After stroke, admission to designated stroke centre hospitals associated with reduced risk of death

Patients who had an ischaemic stroke and were admitted to hospitals designated as primary stroke centres had a modestly lower risk of death at 30 days, compared to patients who were admitted to non-designated hospitals, according to a study in the January 26 issue of JAMA.

Stroke is the leading cause of serious long-term disability and the third leading cause of death in the United States. Responding to the need for improvements in acute stroke care, the Brain Attack Coalition (BAC) published recommendations for the establishment of primary stroke centres in 2000, and in 2003 the Joint Commission began certifying stroke centres based on these recommendations, according to background information in the article. Now, nearly 700 of the 5,000 acute care hospitals in the United States are Joint Commission-certified stroke centres, with some states establishing their own designation programs using the BAC core criteria. 'Despite widespread support for the stroke centre concept, there is limited empirical evidence demonstrating that admission to a stroke centre is associated with lower mortality,' the authors write.

Ying Xian, M.D., Ph.D., of the Duke Clinical Research Institute, Durham, N.C., and colleagues conducted a study to evaluate the association between admission to stroke centres for acute ischaemic stroke and the rate of death. Using data from the New York Statewide Planning and Research Cooperative System, the researchers compared mortality for patients admitted with acute ischaemic stroke (n = 30,947) between 2005 and 2006 at designated stroke centres and nondesignated hospitals. Patients were followed up for mortality for 1 year after hospitalisation through 2007. To assess whether the findings were specific to stroke, the researchers also compared mortality for patients admitted with gastrointestinal haemorrhage (n = 39,409) or heart attack (n = 40,024) at designated stroke centres and nondesignated hospitals.

Among the patients with acute ischaemic stroke, 49.4 percent (n = 15,297) were admitted to designated stroke centres (n=104) and 50.6 percent to non-designated hospitals. The overall 30-day all-cause mortality rate was 10.1 percent for patients admitted to designated stroke centres and 12.5 percent for patients admitted to nondesignated hospitals, with analysis indicating that admission to a designated stroke centre hospital was associated with a 2.5 percent absolute reduction in 30-day all-cause mortality. Use of thrombolytic therapy (dissolving blood clots) was 4.8 percent for patients admitted at designated stroke centres and 1.7 percent for patients admitted at nondesignated hospitals (adjusted difference in use, 2.2 percent). Among patients surviving to hospital discharge, there was no difference in rates of 30-day all-cause readmission and discharge to a skilled nursing facility.

'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 centres and nondesignated hospitals had similar 30-day all-cause mortality rates among those with gastrointestinal haemorrhage or acute myocardial infarction,' the authors write.

'Even though the differences in outcomes between stroke centres and nondesignated hospitals were modest, our study suggests that the implementation and establishment of a BAC-recommended stroke system of care was associated with improvement in some outcomes for patients with acute ischaemic stroke.'