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International Journal of Stroke 18(2)
Figure 3. Time-series plots overlapping LOESS smoothing line (solid) with 95% confidence intervals (shadowed area): (a)
median time from door to image, (b) median time from door to needle in local versus comprehensive SCs (CSC), and (c) median
time from Local-SC arrival to groin puncture for drip-and-ship patients.
and P3: 13 (44.1%) (p = 0.28). The average number of
EVT in TRC, increased from P1: 0.6 (0.4% of patients
evaluated in a Local-SC) to P2: 1 (0.8%) and P3: 1 (3.6%)
(p < 0.001).
In Local-SC, we observed a progressive reduction in
DTI (P1: 24 (IQR 15-36), P2: 24 (15-35), P3: 21 (13-
31.5) min, p < 0.001) and DTN times (P1: 42 (31-60), P2:
41 (29-58), P3: 35 (25-50), p > 0.001). In P1, in-hospital
workflow times were shorter at CSCs (DTI 20 (13-29)
and DTN 33 (25-42) min, p < 0.001); however, at the
end of the study period (P3), Local-SC achieved similar
performance than CSC (Table 2; Figure 3; Supplemental
Table S2).
Among patients following a drip-and-ship protocol,
DIDO also tended to improve over the three time periods
(P1: 86 (68-111) vs. P2: 87 (66-110) vs. P3: 79 (64-104)
min, p = 0.108)). Median time from Local-SC arrival to
groin puncture decreased from P1: 188 (151-229) and
P2: 190 (157-233) to P3: 168 (127-215) min (p < 0.001)
(Table 2; Figure 3; Supplemental Table S2) and the median
time from symptom onset to groin puncture at each period
was P1: 296 (228-376), P2: 326 (235-515), and P3: 289
(220-489) min (p = 0.495).
International Journal of Stroke, 18(2)
Discussion
Our study assessed the evolution of acute stroke key performance
indicators in the areas of Catalonia covered by different
types of SC during a 3-year period. The main finding of
our study is that the higher-than-expected increase in the
EVT rates observed within the RACECAT trial was in fact
extended to the whole population. During the first time
period, prior to the start of the trial, annual EVT rates were
similar to those reported in earlier years in our region3; however,
during trial conduction, we found a progressive reduction
in the EVT-access gap between geographical areas.
Critical changes in acute stroke management that
occurred during this period may explain the increase in
EVT rates among stroke patients: indications of EVT were
expanded to include patients in an extended time window.11
Moreover, despite not being supported by current guidelines,
in many centers, EVT is increasingly being offered to
patients for whom EVT benefits are still uncertain (e.g.
higher premorbid Rankin scale, lower NIHSS, and lower
ASPECTS scores). Accordingly, we found a 30% relative
increase in the rate of EVT in areas covered by CSC; however,
in regions covered by Local-SC, the rate of EVT

WSO - February 2023

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