HIQA review recommends national emergency endovascular service for acute stroke in Ireland
A health technology assessment (HTA) published today by the Health Information and Quality Authority has recommended establishment of a national emergency service providing next-generation stroke therapy in two hospital sites in Ireland for selected stroke patients. This treatment would be in addition to the standard medical care for stroke.
In comprehensive stroke centres, the HIQA HTA found that endovascular treatment with mechanical thrombectomy using tiny devices to physically retrieve clots from the brain is safe and effective when provided in addition to the current standard medical care. This procedure needs to be carried out within six to 12 hours of onset of symptoms of an acute ischaemic stroke.
Dr Máirín Ryan, HIQA’s Deputy Chief Executive and Director of Health Technology Assessment, commented: “Based on doing 268 procedures a year in carefully selected patients, an additional 57 patients are predicted to regain functional independence at 90 days after a stroke. This represents a substantial improvement, with almost 60% regaining functional independence compared with less than 40% without the procedure.”
“Mechanical thrombectomy in conjunction with the current standard medical care is significantly more likely to result inpatients who have had a stroke regaining functional independence.The evidence is conditional on the procedure being used with non-invasive arterial imaging, in selected patients, and when using newer stent-retriever devices to remove blood clots from the brain.
“Expanding access to mechanical thrombectomy in Ireland has implications for the organisation of acute stroke service to ensure efficient presentation, identification and treatment of patients in the first hours after the onset of the symptoms of a stroke.” The findings have been presented as advice to Minister for Health and the Health Service Executive (HSE).
HIQA’s HTA also found that an organised national service would need detailed planning to ensure it adheres to quality standards. An equitable, high quality and cost-effective national service can only be provided if the procedure is offered in a small number of centres that are adequately resourced and sited to maximise patient access, workforce expertise and geographical coverage.
Dr Ryan concluded: “Ensuring equitable access to and benefit from mechanical thrombectomy will require the existing regional variability in timely access to acute stroke care and stroke services to be addressed. There are significant organisational and resource implications also for the National Ambulance Service to ensure the timely transfer of patients to the national treatment centres and to repatriate them to their local acute stroke service post-procedure without compromising provision of ambulance services for other patients.”
Marty Whelan, Head of Communications and Stakeholder Engagement, HIQA, 01 814 7480 / 086 2447 623, firstname.lastname@example.org
Notes to editors
- Acute ischaemic stroke happens when there is a sudden loss of blood flow to an area of the brain due to an obstruction of a blood vessel, most commonly due to a clot. This obstruction impairs brain function. Symptoms and signs of stroke include:
- loss of vision in one or both eyes
- impaired speech
- muscular weakness or paralysis on one side of the body (including facial droop, arm drift or leg weakness).
- Each year in Ireland an estimated 10,000 people have a stroke-related event and an estimated 2,000 people die as a result of stroke.
- In Ireland, approximately 4,300 people are admitted to hospital following an acute ischaemic stroke each year. Approximately 30,000 people live in the community with disabilities as a result of stroke.
- Mechanical thrombectomy procedures have been provided in Ireland by specialist neuroendovascular radiologists in Beaumont Hospital and Cork University Hospital. Approximately 200 procedures were undertaken in 2016. However, in the absence of an organised national service, access to this procedure is not equitable.
- The five-year budget impact of a national emergency mechanical thrombectomy service compared to no service is estimated in HIQA’s HTA at €7.2 million, comprising €3.3 million in the first year and annual running costs afterwards estimated at €0.8 to €1.2 million based on treating 268 patients each year. Moving from the current ad hoc service, through which 200 patients were treated last year using existing facilities, to a national service resourced with one new additional biplane angiographic suite would cost an additional €2.8 million over five years with €2 million of this incurred in the first year.
- Intravenous thrombolysis (anti-blood-clotting drugs injected into a vein to dissolve the clot) is part of standard medical care for the management of acute ischaemic stroke. In order for it to be effective and provide maximum benefit, it must be administered within 4.5 hours of the onset of stroke symptoms.
- Endovascular therapy using mechanical thrombectomy devices aim to physically break up or retrieve clots and rapidly restore blood flow. This procedure is indicated as an addition to standard medical care in selected patients.
- HTA supports evidence-based decision-making in relation to making best use of resources in healthcare services. Measured investment and disinvestment decisions are essential to ensure that overall population health gain is maximised.