title: [Thrombolysis in acute ischemic stroke in centers lacking a stroke unit: referral to reference center or on-site treatment?].
abstract: OBJECTIVE
  To assess the clinical impact of on-site thrombolysis versus referral to another hospital in patients with ischemic stroke attended in a hospital lacking a stroke unit.
  
  
  METHODS
  Expected value decision analysis and Monte Carlo simulation.
  
  
  METHODS
  Decision analysis based on a cohort study (SIT-MOST) and a meta-analysis of randomized trials of thrombolysis versus placebo in patients with acute ischemic stroke.
  
  
  METHODS
  On-site thrombolysis (in hospitals lacking a stroke unit) versus delayed thrombolysis in a reference hospital.
  
  
  RESULTS
  Neurological outcome (modified Rankin scale) three months after admission according to the delay in the administration of thrombolysis.
  
  
  RESULTS
  At baseline (initial delay of 135 min, travel time 60 minutes), on-site treatment was more effective than referral to another hospital (number of patients with favorable neurological outcome 45.3% versus 41.3%). In patients seen within 45 minutes of the onset of symptoms, for every 10 patients transferred there was an additional case with an unfavorable neurological outcome that could have been avoided with on-site thrombolysis. In the Monte Carlo analysis, biased against on-site treatment by a reduction in effectiveness of 30%, on-site treatment was superior to patient referral in 77.2% of the cases.
  
  
  CONCLUSIONS
  The available evidence does not support the recommendations of the national stroke strategy or some regional plans that discourage the administration of thrombolysis in hospitals without stroke units.
authors.affiliation: Servicio de Medicina Intensiva, Hospital General Universitario de Elche, Elche, Alicante, España. jlatour@coma.es
authors.forename: J
authors.initials: J
authors.lastname: Latour-Pérez
authors.forename: P
authors.initials: P
authors.lastname: Galdos Anuncibay
mesh_terms: D006801:Humans; D001925:Brain Damage, Chronic / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D002545:Brain Ischemia / Q000188:drug therapy; D015331:Cohort Studies; D003198:Computer Simulation; D003663:Decision Trees; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D005500:Follow-Up Studies; D006757:Hospital Units; D008962:Models, Theoretical; D010360:Patient Transfer; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D012017:Referral and Consultation; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents