Evaluating Transport Strategies and Local Hospital Impact on Stroke Outcomes: A RACECAT Trial Substudy

The optimal strategy for transferring patients to specialized acute stroke care remains controversial. This substudy of the Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients with suspected Large-Vessel Occlusion Stroke in Nonurban Areas (RACECAT) trial aims to investigate the impact of local hospital characteristics and performance on the optimal transport strategy and stroke outcomes.

This was a secondary post hoc analysis of the RACECAT trial, evaluating factors potentially associated with functional outcomes among patients initially evaluated at a local stroke center (Local-SC) versus a thrombectomy-capable center. The primary outcome was the shift in the 90-day modified Rankin Scale score in the target population of the RACECAT trial. Door-to-needle time, level of care of the Local-SC (telestroke versus primary stroke center), the specialty of the physician involved with therapeutic decisions, and Local-SC case volume were assessed for subgroup analyses.

Of the 1367 patients included in the analysis, 903 had acute ischemic strokes (modified intention to treat). The 90-day modified Rankin Scale score was associated with door-to-needle time in the entire modified intention-to-treat cohort (P = 0.026) and in patients initially evaluated in a Local-SC (P = 0.063), and with local hospital level of care (telestroke versus primary stroke center; P = 0.10). There was a trend favoring direct transport to thrombectomy-capable center for patients whose assigned Local-SC was a telestroke center (adjusted odds ratio [OR], 1.47 [95% CI, 0.93-2.33] versus 0.94 [95% CI, 0.71-1.24]; P _interaction = 0.08) or had door-to-needle time over the global median (adjusted OR, 1.52 [95% CI, 0.97-2.40] versus 0.94 [95% CI, 0.71-1.25]; P _interaction = 0.06). In patients with confirmed large-vessel occlusion, the benefit of direct transport to thrombectomy-capable centers when the Local-SC was a telestroke center (P _interaction = 0.04) or had longer door-to-needle time (P _interaction = 0.07) was more evident.

Direct transport to thrombectomy-capable centers may be preferable in areas primarily covered by telestroke or Local-SCs with poorer performance, especially in patients with large-vessel occlusion. These findings can contribute to refining prehospital triage strategies and optimizing stroke systems of care.