Global Access to Mechanical Thrombectomy Significantly Low, Study Suggests
Among countries with non-zero mechanical thrombectomy access, there was a 460-fold difference in availability of this care between the country with the highest and lowest access rate reported.
Dileep Yavagal, MD
Recently published data from the large-scale, global, MT-GLASS survey study showed that access to mechanical thrombectomy (MT) is extremely low, with significant disparities between countries by income level.
Published in Circulation, this was the first-ever global analysis of access to mechanical thrombectomy. The study was conducted throughout 75 countries using the Mission Thrombectomy global network of regions between November 2020 and February 2021, and received participation from 887 responses in 67 countries. The primary end point were the current annual MT access (MTA), MT operator availability (MTOA), and MT center availability (MTCA), with MTA defined as the estimated proportion of patients with large vessel occlusion (LVO) receiving MT in a given region annually.
The median global MTA for the analysis was 2.79 (interquartile range [IQR], 0.70-11.74), with median rates of 21.56% (IQR, 10.04-32.65) for those in high-income countries (HICs) and rates of 0.48% (IQR, 0.00-1.13) in lower- or middle-income countries (LMICs)(P <.001). About one-third (n = 18) of the surveyed countries had an MTA of less than 1.0%, as well as 7 countries that reported no MT access at all. Among countries with nonzero MT capacity, there was a 460-fold difference in MTA between the country with the highest (Australia) and the lowest (Bangladesh).
"The study findings validate why we founded Mission Thrombectomy in 2016 and our continued mission that has now grown to include 95 countries," corresponding author Dileep Yavagal, MD, chair of the Mission Thrombectomy Initiative, and past president and co-founder of the Society of Vascular and Interventional Neurology (SVIN), said in a statement. “The global access to thrombectomy is dismally low with the country's income level, pre-hospital protocols to bypass non-thrombectomy centers, and operators and thrombectomy center availability all playing critical roles in thrombectomy access in a given region."
The secondary outcomes were the number of MT-capable centers, MT operators, and the yearly MT volume of each country. For numerical survey responses, investigators calculated the median, while mode was used for dichotomous "yes/no" responses. The available metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150, with multivariable-adjusted generalized linear models to assess factors associated with MTA.
Compared with HIC, MT was 88% lower (mean ratio, 0.12; 95% CI, 0.06-0.25) in LMIC and 66% lower (mean ratio, 0.34; 95% CI, 0.29-0.60) in UMIC. In terms of MTAO, HIC had significantly greater rates (35.52%) compared with LMIC (4.51%; P <.001). Additionally, MT operators in LMIC performed fewer MTs when compared with those in upper- or middle-income countries (UMIC) and HIC, despite LMIC having lower MTOA. Between countries with the highest (Japan) and lowest (Bangladesh) nonzero availability for MTOA and MTCA, there were 128-fold and 67-fold differences recorded, respectively.
Increased odds of MTA were linked with country’s per capita gross net income (GNI), prehospital LVO triage policy, and MTOA and MTCA. Each percentage increase in MTOA (OR, 3.35; 95% CI, 2.07-5.42) or MTCA (OR, 2.86; 95% CI, 1.84-4.48) was associated with around 300% greater odds of MTA. Notably, there was a 4-fold increase in the odds of MTA in countries with stroke protocol with prehospital triage of patients with LVO stroke to MT-capable centers relative to those without.
"Mechanical thrombectomy has proven to be a highly effective therapy for mitigating death and disability since 2015, and it is the largest advancement in stroke treatment in 30 years. Given the widely distributed global burden of stroke, it is critical to have rapid access to MT worldwide in an equitable manner. In the US Stroke is now the number 5 killer but in the rest of the world it is still number 2," Ameer E. Hassan, DO, president, SVIN, professor, University of Texas Rio Grande Valley, and head, Neuroscience, Valley Baptist Neuroscience Institute, said in a statement.1 "The findings highlight distressing results on a global scale, and represent many lives that could have been saved or significantly improved with better access to thrombectomy treatments."
Although not significant on multivariable models, investigators found that reimbursement for MT, presence of prehospital medical service, and emergency medical services education on acute stroke were each associated with increased odds of MTA on univariable models. Presence of cultural barriers to MT were associated with at least a 50% lower odds of MT (OR, 0.41; 95% CI, 0.24-0.70).
