Mobile stroke units: filling gaps in prehospital stroke care
Perez, Stephen Benjamin
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Acute ischemic stroke (AIS) is a major cause of death and disability in the United States. With advancements in therapeutic reperfusion, it has become clear that improving time-to-treatment is among the most important factors in yielding better outcomes for patients. When AIS occurs in the community, away from readily available interventions, timely recognition and transport are paramount to decreasing the time-to-treatment and ultimately increasing rates of reperfusion and reducing morbidity and mortality. Over the past several years, investigations have launched studying the efficacy of mobile stroke units (MSU) in reducing the morbidity and mortality burden of AIS. MSUs are specially designed transport vehicles, run by trained expert stroke management personnel, and stocked with diagnostic imaging equipment in the form of computed tomography scanners and fibrinolytic therapy. In a number of prospective study designs comparing MSUs to standard management by emergency medical services, researchers have utilized several endpoints including time-to-treatment, rates of symptom resolution, and long-term recovery from AIS. These studies have generally demonstrated better outcomes with MSUs and provided evidence for the efficacy of the MSU model in treating AIS. However, most studies have been limited to metropolitan regions of the country, and no randomized-controlled trials have been completed, although one is currently underway. There is little evidence, however, evaluating the cost-effectiveness of MSUs in the management of AIS. The expense of constructing and operating these specialized vehicles over ten years has been estimated to be millions of dollars, while the cost of a single case of AIS can range anywhere from the cost of the emergency department visit to the inclusion of long-term care from resultant sequelae depending on the patient outcome. It remains unclear to what degree the upfront investment in quicker management for AIS is capable of producing downstream cost savings for the healthcare system in the setting of demonstrated improved outcomes. In this study, I propose a method of cost-effectiveness analysis to compare the MSU model to standard management of AIS occurring in metropolitan communities to determine whether MSUs are cost-effective, or possibly cost-saving.