Stroke Center Hospitalization for Elderly Stroke Patients

Study Questions:

What is the association of case fatality with receiving care in a Primary Stroke Center (PSC) versus other hospitals for patients with stroke, and does prolonged travel time offset the effect of PSCs?

Methods:

This was a retrospective cohort study of Medicare beneficiaries with stroke admitted to a hospital between January 1, 2010, and December 31, 2013. Drive times were calculated based on zip code centroids and street-level road network data. The investigators used an instrumental variable analysis based on the differential travel time to PSCs to control for unmeasured confounding. The setting was a 100% sample of Medicare fee-for-service claims. The main outcome measures were 7-day and 30-day post-admission case-fatality rates.

Results:

Among 865,184 elderly patients with stroke (mean age, 78.9 years; 55.5% female), 53.9% were treated in PSCs. The authors found that admission to PSCs was associated with 1.8% (95% confidence interval [CI], −2.1% to −1.4%) lower 7-day and 1.8% (95% CI, −2.3% to −1.4%) lower 30-day case fatality. Fifty-six patients with stroke needed to be treated in PSCs to save one life at 30 days. Receiving treatment in PSCs was associated with a 30-day survival benefit for patients traveling <90 minutes, but traveling ≥90 minutes offset any benefit of PSC care.

Conclusions:

The authors concluded that hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals.

Perspective:

This study reports that hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals. Traveling at least 90 minutes to receive care offset the 30-day survival benefit of PSCs. Further investigations are necessary to identify the best combination of approaches to improve access to centers of excellence and stroke outcomes, and to improve care in noncertified hospitals. The most cost-effective and optimal strategies will occur in the context of a unified stroke system of care that brings together centers of varying capability that are publicly and accurately reporting their performance data, engaged in continuous quality improvement, and focused on what is best for each and every patient.

Clinical Topics: Geriatric Cardiology

Keywords: Aged, Fee-for-Service Plans, Geriatrics, Hospitalization, Medicare, Mortality, Outcome Assessment (Health Care), Quality Improvement, Stroke, Travel, Vascular Diseases


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