Americans have a slightly greater chance of surviving an acute ischemic stroke if they are admitted to a hospital designated as a primary stroke center than one that is not, concluded US researchers in a study that measured patients’ risk of death during the 30 days following a stroke.
You can read how Dr Ying Xian, of the Duke Clinical Research Institute in Durham, North Carolina, and colleagues, arrived at their findings in a paper published online in JAMA on 26 January.
Strokes occur when blood flow to a part of the brain is blocked, often killing off the starved brain tissue. There are two main types: ischemic and hemorrhagic, the first caused by a blood vessel blockage and the second by a rupture.
Strokes are the leading cause of serious long-term disability and the third leading cause of death among Americans. In order to address this, in 2000 the Brain Attack Coalition (BAC), a group of professional, voluntary and government medical bodies, issued recommendations to improve acute stroke care which called for primary stroke centers to be set up to provide more advanced care for patients.
In 2003, the Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 18,000 health care organizations and programs in the US, started certifying stroke centers based on the BAC recommendations.
However, although stroke centers are now widely accepted and supported in the US, there is little information about their effect on patient outcomes, so Xian and colleagues decided to conduct a study to evaluate the link between admission to stroke centers for acute ischemic stroke and the rate of death.
Searching the New York Statewide Planning and Research Cooperative System for data on stroke patients, they found 30,947 patients admitted with acute ischemic stroke between 2005 and 2006, and compared the mortality rates at designated stroke centers and non-designated hospitals.
They followed up the patients to determine deaths during the 12 months after hospitalization (stopping at the end of 2007).
To make sure the findings related to stroke, they compared them with that of 39,409 patients admitted with gastrointestinal hemorrhage and 40,024 admitted with heart attack at designated stroke centers and non-designated hospitals.
The results showed that:
- 49.4 per cent (15,297) of acute ischemic stroke patients were admitted to 104 designated stroke centers while 50.6 per cent were admitted to to non-designated hospitals.
- The overall 30-day, all-cause, mortality rate was 10.1 per cent for the patients who went to designated stroke centers and 12.5 per cent for those who went to non-designated hospitals.
- Further analysis showed that admission to a designated stroke center was linked with a 2.5 per cent absolute reduction in 30 -day all-cause mortality.
- 4.8 per cent of patients admitted to designated stroke centers underwent thrombolytic therapy (where they dissolve the blood clots), compared with only 1.7 per cent admitted to non-designated hospitals.
- Among patients discharged from hospital, there was no difference in the rate of 30-day all-cause readmission and discharge to a skilled nursing facility.
- There were also differences in 1-day, 7-day and 1-year follow up.
- The findings were specific for stroke as stroke centers and non-designated hospitals had similar 30-day all-cause mortality rates for gastrointestinal hemorrhage and heart attack admissions.
The authors concluded that:
“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. “
“Even though the differences in outcomes between stroke centers 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 ischemic stroke,” they added.
Commenting on how stroke care is gearing up to improve care of patients, in an accompanying editorial, Dr Mark J. Alberts, of the Stroke Program at the Northwestern University School of Medicine in Chicago, noted that:
“A multitiered system of stroke care is developing, with the comprehensive stroke center (CSC) at the top of the pyramid, the primary stroke center (PSC) in the middle, and the acute stroke ready hospital (ASRH) at the base.”
“Within a geographical region, a small number of CSCs would provide care for patients with the most complicated stroke cases; a larger number of PSCs would provide care for the patients with typical, uncomplicated cases; and the ASRH would provide initial screening and triage and begin acute care for patients in a rural, small urban, or suburban setting,” he added.
In addition, emergency medical services would provide initial screening and triage and take patients clearly identified with stroke to the nearest stroke center, while telemedicine would enable hospitals to communicate and transfer patients to the center best equipped to offer the level of care they need.
“Many states and guidelines now support and even mandate the diversion of patients suspected of having a stroke to the nearest stroke center facility,” he wrote.
“Association Between Stroke Center Hospitalization for Acute Ischemic Stroke and Mortality.”
Ying Xian, Robert G. Holloway, Paul S. Chan, Katia Noyes, Manish N. Shah, Henry H. Ting, Andre R. Chappel, Eric D. Peterson, and Bruce Friedman.
DOI: 10.1001/jama.2011.22
Additional source: JAMA Archives (news release 25 Jan 2011).
Written by: Catharine Paddock, PhD