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BEnefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU)

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ClinicalTrials.gov Identifier: NCT02190500
Recruitment Status : Recruiting
First Posted : July 15, 2014
Last Update Posted : September 6, 2018
Sponsor:
Collaborators:
The University of Texas Health Science Center, Houston
Baylor College of Medicine
CHI St. Luke's Health, Texas
City of Houston Fire Department
The Methodist Hospital System
West University Fire Department
City of Bellaire Fire Department
Ben Taub Hospital
Harris Health
Patient-Centered Outcomes Research Institute
Information provided by (Responsible Party):
James Grotta, MD, Memorial Hermann Health System

Brief Summary:
The primary goal of this project is to carry out a trial comparing pre-hospital diagnosis and treatment of patients with stroke symptoms using a Mobile Stroke Unit (MSU) with subsequent transfer to a Comprehensive Stroke Center (CSC) Emergency Department (ED) for further management, to standard pre-hospital triage and transport by Emergency Medical Services (EMS) to a CSC ED for evaluation and treatment (Standard Management-SM).

Condition or disease Intervention/treatment
Acute Ischemic Stroke Other: Mobile Stroke Unit Management

Detailed Description:

There are many ways that use of a MSU might prove valuable in stroke patients, but we will focus on acute ischemic stroke (AIS) and treatment with IV tissue plasminogen activator (tPA) within 4.5 hours of symptom onset since that is the most evidence based effective emergency treatment for the most prevalent stroke diagnosis. We hypothesize that the MSU pathway will result in an overall shift towards earlier evaluation and treatment, particularly into the first hour after symptom onset, leading to substantially better outcome. We also hypothesize that as a result of improved clinical outcomes resulting from earlier treatment, the costs of a MSU program will be offset by a reduction in the costs of long term stroke care and increase in quality adjusted life years, thereby supporting more widespread use of this technology. To make MSU deployment more practical, we will confirm that a Vascular Neurologist (VN) on board the MSU can be replaced by a remote VN connected to the MSU by telemedicine (TM) thereby reducing manpower requirements and costs.

The successful completion of this project will provide data on important outcomes and costs associated with the use of MSU vs SM in the United States (U.S.) that will help determine the value of integrating MSUs into the pre-hospital environment in this country. Successfully addressing our three Specific Aims (time saved/ complications encountered, utility of TM, and cost effectiveness) will provide critical information that will be needed to determine if and how a subsequent more definitive study should be conducted. We anticipate that emanating from this exploratory study would be a larger multicenter trial carried out in both urban and rural U.S. pre-hospital environments, with treatment orchestrated via TM, and having sufficient power to determine a difference in long term outcome and costs between patients managed on the two pathways, following a study design that will be tested in this exploratory trial. The present study, therefore, is the necessary first step in a process which may dramatically modify the way that acute stroke patients are managed in the U.S.


Study Type : Observational
Estimated Enrollment : 1200 participants
Observational Model: Cohort
Time Perspective: Prospective
Official Title: BEnefits of Stroke Treatment Delivered Using a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services:The BEST-MSU Study
Study Start Date : August 2014
Estimated Primary Completion Date : January 2021
Estimated Study Completion Date : August 2021

Resource links provided by the National Library of Medicine


Group/Cohort Intervention/treatment
Mobile Stroke Unit Management
Acute ischemic stroke patients treated in the Mobile Stroke Unit
Other: Mobile Stroke Unit Management
Mobile Stroke Unit is a standard 12' Houston Fire Department ambulance equipped with point of care lab, CT scanner and staffed by a Vascular Neurologist, Registered Nurse with acute stroke and research experience, CT Technician and a Registered EMT-P. The MSU is dispatched in coordination with Houston, Bellaire and West University fire department/emergency medical services.

Standard Management
Acute ischemic stroke patients receiving standard management



Primary Outcome Measures :
  1. Utility-weighted modified Rankin Scale (uw-mRS) from baseline to 90 days [ Time Frame: 90 days (+/- 10 days) from date of enrollment ]
    Comparing patients found eligible for tPA (based on a blinded review of the patient's chart, regardless of whether they were treated or not) on MSU weeks compared to SM weeks. With a sample size of 693 total tPA-eligible patients (446 MSU and 247 SM patients, assuming 10% lost to follow-up), the study will have 80% power with a 0.05 Type I error rate to detect a difference between groups of 0.09 in the mean uw-mRS using a two-sample t-test.At total of 693 tPA treated patients will allow 85% power to detect a 25 min decrease in time to treatment between the two groups using a one- sided alpha level of 0.05

  2. Agreement between on scene Vascular Neurologist vs. Remote (Telemedicine) Vascular Neurologist [ Time Frame: up to 4.5 hours from symptom onset ]
    The agreement between a VN remotely assessing a suspected stroke patient via TM in the MSU and in-person assessment by a VN in the MSU will be assessed by using the Kappa statistic. We anticipate that the estimated sample size of 162 is needed to allow us 90 % power to detect 90% agreement between the in-person assessment and the TM.

  3. Cost Effectiveness (N.B. The BEST-MSU study including measurement of heatlhcare utilization is funded by PCORI. The cost-effectiveness measures are not covered by PCORI funding and will be reported separately) [ Time Frame: up to 1 year from date of enrollment ]
    Cost Effectiveness as measured by average patient QALYs, post-stroke healthcare utilization, incremental fixed costs associated with MSU and the per-patient incremental fixed cost due the ambulance outfitting, CT, other equipment, telemedicine technology and staffing requirements.


Secondary Outcome Measures :
  1. 90 day Modified Rankin Score [ Time Frame: 90 days (+/- 10 days) from date of enrollment ]
    90 day Modified Rankin Score 0,1 vs 2-6, and ordinal shift analysis, of patients treated with tPA within 60 minutes of symptom onset according to published guidelines on either MSU or SM weeks, compared to similar patients treated 61-270 minutes after onset, adjusting for any imbalances in stroke severity (baseline NIHSS) between the groups at the time of treatment.

  2. 90 day Modified Rankin Score [ Time Frame: 90 days (+/- 10 days) from date of enrollment ]
    90 day Modified Rankin Score 0,1 vs 2-6, and ordinal shift analysis, of all patients meeting published guidelines for treatment with tPA within 4.5 hours of symptom onset (whether eventually treated or not) on MSU weeks compared to patients meeting the same criteria (whether treated or not) on SM weeks, adjusting for any imbalances in stroke severity (baseline NIHSS) between the groups at the time of treatment.

  3. Time from symptom onset to tPA treatment [ Time Frame: up to 4.5 hours from symptom onset ]
    The time from LSN to tPA treatment on all patients treated within 4.5 hours of LSN on MSU weeks compared to similarly eligible patients on SM weeks.

  4. Time from symptom onset to Endovascular treatment [ Time Frame: up to 6 hours from symptom onset ]
    The time from LSN and from ED arrival to start of endovascular procedure (intra-arterial thrombectomy-IAT) in patients who meet pre-specified criteria for IAT on MSU weeks compared to SM weeks.

  5. Symptomatic intracranial hemorrhage and mortality [ Time Frame: up to hospital discharge ]
    The incidence of symptomatic intracranial hemorrhage (sICH) and mortality in tPA treated patients on MSU weeks compared to SM weeks (Symptomatic intracranial hemorrhage defined as any intracranial blood accumulation associated with a clinical deterioration of 4 points of the NIHSS for which the hemorrhage has been identified as the dominating cause of the neurologic deterioration)

  6. Stroke mimics [ Time Frame: up to hospital discharge ]
    The incidence of stroke mimics and transient ischemic attacks (TIAs) in tPA treated patients on MSU weeks compared to SM weeks.



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Sampling Method:   Probability Sample
Study Population

To be assessed for eligibility (n = 6000) To be enrolled (n = 1200) To be analyzed ("tPA eligible") (n =693 or the total number enrolled by close of enrollment on 8/31/19).

Based on our pilot data in the first 9 months of operation, the MSU is being alerted and dispatched by Criteria 1 above approximately 5 times for every patient that is enrolled into the study by Criteria 2, and 10 times for every patient treated with tPA by Criteria 3. Therefore, we anticipate that slightly over 50% of enrolled patients will be treated with tPA. We calculate that we will need 693 tPA eligible patients (meeting above Criteria 1, 2 and 3) to answer SA 1 allowing for 10% lost to f/u (see Statistical Methods).

Criteria

Inclusion Criteria:

  • Last seen normal within 4hr 30 min of symptom onset
  • History and physical/neurological examination consistent with acute stroke
  • No tPA exclusions per guidelines, prior to CT scan or baseline labs
  • Informed consent obtained from patient (if competent) or legal representative.

Exclusion Criteria:


Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02190500


Contacts
Contact: James Grotta, MD 832-325-7296 james.c.grotta@uth.tmc.edu
Contact: Stephanie Parker, RN,BSN 713-500-6116 stephanie.a.parker@uth.tmc.edu

Locations
United States, Texas
University of Texas Health Science Center, Houston Recruiting
Houston, Texas, United States, 77030
Contact: Stephanie Parker, RN,BSN    713-500-6116    stephanie.a.parker@uth.tmc.edu   
Contact: Yvette Sanders    8323257296    Yvette.Sanders@uth.tmc.edu   
Principal Investigator: James C Grotta, MD         
Sponsors and Collaborators
Memorial Hermann Health System
The University of Texas Health Science Center, Houston
Baylor College of Medicine
CHI St. Luke's Health, Texas
City of Houston Fire Department
The Methodist Hospital System
West University Fire Department
City of Bellaire Fire Department
Ben Taub Hospital
Harris Health
Patient-Centered Outcomes Research Institute
Investigators
Principal Investigator: James C Grotta, MD Memorial Hermann

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: James Grotta, MD, Principal Investigator, Memorial Hermann Health System
ClinicalTrials.gov Identifier: NCT02190500     History of Changes
Other Study ID Numbers: HSC 13-0322
First Posted: July 15, 2014    Key Record Dates
Last Update Posted: September 6, 2018
Last Verified: September 2018

Keywords provided by James Grotta, MD, Memorial Hermann Health System:
stroke
tpa
emergency medical service
ems
mobile
ct scan

Additional relevant MeSH terms:
Stroke
Cerebrovascular Disorders
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Vascular Diseases
Cardiovascular Diseases