A Finnish study included huge numbers of patients – 20,045 at comprehensive stroke centers, 10,749 at primary stroke centers, and 30,891 at general hospitals. Compared with 1-year death rates at general hospitals, rates were 11% lower at primary stroke centers and 16% lower at comprehensive stroke centers. Rates of institutional care were lower at the stroke centers, and the proportions of patients who could go home at 1 year increased by 16% and 22% at the two types of stroke centers, respectively (Stroke 2010;41:1102-7).
Explore This IssueACEP News: Vol 30 – No 12 – December 2011
A second project in New York State looked at 30,947 patients with acute ischemic stroke in 2005-2006, 15,297 of whom were admitted to a designated primary stroke center. As an internal control group, the study looked at 39,000 patients who were admitted for GI hemorrhage and 40,000 who were admitted for MI to see if these were just better hospitals or if the “stroke center” designation made a difference.
Mortality was significantly lower at primary stroke centers compared with other hospitals at four follow-up time points (0.3% lower within 1 day, 1.3% lower at 7 days, 2.5% lower at 30 days, and 3% lower at 1 year). This is a hard end point. This benefit was consistent in analyses comparing subgroups of hospitals by location or by race or ethnicity (JAMA 2011;305:373-80).
A 2%-3% reduction in deaths from strokes in the United States would mean 16,000-24,000 fewer deaths. There are very few medical interventions that reduce deaths. Trauma centers reduce deaths, and we have molded the stroke center concept after that of the trauma center.
Stroke centers are beneficial for patients and improve outcomes in many ways. They reduce death, and few things do. They improve clinical outcomes and increase the use of TPA. They provide more efficient care and are more effective in starting secondary prevention medications. There are more than 800 hospitals designated as primary stroke centers by the Joint Commission – they can’t all be wrong!
Dr. Alberts is professor of neurology, director of the stroke program, and chief of the division of stroke and cerebrovascular disease at Northwestern University, Chicago. He has received honoraria from Genentech, which makes TPA. Dr. Alberts and Dr. Johnston debated this topic at the American Stroke Association’s International Stroke Conference 2011.
Hospital’s efforts and resources matter, not designation.
I want to remind readers what the question is: Does a “stroke center” designation – not the centers themselves, but the designation – improve patient outcomes?