Association Between Stroke Center Hospitalization for Acute Ischemic Stroke and Mortality

Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 01/2011; 305(4):373-80. DOI: 10.1001/jama.2011.22
Source: PubMed


Although stroke centers are widely accepted and supported, little is known about their effect on patient outcomes.
To examine the association between admission to stroke centers for acute ischemic stroke and mortality.
Observational study using data from the New York Statewide Planning and Research Cooperative System. We compared mortality for patients admitted with acute ischemic stroke (n = 30,947) between 2005 and 2006 at designated stroke centers and nondesignated hospitals using differential distance to hospitals as an instrumental variable to adjust for potential prehospital selection bias. Patients were followed up for mortality for 1 year after the index hospitalization through 2007. To assess whether our findings were specific to stroke, we also compared mortality for patients admitted with gastrointestinal hemorrhage (n = 39,409) or acute myocardial infarction (n = 40,024) at designated stroke centers and nondesignated hospitals.
Thirty-day all-cause mortality.
Among 30,947 patients with acute ischemic stroke, 15,297 (49.4%) were admitted to designated stroke centers. Using the instrumental variable analysis, admission to designated stroke centers was associated with lower 30-day all-cause mortality (10.1% vs 12.5%; adjusted mortality difference, -2.5%; 95% confidence interval [CI], -3.6% to -1.4%; P < .001) and greater use of thrombolytic therapy (4.8% vs 1.7%; adjusted difference, 2.2%; 95% CI, 1.6% to 2.8%; P < .001). Differences in mortality also were observed at 1-day, 7-day, and 1-year follow-up. The outcome differences were specific for stroke, as stroke centers and nondesignated hospitals had similar 30-day all-cause mortality rates among those with gastrointestinal hemorrhage (5.0% vs 5.8%; adjusted mortality difference, +0.3%; 95% CI, -0.5% to 1.0%; P = .50) or acute myocardial infarction (10.5% vs 12.7%; adjusted mortality difference, +0.1%; 95% CI, -0.9% to 1.1%; P = .83).
Among patients with acute ischemic stroke, admission to a designated stroke center was associated with modestly lower mortality and more frequent use of thrombolytic therapy.

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    • "Hospital mortality and readmission rates are important indicators of hospital outcomes that are frequently used to assess and publicise hospital and physician performance. They are also often used in health services research to assess issues such as the impact of service organisation (Coyte et al., 2000; Evans and Kim, 2006; Ho and Hamilton, 2000; Lorch et al., 2010), the relationship between hospital inputs and outcomes (Heggestad, 2002; Schreyogg and Stargardt, 2010), the effect of introducing new policies (Evans et al., 2008) and the impact of new technologies (Xian et al., 2011). The idea behind outcome-based quality indicators such as hospital mortality or readmission rates is that, if appropriate adjustment is made for patient case-mix and external environmental factors, then variations in reported levels of such outcome-based quality indicators are likely to be driven by differences in the (unobservable ) quality of hospital services, as reflected in the processes of hospital care and service organisation. "
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    ABSTRACT: Hospital readmission rates are increasingly used as signals of hospital performance and a basis for hospital reimbursement. However, their interpretation may be complicated by differential patient survival rates. If patient characteristics are not perfectly observable and hospitals differ in their mortality rates, then hospitals with low mortality rates are likely to have a larger share of un-observably sicker patients at risk of a readmission. Their performance on readmissions will then be underestimated. We examine hospitals' performance relaxing the assumption of independence between mortality and readmissions implicitly adopted in many empirical applications. We use data from the Hospital Episode Statistics on emergency admissions for fractured hip in 290,000 patients aged 65 and over from 2003 to 2008 in England. We find evidence of sample selection bias that affects inference from traditional models. We use a bivariate sample selection model to allow for the selection process and the dichotomous nature of the outcome variables.
    Journal of Health Economics 06/2013; 32(5):909-921. DOI:10.1016/j.jhealeco.2013.06.004 · 2.58 Impact Factor
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    • "Added Value and Feasibility. Finally, organized stroke care adds value in that it reduces the following risks associated with stroke: death by 14%, death or institutionalized care by 18%, and death or dependency by 18%.30-33 Importantly, in the US it has been shown that the possibility of establishing a primary stroke center is both desirable and reachable as the presence of resources needed to achieve primary stroke center status is present in an estimated over 40% of US hospitals. "
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    ABSTRACT: In the United States (US) stroke care has undergone a remarkable transformation in the past decades at several levels. At the clinical level, randomized trials have paved the way for many new stroke preventives, and recently, several new mechanical clot retrieval devices for acute stroke treatment have been cleared for use in practice by the US Federal Drug Administration. Furthermore, in the mid 1990s we witnessed regulatory approval of intravenous recombinant tissue plasminogen activator for administration in acute ischemic stroke. In the domain of organization of medical care and delivery of health services, stroke has transitioned from a disease dominated by neurologic consultation services only to one managed by vascular neurologists in geographical stroke units, stroke teams and care pathways, primary stroke center certification according to The Joint Commission, and most recently comprehensive stroke center designation under the aegis of The Joint Commission. Many organizations in the US have been involved to enhance stroke care. To name a few, the American Heart Association/American Stroke Association, Brain Attack Coalition, and National Stroke Association have been on the forefront of this movement. Additionally, governmental initiatives by the US Centers for Disease Control and Prevention and legislative initiatives such as the Paul Coverdell National Acute Stroke Registry program have paved the way to focus on stroke prevention, acute treatment and quality improvement. In this invited review, we discuss a brief history of organized stroke care in the United States, evidence to support the value of primary and comprehensive stroke centers, and the certification criteria and process to become a primary or comprehensive stroke center.
    05/2013; 15(2):78-89. DOI:10.5853/jos.2013.15.2.78
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    • "Stroke is the leading cause of serious long-term disability and mortality in Korea.1 Organized treatment in stroke centers for patients with an acute stroke may reduce the mortality from this disorder.2,3 The Brain Attack Coalition categorized the types of stroke centers into primary and comprehensive,4-6 and outlined the recommendations for comprehensive stroke centers (CSC).6 "
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    ABSTRACT: Organized inpatient stroke care is one of the most effective therapies for improving patient outcomes. Many stroke centers have been established to meet this need, however, there are limited data on the effectiveness of these organized comprehensive stroke center (CSC) in the real-world setting. Our aim is to determine whether inpatient care following the establishment of CSC lowers mortality of patients with acute ischemic stroke (AIS). Based on a prospective stroke registry, we identified AIS patients hospitalized before and after the establishment of a CSC. We observed all-cause mortality within 30 days from time of admission. Logistic regression was used to determine whether the establishment of the CSC affects independently the 30-day all-cause mortality. A total of 3,117 consecutive patients with AIS were admitted within seven days after the onset of the symptoms. Unadjusted 30-day mortality was lower for patients admitted to our hospital after the establishment of the CSC than before (5.9% vs. 8.2%, P=0.012). Advanced age, female gender, previous coronary artery disease, non-smoking, stroke subtype, admission on a holiday, referral from other hospitals, high NIHSS on admission, and admission before the establishment of CSC were associated with increased 30-day stroke case fatality. After adjustment for these factors, stroke inpatient care subsequent to the establishment of the CSC was independently associated with lower 30-day mortality (OR, 0.57; 95% CI, 0.412-0.795). Patients treated after the establishment of a CSC had lower 30-mortality rates than ever before, even adjusting for the differences in the baseline characteristics. The present study reveals that organized stroke care in a CSC might improve the outcome after AIS.
    01/2013; 15(1):57-63. DOI:10.5853/jos.2013.15.1.57
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