Geographic differences in acute stroke care in Catalunya: impact of a regional interhospital network.
Limited resources prevent specialized care in community hospitals (CH) challenging geographical equity. We studied the impact of a regional interhospital network based on urgent transfer from 4 CH to a referral stroke center (RSC).


METHODS
During 2006, all stroke patients admitted to the 5 networked hospitals (4 CH, 1 RSC) were studied: clinical pathways and stroke interventions were recorded. Physicians at CH decided emergent transfer under their clinical judgment. Quality therapeutic measures where defined: urgent expert neurological evaluation, stroke unit admission and thrombolytic treatment. For patients receiving tissue plasminogen activator, demographic and outcome data were recorded: clinical improvement (decrease > or =4 National Institute of Health Stroke Scale points at discharge), total recovery (3-month modified Rankin Scale score > or =1).


RESULTS
From a total of 1,925 acute stroke patients, 1,587 were admitted to the RSC (1,396 primarily). Of 529 primarily admitted to CH, 191 (36.1%) were emergently transferred. Patients primarily admitted to the RSC were more frequently evaluated by a neurologist (100 vs. 34%; p < 0.001) and admitted to a stroke unit (22.7 vs. 11.7%; p < 0.001). However, the rate of thrombolytic treatment was similar (4.4 vs. 5.1%; p = 0.491). After initial assessment at the RSC, 92 (48.2%) transfers were considered unnecessary. Transferred patients accounted for 27/88 (30.7%) thrombolyses performed in the RSC. Baseline characteristics were similar, except a longer time to treatment (164 vs. 211 min; p = 0.004) and more frequent early ischemia CT signs among transferred patients (23 vs. 53%; p = 0.037). Clinical improvement (62 vs. 50%; p = 0.273) and symptomatic hemorrhagic transformation (6.8 vs. 3.8%; p = 0.596) were similar. However, among transferred patients, the degree of total recovery was lower (44 vs. 22%; p = 0.05).


CONCLUSIONS
An interhospital network based on transfers to an RSC does not warrant geographical equity: equal access to best therapeutic interventions is only partially achieved at the expense of a high proportion of unnecessary transfers.
Ribo
Marc
M
Unitat Neurovascular, Servei de Neurología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España. marcriboj@hotmail.com
Molina
Carlos A
CA
Pedragosa
Angels
A
Sanclemente
Carme
C
Santamarina
Estevo
E
Rubiera
Marta
M
Delgado-Mederos
Raquel
R
Maisterra
Olga
O
Quintana
Manuel
M
Alvarez-Sabin
Jose
J
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D019058:Community Networks / Q000458:organization & administration*; D019091:Critical Pathways / Q000458:organization & administration; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006764:Hospitals, Community / Q000458:organization & administration*; D006785:Hospitals, University / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D010043:Outcome and Process Assessment, Health Care; D010360:Patient Transfer; D015397:Program Evaluation; D012040:Regional Health Planning; D012111:Residence Characteristics; D013030:Spain; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D015912:Thrombolytic Therapy; D016896:Treatment Outcome