Scaling up thrombectomy care in transitioning health systems: a qualitative study of stroke centres in Canada.

Abstract

Introduction: Endovascular thrombectomy has shown significant benefits for patients with large-vessel ischaemic stroke. However, many countries face challenges establishing effective thrombectomy delivery systems, even when thrombolysis services are already in place. Moreover, there is limited research on implementing thrombectomy care delivery, particularly for scale-ups in low- and middle-income countries. This study identifies the key drivers of enhancing thrombectomy delivery systems in three Canadian regions and provides lessons for health systems in transition.

Methods: A qualitative research design with a phenomenological approach was employed. From January to December 2022, at three comprehensive ischaemic stroke centres in Canada, we involved non-participant observation and in-depth interviews with 91 key informants, including care providers and administrators engaged in large-vessel stroke care. Guided by the Behaviour Change Wheel and Theoretical Domains Framework, the data were transcribed and analysed using thematic content analysis.

Results: Three critical themes emerged. First, establishing a cohesive, goal-oriented, multidisciplinary patient care team with an egalitarian culture is vital. Second, integrating specific feedback data is essential for continuous quality improvement and for optimising workflow through collective leadership. Lastly, even with existing thrombolytic services, centralised regional planning and outreach to local thrombectomy implementers is necessary. Development must occur at stroke centres and their associated peripheral hospitals to build effective thrombectomy care delivery systems.

Conclusions: Enhancing thrombectomy care delivery systems requires a stepwise approach: first, establishing multidisciplinary teams at the micro-level; next, fostering collective leadership for continuous quality improvement at the meso-level and finally, coordinating regional outreach and centralised planning at the macro-level. The Canadian experience highlights the importance of addressing these interconnected levels and underscores the critical role of central planning and collaboration between policymakers and care providers. These strategies offer a structured pathway for improving stroke care globally, particularly in transitioning health systems.