title: Acute ischaemic stroke patients - direct admission to a specialist centre or initial treatment in a local hospital? A systematic review.
abstract: OBJECTIVE
  To assess the clinical effectiveness, in acute ischaemic stroke patients, of bypassing non-specialist centres in preference for a specialist stroke centre to receive the time-critical intervention of thrombolysis.
  
  
  METHODS
  Systematic review and meta-analysis using: MEDLINE; MEDLINE In-Process; EMBASE; CINAHL; Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane CENTRAL Controlled Trials Register, DARE, NHS EED and HTA databases. Studies were included if they compared acute ischaemic stroke patients directly triaged to a specialist centre versus those initially triaged to a non-specialist centre with some or all later transferred to a specialist centre. Studies were excluded if they compared patients ever treated in a specialist centre versus those never treated in such a centre, since the aim was to assess the optimum initial triage route rather than the optimum location for overall management. The assumption being, based on previous research, that management in a specialist centre leads to better patient outcomes.
  
  
  RESULTS
  Fourteen studies investigating 2790 patients were identified. Studies comparing commencement of thrombolysis in non-specialist centres versus the specialist centres (n=1394) showed no significant difference in unadjusted mortality (OR = 0.89; 95% CI = 0.61-1.30) or morbidity (favourable modified Rankin Score, n = 899) (OR = 1.16; 95% CI = 0.85-1.59) among thrombolysed patients. In studies where thrombolysis could only be administered in a specialist centre, data for patients arriving within the therapeutic window (n = 140) revealed significantly higher mortality for those initially admitted to a non-specialist centre compared to directly admitted to a specialist centre (OR = 6.62; 95% CI = 2.60-16.82); morbidity data also favoured direct admission to a specialist centre, although not consistently.
  
  
  CONCLUSIONS
  For ischaemic stroke patients, the location of initial thrombolysis treatment does not affect outcomes. However, if thrombolysis is only available at a specialist centre, outcomes are considerably better for those patients admitted directly. However, these conclusions are based on poor quality data with small sample populations, significant heterogeneity and subject to confounding.
authors.affiliation: Honorary Senior Clinical Lecturer in Emergency Medicine, Department of Health Services Research, School of Health and Related Research, University of Sheffield, UK A.Pickering@sheffield.ac.uk.
authors.forename: Alastair
authors.initials: A
authors.lastname: Pickering
authors.affiliation: Research Fellow, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Harnan
authors.affiliation: Research Fellow, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Katy
authors.initials: K
authors.lastname: Cooper
authors.affiliation: Information Specialist, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Anthea
authors.initials: A
authors.lastname: Sutton
authors.affiliation: Professor of Emergency Medicine, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Mason
authors.affiliation: Dean, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Jon
authors.initials: J
authors.lastname: Nicholl
keywords: stroke; systematic review; thrombolysis