Stroke Center Certification and Mortality After Stroke

Study Questions:

Primary Stroke Center (PSC) certification is associated with improvement in stroke process measures, but is certification also associated with better stroke outcomes?

Methods:

Patient-level data for Medicare beneficiaries ≥65 years with a primary discharge diagnosis of ischemic stroke were obtained from the Medicare Provider Analysis and Review (MEDPAR) database. Hospitals were classified as new PSCs (certification between 2009 and 2013), existing PSCs (certification before 2009), and non-PSCs. Outcome measures included in-hospital, 30-day, and 1-year all-cause mortality; hospital length of stay (LOS); and proportion discharged-to-home.

Results:

A total of 1,165,960 Medicare beneficiaries hospitalized between 2009 and 2013 for ischemic stroke were included in the analysis. Among them, 286,396 (24.6%) were treated at 634 new PSCs; 542,875 (46.6%) were treated at 785 existing PSCs; and 336,689 (28.9%) were treated at 2,640 non-PSCs. Existing PSCs had more beds and more annual stroke admissions than new PSCs, which in turn had more beds and more stroke admissions that non-PSCs. Patients at existing PSCs were more likely to have complicated and uncomplicated hypertension, myocardial infarction, congestive heart failure, atrial fibrillation, prior cerebrovascular disease, and malignancy. Of the three hospital classifications, new PSCs had lower in-hospital and 30-day all-cause mortality than existing PSCs, both before and after adjustment for patient and hospital characteristics. New PSCs had lower in-hospital, 30-day, and 1-year mortality than non-PSCs before and after adjustment. Existing PSCs had lower 1-year mortality than non-PSCs before and after adjustment. Non-PSCs had a shorter LOS and higher proportion discharged-to-home than new and existing PSCs.

Conclusions:

New PSCs had lower in-hospital and 30-day unadjusted and adjusted all-cause mortality than existing PSCs and non-PSCs. These data suggest that the process of obtaining initial PSC certification may improve stroke care for Medicare beneficiaries ≥65 years.

Perspective:

This study is most limited by the lack of patient-level information about stroke severity. Patients at existing PSCs, which tend to be larger hospitals with more annual stroke admissions, likely have more severe strokes than patients at new or non-PSCs. Stroke severity is likely associated with higher mortality, longer LOS, and a lower proportion of patients discharged-to-home, independent of the quality of stroke care delivered.


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