Certified stroke centers may improve outcomes, but travel time may be a hindrance

In December 2003, the American Heart Association and American Stroke Association worked with the Joint Commission to established a primary stroke center certification program. Since then, more than 1,000 acute care hospitals have received the certification. It is a recognition that they have met certain standards and implemented performance measures and clinical practice guidelines.

Although the certification is a step in the right direction, researchers recently wondered whether the benefits of primary stroke centers outweighed the often longer travel time it takes for patients to get to the centers.

Lead researcher Kimon Bekelis, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues evaluated more than 865,000 Medicare beneficiaries who were admitted to a hospital between Jan. 1, 2010 and Dec. 31, 2013. Of the patients, 53.9 percent were treated in primary stroke centers.

Their conclusion? Sending patients to primary stroke centers was associated with a 30-day survival benefit if they traveled less than 90 minutes. Otherwise, there was no survival benefit.

Overall, admission to primary stroke centers was associated with a 1.8 percent reduction in both 7-day and 30-day case fatality.

“Travel times of at least 90 minutes appear to negate 30-day mortality gains arising from admission to a [primary stroke center],” the researchers wrote in JAMA Internal Medicine on July 25. “As suggested by our finding of higher thrombolytic and mechanical thrombectomy rates in [primary stroke centers], superior outcomes in [primary stroke centers] likely reflect organized, disease-specific, efficient care, as well as the timely administration of the optimal treatments and efficient blood pressure optimization. Among those living between 60 and 89 minutes from a [primary stroke center], the finding that [primary stroke center] benefits arise only after 30 days (but not at 7 days) could reflect additional postacute services available through [primary stroke centers].”

The researchers noted that a significant number of patients who suffer strokes live more than 90 minutes from a primary stroke center. As such, healthcare leaders have discussed creating more stroke centers, although the costs and time may be prohibitive.

“Building on the experience of trauma care, the optimal use of air services with the existing [primary stroke center] locations could expand access within this time frame for almost all patients with stroke,” the researchers wrote. “This alternative is just one approach from a plethora of available options to address disparities in access and follow the recommendations of the Institute of Medicine to maximize the use of local referral centers. Other potential solutions include expanding telemedicine applications, enhancing smaller hospitals into Acute Stroke–Ready Hospitals, and creating broader hospital networks. Further investigations are necessary to identify the best combination of approaches to treat patients with stroke.”