ARTICLE IN BRIEF
A new study found that the overall 30-day all-cause mortality rate for patients admitted to stroke centers in New York state was 10.1 percent compared to 12.5 percent for patients admitted to nondesignated hospitals; the use of thrombolytic therapy was 4.8 percent for patients at stroke centers, compared to 1.7 percent at nondesignated centers.
DR. JAMES C. GROTTA ...Image Tools
Patients who had an acute ischemic stroke had a better chance of surviving if they went to a designated stroke center, according to a study in the Jan. 26 issue of the Journal of the American Medical Association.
Although there have been anecdotal reports to support that finding, few empirical studies had been done to confirm it — until now.
The investigators compared 30,497 patients in New York state hospitals between 2005 and 2006. Almost half, 49.4 percent, were admitted to designated stroke centers and the rest went to nondesignated hospitals; mortality rates were recorded at one-day, seven-day and one-year markers.
“This is a valuable study and well carried out,” said Robert J. Adams, MD, director of the South Carolina Stroke Center of Excellence, and professor of neuroscience at the Medical University of South Carolina in Charleston, who was not involved with the study. “It's a good place to carry it out because New York has been doing state certification for its stroke centers for almost a decade.
“What we'd like to know is how to make the system better,” Dr. Adams continued. “We'd like to understand whether morbidity is also improved because you can change mortality and still have a less favorable outcome overall, depending on what happens with the survivor,h Dr. Adams said. You can just move them to the next rank of severely disabled and you wonder: YDid you do them any big favor?”D
The investigators found that the overall 30-day all-cause mortality rate for patients admitted to stroke centers was 10.1 percent compared to 12.5 percent (p<.001) for patients admitted to nondesignated hospitals.
USE OF THROMBOLYTIC THERAPY
The study also found that the use of thrombolytic therapy was 4.8 percent for patients at stroke centers, compared to 1.7 percent (p<.001) at nondesignated centers.
Jeffrey L. Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California Los Angeles (UCLA) and director of the UCLA Stroke Center, said he didn't think the mortality endpoint was influenced by the higher use of tissue plasminogen activator (tPA), but by the expertise and experience at the stroke centers.
“The brain is a complex organ and stroke is a complex disease, so using hospital systems to provide a package of supportive care makes a major difference,” Dr. Saver said. “Optimal care includes early implementation of antiplatelet agents, use of antipyretics and antibiotics to lower elevated temperature, delivering the right amount of intravenous fluids, early institution of rehabilitation, deep venous thrombosis prophylaxis, and early start of secondary prevention therapies — each plays a modest role, but when a team integrates them all correctly, collectively they have a great impact.”
Nearly 700 of the 5,000 acute care hospitals in the United States are Joint Commission-certified stroke centers. According to the study, several states, including New York, Florida, and Massachusetts, established their own designated stroke programs.
The hope in completing the study was to provide empirical evidence demonstrating that admission to a stroke center is associated with lower mortality, the study authors said.
Study author Robert G. Holloway, MD, MPH, professor of neurology and community and preventive medicine at the University of Rochester School of Medicine and Dentistry, said he wasn't surprised by the findings. The results were “a long time in coming” because while there was a lot of anecdotal evidence to support the benefits of stroke centers, it was more of a challenge to develop empirical data. Similar studies with similar results had previously been completed in Finland and Europe. Dr. Holloway is an associate editor of Neurology Today.
While researchers were unable to measure other types of outcome besides mortality, it was interesting to note what did not change. The proportion of patients discharged to a nursing home, or readmitted within 30 days, did not differ between the two groups.
“The concept of care coordination will only become more important as health care reform unfolds and we are increasingly held accountable to the care, outcomes and resources we provide,” said Dr. Holloway. “The stroke center concept — developing criteria or exemplary attributes to achieve superior performance — will become increasingly important for many of our neurological conditions.”
Dr. Holloway said the future of stroke care will definitely include further regionalization, specialization, and increasing use of telemedicine.
The hope is that primary (or designated) stroke centers will be the first level of specialized stroke care and that comprehensive stroke centers will emerge as the most specialized center, offering full intra-arterial and neurosurgical capabilities.
That's not realized yet nationally, but that kind of tiered approach would allow for geographic challenges,” he said, adding that future evaluations of these system changes can continue to guide the planning of stroke care in the future.
HOW TO TRIAGE PATIENTS
What do the study findings mean in terms of triaging patients who have strokes? James C. Grotta, MD, chair of neurology at the University of Texas Medical School at Houston and director of the Stroke Program at Texas Medical Center, who was not involved with the study, said: “Simply having all the patients going to primary stroke centers at first is not the way.”
[Primary stroke centers deal with typical, uncomplicated cases of stroke, while more complex strokes can be referred to specialized comprehensive stroke centers, which include options for neuro-interventional radiology.]
DR. JEFFREY L. SAVER...Image Tools
“We need to figure out which ones should go to primary and which patients should go to a comprehensive center,” said Dr. Grotta, a member of the Neurology Today editorial advisory board. “It makes sense that stroke triage should be more like trauma triage. Severe strokes should go straight to a comprehensive center just as severe trauma goes to a level 1 trauma center. The milder strokes should stop at the nearest primary stroke centers.
“The main question of how to orchestrate the triage of patient and which hospital they should go to is something we urgently need to address, because, as this paper demonstrates, it makes a difference.
“If the stroke is severe, they should be routed to a comprehensive center, and the whole question is how to orchestrate the triage of patient and which hospital is something we need to develop, because, as this paper demonstrates, it makes a difference.”
The study might help hospitals that were looking for funding to become a designated stroke center, said Ralph L. Sacco, MD, chairman of neurology at the University of Miami Miller School of Medicine, who was not involved with the study. But he cautioned that it wasn't simply a matter of money.
“Protocols need to be set up regarding stroke care, and there needs to be a certain amount of education and collection of data,” said Dr. Sacco. “They can't just hand out a shingle and be a stroke center.”
Dr. Adams agreed. “Everybody can't be good at everything,” he said. “But this study makes it clear that going to a stroke certified hospital improves the chances for survival.” •