JAMA: Can individualized treatment help prevent stroke death?

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Patients who had an ischemic stroke and were admitted to hospitals designated as primary stroke centers had a modestly lower risk of death at 30 days, compared to patients who were admitted to non-designated hospitals, according to a study in the Jan. 26 issue of the Journal of the American Medical Association.

Responding to the need for improvements in acute stroke care, the Brain Attack Coalition (BAC) published recommendations for the establishment of primary stroke centers in 2000, and in 2003 the Joint Commission began certifying stroke centers based on these recommendations, according to background information in the article. Now, nearly 700 of the 5,000 acute care hospitals in the U.S. are Joint Commission-certified stroke centers, with some states establishing their own designation programs using the BAC core criteria.

"Despite widespread support for the stroke center concept, there is limited empirical evidence demonstrating that admission to a stroke center is associated with lower mortality," the authors wrote.

Ying Xian, MD, PhD, of the Duke Clinical Research Institute in Durham, N.C., and colleagues conducted a study to evaluate the association between admission to stroke centers for acute ischemic stroke and the rate of death. Using data from the N.Y. Statewide Planning and Research Cooperative System, the researchers compared mortality for patients admitted with acute ischemic stroke (30,947 patients) between 2005 and 2006 at designated stroke centers and non-designated hospitals. Patients were followed up for mortality for one year after hospitalization through 2007.

To assess whether the findings were specific to stroke, they also compared mortality for patients admitted with gastrointestinal hemorrhage (39,409 patients) or MI (40,024 patients) at designated stroke centers and non-designated hospitals.

Among the patients with acute ischemic stroke, 49.4 percent were admitted to designated stroke centers and 50.6 percent to non-designated hospitals, Xian and colleagues reported. The overall 30-day all-cause mortality rate was 10.1 percent for patients admitted to designated stroke centers and 12.5 percent for patients admitted to non-designated hospitals, with analysis indicating that admission to a designated stroke center hospital was associated with a 2.5 percent absolute reduction in 30-day all-cause mortality.

The use of thrombolytic therapy was 4.8 percent for patients admitted at designated stroke centers and 1.7 percent for patients admitted at non-designated hospitals (adjusted difference in use, 2.2 percent). Among patients surviving to hospital discharge, there was no difference in rates of 30-day all-cause readmission and discharge to a skilled nursing facility.

"Differences in mortality also were observed at one-day, seven-day and one-year follow-up," the authors wrote. “The outcome differences were specific for stroke, as stroke centers and non-designated hospitals had similar 30-day all-cause mortality rates among those with gastrointestinal hemorrhage or acute MI.”

"Even though the differences in outcomes between stroke centers and non-designated hospitals were modest, our study suggests that the implementation and establishment of a BAC-recommended stroke system of care was associated with improvement in some outcomes for patients with acute ischemic stroke," Xian and colleagues said.

In an accompanying JAMA editorial, Mark J. Alberts, M.D., of the Stroke Program, Northwestern University School of Medicine in Chicago, commented on the future of acute stroke care.

"A multi-tiered system of stroke care is developing, with the comprehensive stroke center (CSC) at the top of the pyramid, the primary stroke center (PSC) in the middle, and the acute stroke ready hospital (ASRH) at the base,” Alberts said. “Within a geographical region, a small number of CSCs would provide care for patients with the most complicated stroke cases; a larger number of PSCs would provide care for the patients with typical, uncomplicated cases; and the ASRH would provide initial screening and triage and begin acute care for patients in a rural, small urban or suburban setting. Emergency medical services personnel would perform initial screening and triage and would transport patients with a clearly defined stroke to the closest stroke center facility.”

Alberts concluded that using “telemedicine technologies, hospital personnel could communicate and transfer patients to the facility with the most appropriate