title: Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis.
abstract: OBJECTIVE
  To investigate whether centralisation of acute stroke services in two metropolitan areas of England was associated with changes in mortality and length of hospital stay.
  
  
  METHODS
  Analysis of difference-in-differences between regions with patient level data from the hospital episode statistics database linked to mortality data supplied by the Office for National Statistics.
  
  
  METHODS
  Acute stroke services in Greater Manchester and London, England.
  
  
  METHODS
  258,915 patients with stroke living in urban areas and admitted to hospital in January 2008 to March 2012.
  
  
  METHODS
  "Hub and spoke" model for acute stroke care. In London hyperacute care was provided to all patients with stroke. In Greater Manchester hyperacute care was provided to patients presenting within four hours of developing symptoms of stroke.
  
  
  METHODS
  Mortality from any cause and at any place at 3, 30, and 90 days after hospital admission; length of hospital stay.
  
  
  RESULTS
  In London there was a significant decline in risk adjusted mortality at 3, 30, and 90 days after admission. At 90 days the absolute reduction was -1.1% (95% confidence interval -2.1 to -0.1; relative reduction 5%), indicating 168 fewer deaths (95% confidence interval 19 to 316) during the 21 month period after reconfiguration in London. In both areas there was a significant decline in risk adjusted length of hospital stay: -2.0 days in Greater Manchester (95% confidence interval -2.8 to -1.2; 9%) and -1.4 days in London (-2.3 to -0.5; 7%). Reductions in mortality and length of hospital stay were largely seen among patients with ischaemic stroke.
  
  
  CONCLUSIONS
  A centralised model of acute stroke care, in which hyperacute care is provided to all patients with stroke across an entire metropolitan area, can reduce mortality and length of hospital stay.
authors.affiliation: Department of Applied Health Research, University College London, London WC1E 7HB, UK steve.morris@ucl.ac.uk.
authors.forename: Stephen
authors.initials: S
authors.lastname: Morris
authors.affiliation: Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
authors.forename: Rachael M
authors.initials: RM
authors.lastname: Hunter
authors.affiliation: Department of Applied Health Research, University College London, London WC1E 7HB, UK.
authors.forename: Angus I G
authors.initials: AI
authors.lastname: Ramsay
authors.affiliation: Manchester Business School, University of Manchester, Manchester M15 6PB, UK.
authors.forename: Ruth
authors.initials: R
authors.lastname: Boaden
authors.affiliation: Division of Health and Social Care Research, School of Medicine, King's College London, London SE1 3QD, UK.
authors.forename: Christopher
authors.initials: C
authors.lastname: McKevitt
authors.affiliation: Manchester Business School, University of Manchester, Manchester M15 6PB, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Perry
authors.affiliation: King's College London Stroke Research Patients and Family Group, Division of Health and Social Care Research, School of Medicine, King's College London, London SE1 3QD, UK.
authors.forename: Nanik
authors.initials: N
authors.lastname: Pursani
authors.affiliation: Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK.
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Rudd
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
authors.affiliation: Department of Applied Health Research, University College London, London WC1E 7HB, UK.
authors.forename: Simon J
authors.initials: SJ
authors.lastname: Turner
authors.affiliation: University of Manchester Stroke and Vascular Centre, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford M6 8HD, UK.
authors.forename: Pippa J
authors.initials: PJ
authors.lastname: Tyrrell
authors.affiliation: Division of Health and Social Care Research, School of Medicine, King's College London, London SE1 3QD, UK National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.
authors.forename: Charles D A
authors.initials: CD
authors.lastname: Wolfe
authors.affiliation: Department of Applied Health Research, University College London, London WC1E 7HB, UK.
authors.forename: Naomi J
authors.initials: NJ
authors.lastname: Fulop
mesh_terms: D000368:Aged; D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D020379:Risk Adjustment; D020521:Stroke / Q000401:mortality* / Q000628:therapy*; D019037:Urban Health Services / Q000458:organization & administration*
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