A large US registry-based study shows that longer door-in-door-out (DIDO) times at the referring hospital are strongly associated with poor functional outcomes, lower rates of endovascular therapy, and higher complication rates. The results of this study emphasize the importance of the pre-transfer period and the need for system-level interventions to reduce DIDO time. The study was published in the Lancet Neurology journal by Regina R. and colleagues.
Timely access to endovascular therapy is a key determinant of outcomes in patients with acute ischaemic stroke due to large vessel occlusion. However, many patients are initially admitted to hospitals that do not have the capability to deliver endovascular therapy and thus need interhospital transfer. The purpose of this study was to determine whether DIDO time at the initial hospital was associated with functional outcomes, endovascular therapy, and complications in patients with acute ischaemic stroke who were transferred for evaluation of endovascular therapy.
This retrospective cohort study included patients with acute ischaemic stroke and visualized target occlusion on cerebrovascular imaging who were transferred from acute care hospitals to participating centers in the US nationwide Get With The Guidelines–Stroke registry. The time period for this study was from January 1, 2019, to December 31, 2023. The DIDO time, which is the time from arrival to discharge from the presenting emergency department, was the main exposure.
Key findings
A total of 22,410 patients with acute ischaemic stroke contributed to the analysis.
The median age was 70 years (IQR, 60-80), and 11,236 patients (50.1%) were female.
The population consisted of 16,558 White patients (73.9%), 3,146 Black or African American patients (14.0%), and 1,338 Hispanic patients (6.0%).
The median DIDO time was 121 minutes (IQR, 89-175).
The primary outcome was the ordinal modified Rankin Scale (mRS) score at hospital discharge, measured as the odds of a 1-point increase in mRS score.
Secondary outcomes were mRS dichotomies (mRS 3-6 vs 0-2 and mRS 4-6 vs 0-3), receipt of endovascular therapy, discharge ambulatory status, and complications after reperfusion therapy.
Endovascular therapy was received by 16,976 patients (75.8%) at the receiving hospital.
Compared with patients who had a DIDO time of 90 minutes or less, longer DIDO times were associated with significantly worse functional outcomes at discharge.
The adjusted odds of a 1-point increase in mRS score increased progressively with longer delays: 91-180 minutes (aOR 1.29; 95% CI 1.20-1.37), 181-270 minutes (aOR 1.49; 95% CI 1.36-1.64), and >270 minutes (aOR 1.70; 95% CI 1.53-1.89).
This large-scale study clearly indicates that the longer the door-in-door-out time, the lower the rate of endovascular therapy, the higher the rate of complications, and the poor functional outcome in patients with acute ischaemic stroke. It is important to reduce the DIDO time by implementing system-level strategies.
Reference:
Royan, R., Stamm, B., Giurcanu, M., Messe, S. R., Jauch, E. C., Saver, J. L., & Prabhakaran, S. (2026). Door-in-door-out times and outcomes in patients with acute ischaemic stroke transferred for endovascular therapy in the USA: a retrospective cohort study. Lancet Neurology, 25(2), 160–169. https://doi.org/10.1016/S1474-4422(25)00478-8
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