centres may increase treatment rates yet could affect efficient use of resources and quality of care due to lower treatment volume. The aim was to study the organisation of care and patient logistics of IAT for patients with ischaemic stroke in the Netherlands.

Methods and analyses Using a simulation modelling approach, we will quantify performance of 16 primary and CSCs offering IAT in the Netherlands. Patient data concerning both prehospital and intrahospital pathway logistics will be collected and used as input for model validation. A previously validated simulation model for intravenous thrombolysis (IVT) patients will be expanded with data of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry and trials performed in the Collaboration for New Treatments in Acute Stroke consortium to represent patient logistics, time delays and outcomes in IAT patients. Simulation experiments aim to assess effectiveness and efficiency of alternative network topologies, that is, IAT with or without IVT at the nearest primary stroke centre (PSC) versus centralised care at a CSC. Primary outcomes are IAT treatment rates and clinical outcome according to the modified Rankin Scale. Secondary outcomes include onset-to-treatment time and resource use. Mann-Whitney U and Fisher’s exact tests will be used to estimate differences for continuous and categorical variables. Model and parameter uncertainty will be tested using sensitivity analyses.

Ethics and dissemination This will be the first study to examine the organisation of acute stroke care for IAT delivery on a national scale using discrete event simulation. There are no ethics or safety concerns regarding the dissemination of information, which includes publication in peer-reviewed journals and (inter)national conference presentations.

Trial registration number ISRCTN99503308, ISRCTN76741621, ISRCTN19922220, ISRCTN80619088, NCT03608423; Pre-results.

  • stroke
  • stroke medicine
  • epidemiology
  • organisation of health services

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  • Contributors MMHL, WJM, D-JvdZ, MU and EB designed the study with MU and EB as principal investigators. MMHL, MU and EB applied for, received and organised the study funding. MMHL drafted the manuscript. WJM, D-JvdZ, MU and EB critically revised the manuscript for intellectual content and approved the final version of the manuscript for publication.

  • Funding The Collaboration for New Treatments in Acute Stroke consortium is supported by Netherlands Cardiovascular Research Initiative, an initiative of the Dutch Heart Foundation, by the Brain Foundation Netherlands and powered by Health~Holland, Top Sector Life Sciences, and receives unrestricted funding from Medtronic.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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