We are grateful to the following individuals and groups:Peter Dodds (stroke survivor; co-applicant and Programme Steering Committee member).Bill Laing (stroke survivor; PASTA TSC member).Melissa Roberts (carer; PASTA TSC member).David Burgess (carer; WP2 group member).The NIHR Clinical Research Network North-East Stroke Patient and Carer Research Panel.The National Lay Member Stroke Research Network.All of the patients who took part in the PASTA trial, stakeholder engagement and surveys.
The following ambulance services assisted with the development and evaluation of the PASTA intervention: NEAS NHS Foundation Trust, North West Ambulance Service NHS Foundation Trust, and Welsh Ambulance Service NHS Trust. We would particularly like to thank Chris Moore (Welsh Ambulance Service) and Andy Mawson (Great North Air Ambulance).
We also thank the external Data Monitoring Committee members [Tom Robinson (chairperson), Caroline Watkins, Tom Quinn and Chris Sutton] and TSC members [Charles Wolfe (chairperson), Martin James, Niro Siriwardena, Amanda Farrin, Olivia Wu, Christine Roffe, Damian Jenkinson and Michael Speed].
We are grateful for the administration support provided by Liam Dale, Deborah Jones, Anne Harrison and Clare Bowes.
We also want to acknowledge the assistance provided by the following individuals:Amy Crowder (NIHR Clinical Research Network North East and North Cumbria).Dominic Brand (The Stroke Association, London, UK).Terry Flynn (TF Choices Ltd, Nottingham, UK).Tomos Robinson (Newcastle University).Kai Wai Lee (Newcastle University).Stephen Rice (Newcastle University).Daniel Nesbitt (Newcastle University).
Contributions of others
Gary A Ford, Christopher I Price, Phil White, Luke Vale, Peter McMeekin, Helen Snooks, Ian Russell (retired), Catherine Exley, Pippa Tyrrell (retired), Paul Fell and Peter Dodd were responsible for the original proposal and for securing funding.
The papers described in this report and listed as outputs have author lists that reflect the contributions of individuals funded by the programme and external collaborators. Those individuals who are not report authors but are co-authors on a programme output are thanked and acknowledged below.
Work package 1
Richard Francis, Saiful Islam, Medhi Javanbakht, Rachel Lakey, Graham McClelland, Shannon Robalino, Helen Rodgers and Lou Sutcliffe.
Work package 2
Michael Allen, Ajay Bhalla, Alastair Buchan, Jayan Chembala, Adela Cora, Dawn Craig, Anand Dixit, Peter Flynn, Eduardo Gonzalo-Almorox, Alastair Gray, Martin James, Nader Khandanpour, Hannah Lumley, Indira Natarajan, Sanjeev Nayak, Stephen Rice, Shannon Robalino, Christine Roffe, Yezen Sammaraiee, Rob Simister, Don Sims, Ken Stein (NIHR Journals Library Editor-in-Chief) and Ivan Wiggam.
Contributions of authors
Christopher I Price (https://orcid.org/0000-0003-3566-3157) was a co-applicant and lead for WP1, was the chief investigator for the PASTA trial and provided design and data interpretation assistance for WP2.
Phil White (https://orcid.org/0000-0001-6007-6013) was a co-applicant, was a lead for WP2 and contributed to the design, analysis and reporting of all relevant studies.
Joyce Balami (https://orcid.org/0000-0001-9968-3179) led the thrombectomy safety review and the costing data collection, analysis and interpretation for WP2.
Nawaraj Bhattarai (https://orcid.org/0000-0002-1894-2499) assisted with the economic analysis design, interpretation and reporting for the PASTA trial.
Diarmuid Coughlan (https://orcid.org/0000-0002-5348-3750) assisted with the design, analysis and reporting of the helicopter survey, public survey and economics modelling in WP2.
Catherine Exley (https://orcid.org/0000-0002-5348-3750) was a co-applicant, and designed and supervised the PASTA trial process evaluation. She also provided guidance on data interpretation.
Darren Flynn (https://orcid.org/0000-0001-7390-632X) led on the development work for the PASTA intervention and the PPI components of WP2, and contributed to the design, analysis and reporting of all studies.
Kristoffer Halvorsrud (https://orcid.org/0000-0002-8813-0939) assisted with the design, data collection, analysis and interpretation of the Delphi exercise and systematic review in WP2.
Joanne Lally (https://orcid.org/0000-0002-8468-1397) assisted with the design, data analysis, interpretation and reporting of the process evaluation during the PASTA trial.
Peter McMeekin (https://orcid.org/0000-0003-0946-7224) was a co-applicant and provided methodological expertise, data analysis and interpretation for the economic modelling in WP2. He also oversaw the web tool development and assisted with the economic analysis design and interpretation for the PASTA trial.
Lisa Shaw (https://orcid.org/0000-0002-3435-9519) co-designed the PASTA trial, prepared the protocol, developed the intervention, led the trial delivery team, provided trial reports, and assisted with data verification and interpretation.
Helen Snooks (https://orcid.org/0000-0003-0173-8843) was co-applicant, provided methodological expertise for the PASTA trial and assisted with data interpretation.
Luke Vale (https://orcid.org/0000-0001-8574-8429) was co-applicant, provided oversight of the economic analysis for the PASTA trial and provided methodological expertise for all aspects of economic evaluation.
Alan Watkins (https://orcid.org/0000-0003-3804-1943) provided oversight of the statistical analysis and provided methodological expertise for the PASTA trial.
Gary A Ford (https://orcid.org/0000-0001-8719-4968) was lead applicant for the PEARS programme and contributed to the design, analysis and reporting of all studies.
All authors have provided substantial contributions to the conception and design of the PEARS programme and interpretation of data, and had input into drafting the report and/or revising it critically for important intellectual content. All authors have given final approval of the version to be published.
Publications
Work package 1 publications
Flynn D, Francis R, Robalino S, Lally J, Snooks H, Rodgers H, et al. A Systematic Review of Paramedics in Hospital for Acute Stroke, Acute Myocardial Infarction and Trauma Patients. PROSPERO 2014 CRD42014010785. URL: www.crd.york.ac.uk/prospero/display_record.php?ID%20=%20CRD42014010785 (accessed 8 May 2021).
Flynn D, Francis R, Robalino S, Lally J, Snooks H, Rodgers H, et al. A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients. BMC Emerg Med 2017;17:5. https://doi.org/10.1186/s12873-017-0118-5
Price CI, Shaw S, Dodd P, Exley C, Flynn D, Francis R, et al. Paramedic Acute Stroke Treatment Assessment (PASTA): study protocol for a randomised controlled trial. Trials 2019;20:121. https://doi.org/10.1186/s13063-018-3144-z
Price CI, Shaw L, Islam S, Javanbakht M, Watkins A, McMeekin P, et al. The effect of an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) on thrombolysis delivery during emergency stroke care: a cluster randomised controlled trial. JAMA Neurol 2020;77:840–8. https://doi.org/10.1001/jamaneurol.2020.0611
Lally J, Vaittinen A, McClelland G, Price CI, Ford GA, Shaw L, et al. Paramedic experiences of using an enhanced stroke assessment during a cluster randomised trial: a qualitative thematic analysis. EMJ 2020;37:480–5. https://doi.org/10.1136/emermed-2019-209392
Bhattarai N, Price CI, McMeekin P, Javanbakht M, Vale L, Ford GA, Shaw L. Cost-effectiveness of an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) during emergency stroke care: economic results from a pragmatic cluster randomized trial. Int J Stroke 2021;7:17474930211006302. https://doi.org/10.1177/17474930211006302
Work package 1 conference abstracts
Lally J, Flynn D, Ford GA, Price CI, Exley C. Barriers and facilitators to further development of the paramedic role during assessment of suspected stroke patients. Int J Stroke 2015;10:50–1.
Lally J, McClelland G, Exley C, Ford GA, Price CI. Stakeholder engagement in the design of a novel pre-hospital acute stroke assessment. Emerg MedJ 2016;33:e9–10. https://doi.org/10.1136/emermed-2016-206139.31
Work package 2 publications
Flynn D, Francis R, McMeekin P, Price C, Ford G, Robalino S, et al. Intra-arterial Mechanical Thrombectomy in the Treatment of Acute Ischaemic Stroke: A Systematic Review and Meta-analysis. PROSPERO 2015 CRD42015016649. URL: www.crd.york.ac.uk/PROSPERO/display_record.asp?ID%20=%20CRD42015016649 (accessed 8 May 2021).
Flynn D, Ford GA, McMeekin PJ, White P. Characteristics of intra-arterial thrombectomy service provision in England. Int J Stroke 2016;11:NP83–5. https://doi.org/10.1177/1747493016655363
Flynn D, Francis R, Halvorsrud K, Gonzalo-Almorox E, Craig D, Robalino S, et al. Intra-arterial mechanical thrombectomy in the treatment of acute ischaemic stroke: a systematic review and meta-analysis. Eur Stroke J 2017;2:308–18. https://doi.org/10.1177/2396987317719362
McMeekin P, White P, James MA, Price CI, Flynn D, Ford GA. Estimating the numbers of stroke patients in the UK that are eligible for treatment with mechanical thrombectomy. Eur Stroke J 2017;2:319–26. https://doi.org/10.1177/2396987317733343
Balami J, White P, McMeekin P, Ford GA, Buchan AM. Complications of endovascular treatment for acute ischaemic stroke: prevention and management. Int J Stroke 2018;13:348–61. https://doi.org/10.1177/1747493017743051
Halvorsrud K, Flynn D, Ford GA, McMeekin P, Bhalla A, Balami J, et al. Future delivery of thrombectomy services in England: a Delphi study and ranking exercise with clinicians. BMC Health Serv Res 2018;18:135. https://doi.org/10.1186/s12913-018-2922-3
McMeekin P, Flynn D, Allen M, Coughlan D, Ford GA, Lumley H, et al. Estimating the effectiveness and cost-effectiveness of establishing additional endovascular thrombectomy stroke centres in England: a discrete event simulation. BMC Health Serv Res 2019;19:821. https://doi.org/10.1186/s12913-019-4678-9
Oxford Academic Health Science Network. Mechanical Thrombectomy for Acute Ischaemic Stroke: An Implementation Guide for the UK. Ford G, James M, White P, editors. 2019. URL: www.oxfordahsn.org/our-work/adopting-innovation/cardiovascular-disease/mt-guide/ (accessed 6 July 2021).
Ford GA, James M, White P. Mechanical Thrombectomy for Acute Ischaemic Stroke: Challenges and Opportunities. Specialised Commissioning. November 2019. URL: www.specialisedmedicine.co.uk/articles/mechanical-thrombectomy-for-acute-ischaemic-stroke-challenges-and-opportunities/ (accessed 8 May 2021).
Balami JS, Coughlan D, White PM, McMeekin P, Flynn D, Roffe C, et al. The cost of providing mechanical thrombectomy in the UK National Health Service: a micro-costing study. Clin Med 2020;2:e40–5. https://doi.org/10.7861/clinmed.2019-0413
Coughlan D, McMeekin P, Flynn D, Ford GA, Lumley H, Burgess D, et al. Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: economic evaluation and considerations. Emerg Med J 2021;38:33–9. https://doi.org/10.1136/emermed-2019-209039
Work package 2 conference abstracts
Flynn D, Ford G, McMeekin P, Halvorsrud K, Bhalla A, Balami J, White P. Future delivery of thrombectomy services in England: a Delphi study with stroke physicians. Int J Stroke 2016;11:S6.
Balami JS, McMeekin P, White PM, Flynn D, Roffe C, Wiggam I, et al. Case costing of mechanical thrombectomy for acute ischaemic stroke in routine clinical setting: cost differences between mothership vs drip and ship. Int J Stroke 2018;13(Suppl. 3):10–65.
Lumley H, Flynn D, Coughlan D, McMeekin P, Ford GA, Craig D, et al. Secondary transfers by helicopter emergency services for thrombectomy in rural England: a feasibility study. Int J Stroke 2018;13:10–65. https://doi.org/10.1136/emermed-2019-209039
McMeekin P, White PM, James MA, Price CI, Flynn D, Ford GA. Incorporating evidence from recent trials in to estimates of stroke patients eligible for thrombectomy. Int J Stroke 2018;13:10–65.
Data-sharing statement
All data requests should be submitted to the corresponding author for consideration. Access to anonymised data may be granted following review.
Patient data
This work uses data provided by patients and collected by the NHS as part of their care and support. Using patient data is vital to improve health and care for everyone. There is huge potential to make better use of information from people’s patient records, to understand more about disease, develop new treatments, monitor safety, and plan NHS services. Patient data should be kept safe and secure, to protect everyone’s privacy, and it’s important that there are safeguards to make sure that it is stored and used responsibly. Everyone should be able to find out about how patient data are used. #datasaveslives You can find out more about the background to this citation here: https://understandingpatientdata.org.uk/data-citation.
Disclaimers
This report presents independent research funded by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, CCF, PGfAR or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, the PGfAR programme or the Department of Health and Social Care.