Escalating levels of access to in-hospital care and stroke mortality.
OBJECTIVE
Organized stroke care is an integrated approach to managing stroke to improve stroke outcomes by ensuring that optimal treatment is offered. However, limited information is available comparing different levels of organized care. Our aim was to determine whether escalating levels of organized care can improve stroke outcomes.


METHODS
Cohort study including patients with acute ischemic stroke between July 2003 and March 2005 in the Registry of the Canadian Stroke Network (RCSN). The RCSN is the largest clinical database of patients with acute stroke patients seen at selected acute care hospitals in Canada. As stroke unit admission does not automatically imply receipt of comprehensive care, we created the organized care index to represent different levels of access to organized care ranging from 0 to 3 as determined by the presence of occupational therapy/physiotherapy, stroke team assessment, and admission to a stroke unit. The primary end point was early stroke mortality. Secondary end points include 30-day and 1-year mortality.


RESULTS
Overall, 3631 ischemic stroke patients were admitted to 11 hospitals. Seven day stroke mortality was 6.9% (249/3631), 30-day stroke mortality was 12.6% (457/3631), and 1-year stroke mortality was 23.6% (856/3631). Risk-adjusted 7-day mortality was 2.0%, 3.2%, 7.8%, and 22.5% for organized care index of 3, 2, 1, and 0. Higher level of care was associated with lower adjusted mortality (for organized care index 3, OR 0.03, 95% CI 0.02 to 0.07 for 7-day mortality; OR 0.09, 95% CI 0.05 to 0.17 for 30-day mortality; and OR 0.40, 95% CI 0.25 to 0.64 for 1-year mortality).


CONCLUSIONS
Higher level of access to care was associated with lower stroke mortality rates. Establishing a well-organized and multidisciplinary system of stroke care will help improve the quality of service delivered and reduce the burden of stroke.
Saposnik
Gustavo
G
Stroke Research Unit, Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, M5C 1R6, Canada. saposnikg@smh.toronto.on.ca
Fang
Jiming
J
O'Donnell
Martin
M
Hachinski
Vladimir
V
Kapral
Moira K
MK
Hill
Michael D
MD
D000368:Aged; D000369:Aged, 80 and over; D002170:Canada / Q000453:epidemiology; D015331:Cohort Studies; D017281:Cost of Illness; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data* / Q000639:trends; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods*; D010348:Patient Care Team / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000706:statistics & numerical data; D012042:Registries; D020521:Stroke / Q000401:mortality*; D000071939:Stroke Rehabilitation; D015996:Survival Rate / Q000639:trends