Association between stroke center hospitalization for acute ischemic stroke and mortality.
BACKGROUND
Although stroke centers are widely accepted and supported, little is known about their effect on patient outcomes.


OBJECTIVE
To examine the association between admission to stroke centers for acute ischemic stroke and mortality.


METHODS
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.


METHODS
Thirty-day all-cause mortality.


RESULTS
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).


CONCLUSIONS
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.
Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705, USA. ying.xian@duke.edu
Ying
Y
Xian
Robert G
RG
Holloway
Paul S
PS
Chan
Katia
K
Noyes
Manish N
MN
Shah
Henry H
HH
Ting
Andre R
AR
Chappel
Eric D
ED
Peterson
Bruce
B
Friedman
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000150:complications*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006782:Hospitals, Special / Q000145:classification / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality; D009518:New York / Q000453:epidemiology; D020521:Stroke / Q000209:etiology* / Q000401:mortality*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*
Neurology. 2003 Sep 23;61(6):792-6
14504322
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000197
17943737
Circulation. 2010 Dec 7;122(23):2459-69
21098429
JAMA. 2000 Jun 21;283(23):3102-9
10865305
Circulation. 2010 Feb 23;121(7):e46-e215
20019324
Stroke. 1996 Nov;27(11):1937-43
8898795
Med Care Res Rev. 2007 Feb;64(1):83-97
17213459
JAMA. 2007 Jan 17;297(3):278-85
17227979
Health Serv Res. 2005 Apr;40(2):435-57
15762901
JAMA. 2007 Aug 15;298(7):802-4
17699014
Stat Med. 2006 Feb 15;25(3):389-413
16382420
Arch Intern Med. 2010 May 10;170(9):804-10
20458088
Stroke. 2004 Aug;35(8):1941-5
15232123
Neurology. 2006 Jul 11;67(1):88-93
16832083
Health Serv Res. 2003 Dec;38(6 Pt 1):1423-40
14727781
Stroke. 2009 Nov;40(11):3574-9
19797179
Neurology. 2007 Feb 6;68(6):469-70
17283326
Stroke. 2010 Jun;41(6):1102-7
20395609
Stroke. 2010 Jun;41(6):1100-1
20395604
Stroke. 2003 Jun;34(6):e55-7
12750543
Annu Rev Public Health. 1998;19:17-34
9611610
JAMA. 1994 Sep 21;272(11):859-66
8078163
JAMA. 2006 Apr 26;295(16):1912-20
16639050
Neurology. 2005 Feb 8;64(3):422-7
15699369