Journal of the Formosan Medical Association 121 (2022) 978e985

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Original Article

Expanding resources of endovascular

thrombectomy: An optimization model
Chun-Han Wang a, Ting-Yu Liu a, Wen-Chu Chiang b,
Sung-Chun Tang c, Li-Kai Tsai c, Chung-Wei Lee d,
Yen-Heng Lin d, Jiann-Shing Jeng c, Matthew Huei-Ming Ma b,
Ming-Ju Hsieh e,*, Yu-Ching Lee a,**

a
Department of Industrial Engineering and Engineering Management, National Tsing Hua University,
Hsinchu, Taiwan
b
Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin
County, Taiwan
c
Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
d
Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
e
Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan

Received 22 April 2020; received in revised form 3 June 2021; accepted 15 July 2021

KEYWORDS Background/Purpose: Recently optimized models for selecting the locations of hospitals
Stroke; capable of providing endovascular thrombectomy (EVT) did not consider the accuracy of the
Emergency medical prehospital stroke scale assessment and possibility of secondary transport. Our study aimed
service; to propose a new model for selecting existing hospitals with intravenous thrombolysis capa-
Endovascular bility to become EVT-capable hospitals.
thrombectomy; Methods: A sequential order was provided to upgrade hospitals providing intravenous thrombo-
Resource lysis, using a mixed integer programming model based on current medical resource allocation.
redistribution In addition, we drafted a centralized plan to redistribute existing EVT resources by redetermin-
ing locations of EVT-capable hospitals. Using historical data of 7679 on-scene patients with sus-
pected stroke, the model was implemented to determine the hospital that maximizes the
number of patients receiving EVT treatment within call-to-definitive-treatment time.
Results: All suspected stroke patients were sent to EVT-capable hospitals directly under the
current medical resource allocation model. After upgrading one additional hospital to become
an EVT-capable hospital, the percentage of patients receiving definitive treatment within the
standard call-to-definitive-treatment time was elevated from 68.82% to 72.97%. In the model,
assuming that there is no hospital providing EVT, all patients suspected of stroke will be sent to

* Corresponding author. Department of Emergency Medicine, National Taiwan University Hospital, No. 7 Chung Shan South Rd., Taipei 100,
Taiwan. Fax: þ886 2 2322 3150.
** Corresponding author. Department of Industrial Engineering and Engineering Management, National Tsing Hua University, No. 101,
Section 2, Kuang-Fu Road, Hsinchu 300, Taiwan. Fax: þ886 3 572 2204.
E-mail addresses: erdrmjhsieh@gmail.com (M.-J. Hsieh), yclee@ie.nthu.edu.tw (Y.-C. Lee).

https://doi.org/10.1016/j.jfma.2021.07.015
0929-6646/Copyright ª 2021, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 Journal of the Formosan Medical Association 121 (2022) 978e985
EVT-capable hospitals directly after upgrading three or more hospitals to be able to provide
treatment.
Conclusion: All patients eligible for acute stroke treatment are sent to EVT-capable hospitals
in the simulation under the current medical resource allocation model. This model can be uti-
lized to provide insights for capacity redistribution in other regions.
Copyright ª 2021, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
1. Introduction
It has been shown that endovascular thrombectomy (EVT) is
beneficial to patients with large vessel occlusions (LVOs).1e5
In addition, studies have shown that a shorter time interval
between the onset of symptoms and reperfusion using EVT
results in improved functional outcome at three months.6e9
Interhospital transfer also delays the time before receiving
EVT10 and might worsen the outcome of patients with LVO.
One study found that transfer-in patients had significantly
longer last-known-well-to-EVT initiation time, were less
likely to have independent ambulation at discharge or be
discharged to home, and had a higher rate of symptomatic
intracranial hemorrhage.11 Currently, EVT-capable hospitals
only make up a relatively small portion of hospitals in most
of the world. Therefore, the stakeholders in some commu-
nities may need to increase the number of hospitals with EVT
ability. Nevertheless, it is paramount to find a most suitable
hospital for upgrading to be able to perform EVT in order to
provide maximal benefit to patients, since this process re-
quires a large input of resources.
The process to decide which hospital should be upgraded
is complicated and many aspects must be considered.
Common criteria for selecting the optimal location of a
hospital with EVT ability is to let the most of the patient
population receive EVT treatment within one specific time
period.12,13 Many prehospital triage studies14,15 have incor-
porated randomness and dynamic variation of the location of
suspected stroke patients in simulations where an optimal
bypass strategy was inferred. Similar simulations regarding
the location of the suspected stroke patients is also relevant
in selecting which stroke hospital to upgrade. Uncertainty in
the accuracy of the prehospital stroke scales is rarely dis-
cussed. However, this is an important factor to consider
since emergency medical technicians (EMTs) used the scale
to identify patients with LVO, which informs the decision of
the receiving hospital. However, in order to receive a
definitive treatment, patients often go through hospital
transfers and repeated testing, which has been shown to be
statistically associated with inaccurate judgements. Calcu-
lating the scene-to-primary hospital time and the associated
waiting and treatment durations in the primary hospital can
lead to a significant underestimation of the actual call-to-
definitive-treatment time. In addition, the road networks
connecting patients to an EVT-capable hospital, as well as
that in the planning area, need to be assessed. Modern
Geographic Information Systems (GISs), such as Google Maps,
provide for real-time or forecasted drive time for potential
ambulance routes.
A mathematical optimization model is proposed to
decide which existing hospitals providing recombinant
979
tissue plasminogen activator (rt-PA) should be upgraded in
order to maximize the number of patients being covered
within a specific period of time. This model’s merit is the
incorporation of secondary transport probabilities and the
use of an “expectation”, according to the accuracy of
prehospital stroke scale assessment and the call-to-
definitive-treatment time as the measure to extract a
more robust optimal decision. We inputted geographic lo-
cations of a set of archived patient data for simulating the
path to receive definitive treatment within the model. We
chose archived patient data because many epidemiologic
factors, such as age, were associated the occurrence of
stroke, and the available data for past patients was more
representative of other regions across the world.
1.1. Background of case study
We built a mathematical model to determine which hos-
pital will benefit the most patients with LVO if it upgrades.
Since 2010, the EMTs in Taipei City used Cincinnati Pre-
hospital Stroke Scale (CPSS) to identify stroke patients. If
a patients had one of the CPSS indicator symptoms,
including facial droop, arm drift, and slurring of speech,
the patient would be suspected of having a stroke. The
result of CPSS examination was recorded in the ambulance
run-sheet. In addition, the address of the scene was also
recorded in the ambulance run-sheet. We collected the
data of patients who was suspected of having a stroke by
EMTs from ambulance run-sheets from 2010 to 2015. We
put the six years of data from patients suspected of having
a stroke in the set U to determine the sequence of hospital
upgrade.
For considering the distribution of elderly people in
Taipei, we used land area and village population data
published on the Data. Taipei platform.16 The city consists
of 12 administrative districts indexed by a to l, and the
population profile of each administrative districts is shown
in Supplementary Table 1. District a has a larger popula-
tion, yet the elderly population in this district is less than
that in district b. Currently, there are 6 EVT-capable hos-
pitals (ABCDEF, which form the set H) and 4 rt-PA hospitals
(GHIJ, which form the set C) in Taipei City. The relative
geographic locations are shown in Supplementary Figure 1.
2. Methods
2.1. EVT Capacity Expansion Model
We formulated an EVT Capacity Expansion Model, belonging
to the class of integer optimization to identify the most
 C.-H. Wang, T.-Y. Liu, W.-C. Chiang et al.

optimal hospital with respect to location. The most optimal 2.1.2. Parameters
hospital was defined in terms of enabling the largest in-
crease in the number of patients who were able to receive
the definitive treatment within a specific time period,
among all of the existing hospitals in the planning area.
Solving the model multiple times gives a sequence of hos- pu u˛U the probability that patient u
pital upgrade recommendations. The call-to-definitive- has a suspected stroke yet the
treatment time may be the time spent sending a patient cause of stroke is other than
to an EVT-capable hospital directly and giving EVT/rt-PA, to LVO
a rt-PA hospital and giving rt-PA, or initially to a rt-PA hos- 1  pu u˛U the probability that patient u
pital then transferring to a EVT-capable hospital and giving was with LVO
EVT. Since the conjecture about whether a patient is Su u˛U response time for the
suffering from LVO based on the on-scene stroke scale ambulance to reach the site of
assessment is uncertain, this study proposed to compute the the patient u plus on-scene
expected call-to-definitive-treatment time associated with time
an estimated probability distribution of having a LVO based Ti;u u˛U; i˛HWC transport time from getting
on the same prehospital stroke scale. We describe the no- patient u to hospital i
tations of the mathematical optimization model below (see Gc;u u˛U; c˛C the shortest transport time
Fig. 1). from getting the patient u to
its nearest hospital in HWfcg
2.1.1. Sets Gc;u u˛U; c˛C the shortest transport time
from getting patient u to its
nearest hospital in Cyfcg
Q processing time for a hospital
to perform a test
H set of EVT-capable hospitals
Tc c˛C the shortest secondary
C set of rt-PA hospitals
transport time from hospital c
U set of patients
to its nearest EVT-capable
hospital
Tbc;q c˛C; q˛Cyfcg the shortest secondary
This study used past patient data to form the set U. It is transport time from hospital q
also possible to simulate the random occurrence of the ðq scÞ to its nearest EVT-
requests for emergency medical service (EMS) by drawing a capable hospital including
set of patient locations following some probability distri- hospital c
bution. In the later method of forming the set U, the A administration time of hospital
occurrence of these patients being at corresponding sites is transfer
assumed with equal chances.

Figure 1 The decision-making process until a patient receives definitive treatment. EVT: endovascular thrombectomy; rt-PA:
recombinant tissue plasminogen activator.

980
 Journal of the Formosan Medical Association 121 (2022) 978e985

in time Z receiving definitive treatment (rt-PA/EVT) within the standard call-to-definitive-treatment time (rt-PA: 1.5 h/EVT: 3 h). EVT: endovascular thrombectomy; rt-PA: re-
(continued )

(0.00%)

(0.00%)

(0.00%)

(0.00%)

(5.34%)
Du u˛U waiting time for patient u to

410
0

0
receive treatment after a test

J
CTDu u˛U call-to-definitive-treatment

Number (percentage) of suspected patients who receive definitive treatment in individual hospital

(10.46%)
time for patient u

(0.00%)

(0.00%)

(9.12%)

(8.73%)
U threshold

803

700

670
M a large number

0
I

(0.00%)

(8.36%)

(8.36%)

(8.36%)

(8.35%)
642

642

642

641
H

0
2.1.3. Variables

(12.00%)

(12.05%)
(0.00%)

(0.00%)

(0.00%)
921

925
u˛U; i˛HWC

G
Xi;u the auxiliary evacuation decision.

0
1Z if patient u is sent to hospital i

(14.64%)

(14.35%)
from the scene; 0Z otherwise.

(9.08%)

(9.06%)

(4.48%)
Yu u˛U 1Z if patient u is expected to

1124

1102

697

696

344
receive treatment in specific call-

F
to-definitive-treatment time CTDu
minutes for the type of stroke

The result of hospital expansion for endovascular thrombectomy resource redistribution (scenario 1).

(18.22%)

(18.22%)

(17.40%)

(13.02%)

(13.01%)
patient u after receiving the call;

1399

1399

1336

1000

999
0Z otherwise.

E
Zc c˛C 1 Z if hospital c enables the EVT
capacity; 0Z otherwise.

(16.07%)

(8.01%)

(7.37%)

(7.38%)

(7.37%)
1234

615

566

567

566
D

The proposed model is of a bi-objective optimization

(10.86%)

(10.86%)

(10.89%)

(10.89%)

(10.89%)
fashion that maximizes the number of past/simulated pa-
tients who are expected to be covered within a specific
834

834

836

836

836
period of time and minimizes the total expected call-to-
C

definitive-treatment time with the current set of hospitals

providing rt-PA and EVT-capable hospitals. For complete-
(27.40%)

(27.40%)

(26.36%)

(20.14%)

(19.77%)
ness sake, the model and its technical description are
2104

2104

2024

1546

1518
shown in Supplementary Material.
B

2.2. Two scenarios for expansion of EVT resources

(12.80%)

(12.79%)

(10.08%)

(10.03%)

(10.02%)

In the first scenario, we performed a Monte Carlo simula-

983

982

774

770

769
A

tion according to the current distribution of EVT resources.

We attempted to upgrade current four rt-PA hospitals one
treatment
receiving

(68.82%)

(72.97%)

(75.27%)

(77.10%)

(77.27%)

by one based on the recommendation of the proposed

Patients

in timea

model.
5284

5603

5779

5920

5933

In addition to upgrading rt-PA hospitals based on cur-

rent medical resource allocation, we simulated the
combinant tissue plasminogen activator.
Expanded

expansion of rt-PA hospitals to EVT-capable hospitals one

Available
hospital

by one under the assumption that there was no hospital

providing EVT treatment. In other words, in the second
Not

G
H

scenario, we attempted to redistribute the EVT resources

I

in Taipei in order to appropriately allocate the EVT-

ABCDEFGHI
ABCDEFHI

capable hospitals.
ABCDEFH
hospitals
capable

ABCDEF

ABCDEF
Current
EVT-

2.2.1. Data source and software

In this study, there were 7678 patients suspected of having
a stroke, who had at least one of the three CPSS indicator
Number of

symptoms. Their geographic locations were collected in the

hospitals
capable
Table 1

set of patients U. For all the 7678 patients, 4037 patients

EVT-

had three, 1319 had two, and 2322 had one positive CPSS
a
10
6

indicator. This study set the corresponding value of pu ,

981
 C.-H. Wang, T.-Y. Liu, W.-C. Chiang et al.
following the finding in the study by Scheitz et al.,17 at
0.690, 0.735, and 0.761 respectively. The study was
approved by the institutional review board of the National
Taiwan University Hospital.
The mathematical optimization program was imple-
mented with AMPL, which stands for A Modeling Language
for Mathematical Programming. AMPL is an interface
integrating a modeling language very similar to its mathe-
matical notations and a variety of solvers.18 We used the
IBM ILOG CPLEX Optimization Studio (CPLEX), which is an
optimization solver initially developed by ILOG, LLC and
then became part of the International Business Machines
Corporation for solving the integer programming problem.19
The CPU time to solve the model for an optimal solution is
206 s on average for the instance of Taipei City on a per-
sonal computer with Intel Core (TM) i5-6500 CPU @
3.20 GHz and 16G RAM.
3. Results
According to the six-year data and the approach for esti-
mation of probabilities in Scheitz et al.,17 the outcome of
the EVT Capacity Expansion Model recommends upgrading
the rt-PA hospital H to become an EVT-capable hospital
(Table 1). In the past set of 7,678, a total of 5603 suspected
stroke patients (which are 319 more than before expan-
sion), would be able to receive definitive treatment within
the standard call-to-definitive-treatment time (Table 1),
with the percentage elevated from 68.82% to 72.97%.
In the Monte Carlo simulation, all patients with sus-
pected stroke are sent to an EVT-capable hospital directly,
including one upgraded rt-PA hospital (hospital H), ac-
cording to the proposed model. There are 982 suspected
stroke patients sent to hospital A, 2104 suspected stroke
patients sent to hospital B, 834 suspected stroke patients
sent to hospital C, 615 suspected stroke patients sent to
hospital D, 1399 suspected stroke patients sent to hospital
E, 1102 suspected stroke patients sent to hospital F, and
642 suspected stroke patients sent to the upgraded hospital
H, which is shown in Table 1.
Figure 2 The distribution of patients and their receiving hospitals at present (left panel) vs. after the suggested upgrade of
hospital H (right panel) in the most affected district b. Each dot corresponds to the site of a patient. The color of the dot represents
the hospital receiving that patient.
982
Under hospital H upgraded, among all patients, 1 patient
originally sent to hospital A, 619 patients originally sent to
hospital D, and 22 patients originally sent to hospital F are
sent to hospital G instead. Fig. 2 shows the patients dis-
tribution in the districtb, which are the most affected areas
in Taipei when hospital H is upgraded. The receiving hos-
pitals are not affected elsewhere.
Besides upgrading rt-PA hospitals based on current
medical resource allocation, we redistribute EVT resources
so that hospitals providing EVT are appropriately-allocated
in Taipei. Under the assumption that there is no hospital
providing EVT treatment, EVT resources are added to a
hospital providing rt-PA one by one and the result is shown
in Table 2. In the first upgrade, the model recommends
upgrading hospital B. Hospital B is located in the area
where the most stroke cases occur, hence 7576 (98.67%)
suspected stroke patients will be sent to hospital B for
treatment. Other suspected stroke patients, such as pa-
tients living in the eastern and southern parts of Taipei, will
be sent to the rt-PA hospitals on the first occasion. Among
these patients, there are 100 suspected patients sent to
hospital A and 2 suspected stroke patients sent to hospital
G. After upgrading three or more hospitals to EVT-capable
hospitals, all suspected patients will be sent to EVT-
capable hospitals directly (Table 2).
If hospitals A, B, E, F, H, I all become new EVT-capable
hospitals, all suspected stroke patients will be sent to the
EVT-capable hospital directly, and 71.61% of them are able
to receive definitive treatment within the standard call-to-
definitive-treatment time.
When all hospitals are expanded with the EVT re-
sources, there are 769 suspected stroke patients sent to
hospital A, 1518 suspected stroke patients sent to hospital
B, 836 suspected stroke patients sent to hospital C, 566
suspected stroke patients sent to hospital D, 999 sus-
pected stroke patients sent to hospital E, 344 suspected
stroke patients sent to hospital F, 925 suspected stroke
patients sent to hospital G, 641 suspected stroke patients
sent to hospital H, 670 suspected stroke patients sent to
hospital I, and 410 suspected stroke patients sent to hos-
pital J. Among all of them, 5933 (77.27%) patients are able
 Table 2 The result of hospital expansion for endovascular thrombectomy resource redistribution (scenario 2).
Number Current Expanded Patients Number (percentage) of suspected patients who receive

Journal of the Formosan Medical Association 121 (2022) 978e985

of EVT- EVT- hospital receiving definitive treatment in individual hospital
capable capable treatment A B C D E F G H I J
hospitals hospital in timea
1 None B 2548 100 7576 0 0 0 0 2 0 0 0 (0.00%)
(33.19%) (1.30%) (98.67%) (0.00%) (0.00%) (0.00%) (0.00%) (0.03%) (0.00%) (0.00%)
2 B E 3713 0 4412 0 98 3016 0 2 138 11 1
(48.36%) (0.00%) (57.46%) (0.00%) (1.28%) (39.28%) (0.00%) (0.03%) (1.80%) (0.14%) (0.01%)
3 BE F 4473 0 2105 0 0 2623 2950 0 0 0 0
(58.26%) (0.00%) (27.42%) (0.00%) (0.00%) (34.16%) (38.42%) (0.00%) (0.00%) (0.00%) (0.00%)
4 BEF A 4940 1024 2105 0 0 2233 2316 0 0 0 0
(64.34%) (13.34%) (27.42%) (0.00%) (0.00%) (29.08%) (30.16%) (0.00%) (0.00%) (0.00%) (0.00%)
983

5 ABEF H 5321 1024 2104 0 0 2233 1615 0 702 0 0

(69.30%) (13.34%) (27.40%) (0.00%) (0.00%) (29.08%) (21.03%) (0.00%) (9.14%) (0.00%) (0.00%)
6 ABEFH I 5.498 813 2025 0 0 2172 1148 0 707 813 0
(71.61%) (10.59%) (26.37%) (0.00%) (0.00%) (28.29%) (14.95%) (0.00%) (9.21%) (10.59%) (0.00%)
7 ABEFHI D 5627 774 2024 0 564 2172 697 0 643 804 0
(73.29%) (10.08%) (26.36%) (0.00%) (7.35%) (28.29%) (9.08%) (0.00%) (8.37%) (10.47%) (0.00%)
8 ABDEFHI C 5779 774 2024 836 566 1336 697 0 642 803 0
(75.27%) (10.08%) (26.36%) (10.89%) (7.37%) (17.40%) (9.08%) (0.00%) (8.36%) (10.46%) (0.00%)
9 ABCDEFHI G 5920 770 1546 836 567 1000 696 921 642 700 0
(77.10%) (10.03%) (20.14%) (10.89%) (7.38%) (13.02%) (9.06%) (12.00%) (8.36%) (9.12%) (0.00%)
10 ABCDEFGHI J 5933 769 1518 836 566 999 344 925 641 670 410
(77.27%) (10.02%) (19.77%) (10.89%) (7.37%) (13.01%) (4.48%) (12.05%) (8.35%) (8.73%) (5.34%)
a
in time Z receiving definitive treatment (rt-PA/EVT) within the standard call-to-definitive-treatment time (rt-PA: 1.5 h/EVT: 3 h). EVT: endovascular thrombectomy; rt-PA: re-
combinant tissue plasminogen activator.
 C.-H. Wang, T.-Y. Liu, W.-C. Chiang et al.
to receive treatment within the standard call-to-
definitive-treatment time.
4. Discussion
Major innovations of this study are as follows. The patients’
prehospital stroke scale records allow calculation of the
“expected” call-to-definitive-treatment time using a set of
estimated probabilities of correctly identifying patients
with LVO. Known theoretical results from optimization
models suggest that using an expectation of the call-to-
definitive-treatment time yields a more robust optimal
decision (i.e. a decision that is most likely to be optimal in
all situations) compared to using the historical time
because there are uncertainties in the measurement of the
door-to-definitive-treatment time.20 The procedure of
sending patients to the EVT-capable hospital, including the
upgraded hospital capable of providing rt-PA treatment, or
to the hospitals capable of providing rt-PA treatment
excluding the one being upgraded was simulated through
novel modeling techniques. The sequence of hospitals to be
upgraded in order of the number of patients that would be
covered within a specific period of time was obtained. The
proposed model is generally considered to be sufficient to
be used in the planning area in addition to our case study.
In Taipei, 68.82% of patients are estimated to receive
treatment within the expected call-to-definitive-
treatment time based on patient data and current distri-
bution of hospitals. To plan a suitable rt-PA hospital-up-
grade project, both the locations of the hospitals and the
distribution of patients are essential factors and should be
considered. From the perspective of geographical infor-
mation, it is necessary to add the EVT-capable hospital in
the southern part of Taipei since most of the current EVT-
capable hospitals are located in the central and the north-
ern region. Therefore, the results suggest adding EVT re-
sources to hospital H. After expanding the EVT capacity to
hospital H, 8.36% of suspected stroke patients are sent to
hospital H instead.
In the model, under the assumption that there is no
hospital providing EVT treatment, we choose new EVT-
capable hospitals one by one for EVT resource redistribu-
tion. The model suggests that the order of hospital upgrade
is B, E, F, A, H, I, D, C, G and J. After the 6th hospital is
selected to upgrade, hospitals A, B, E, F, H, and I become
new EVT-capable hospitals. It predicts an increase of 2.79%
of suspected stroke patients receiving treatment within
the expected call-to-definitive-treatment time after EVT
resource redistribution, when compared with current
medical resource allocation.
The model built up in our study can be generalized; that
is, it can be used in other regions. For the areas with scarce
EVT resources, the model can help to decide the successive
upgrade of rt-PA hospital until the number of patients
who can receive treatment within the standard call-to-
definitive-treatment time is satisfactory. On the other
hand, for the areas where EVT resources are not evenly
distributed, it provides a suggestion for EVT capacity
redistribution to increase overall. We confirm the feasibility
of this model through past stroke data. It is believed that
984
this model will help improve the quality of stroke treatment
in other regions in the future.
There are some limitations in our study. Numerical
results are based on archived, real-life data in our study.
For example, deciding which rt-PA hospital to upgrade is
based on the previous patient distribution. The patient
distribution may change over time, which means the re-
sults have to be updated as the data change. However,
patient distribution changes slowly with time. On the
other hand, due to the difficulty in data accessibility,
some assumptions are added into the model. For instance,
the door-to-test time and administration time for each
hospital should be of course different, but they are
assumed to be the same. Besides, this expansion plan
focuses on enabling most patients to receive the definitive
treatment within standard time but not other specific
factors. For example, in a real-world implementation, the
cost of extra facilities and personnel and the financial
benefits require further analysis. Moreover, whether pri-
vate hospitals are willing to follow the serial upgrade plan
is also an issue. Under National Health Insurance and
hospital rating system, hospitals are eager to expand their
service and provide EVT. Although there is no way to give
mandatory orders to decide which hospital, especially a
private one, could have the priority to be upgraded, this
model provides the national policymakers an aid. When
necessary, the national policymakers can offer resources
in exchange or give incentives to persuade the hospitals to
cooperate.
In conclusion, we propose a mathematical optimiza-
tion model, considering not only geographical locations
of patients and hospitals, but also the accuracy of the
prehospital stroke scales and the possibility of secondary
transport of patients. All patients suspected of stroke in
Taipei are sent to EVT-capable hospitals directly in the
simulation under the current medical resource alloca-
tion. In addition, under the assumption of no hospital
providing EVT treatment initially, all suspected patients
will be sent to EVT-capable hospitals directly after
upgrading three or more hospitals to become EVT-
capable. This model has generality to be validated and
then applied in both rural and urban areas and is a useful
tool to provide a suggestion for EVT capacity redistribu-
tion in other regions.
Declaration of competing interest
The authors have no conflicts of interest relevant to this
article.
Acknowledgments
We would like to thank the Taipei City Fire Department for
their administrative support. The article was supported by
the Taiwan Ministry of Science and Technology (MOST 106-
2314-B-002-091 and MOST 108-2314-B-002 -131) and Na-
tional Taiwan University Hospital (108-09). The funding
sources had no role in the design of this study or any role
during its execution, analyses, interpretation of the data,
or decision to submit results.
 Journal of the Formosan Medical Association 121 (2022) 978e985
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jfma.2021.07.015.
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