Designated Stroke Center Status and Hospital Characteristics as Predictors of In-Hospital Mortality among Hemorrhagic Stroke Patients in New York, 2008-2012

Abstract

Background: Although designated stroke centers (DSCs) improve the quality of care and clinical outcomes for ischemic stroke patients, less is known about the benefits of DSCs for patients with intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Hypothesis: Compared to non-DSCs, hospitals with the DSC status have lower in-hospital mortality rates for hemorrhagic stroke patients. We believed these effects would sustain over a period of time after adjusting for hospital-level characteristics, including hospital size, urban location, and teaching status. Methods and Results: We evaluated ICH (International Classification of Diseases, Ninth Revision; ICD-9: 431) and SAH (ICD-9: 430) hospitalizations documented in the 2008-2012 New York State Department of Health Statewide Planning and Research Cooperative System inpatient sample database. Generalized estimating equation logistic regression was used to evaluate the association between DSC status and in-hospital mortality. We calculated ORs and 95% CIs adjusted for clustering of patients within facilities, other hospital characteristics, and individual level characteristics. Planned secondary analyses explored other hospital characteristics associated with in-hospital mortality. In 6,352 ICH and 3,369 SAH patients in the study sample, in-hospital mortality was higher among those with ICH compared to SAH (23.7 vs. 18.5%). Unadjusted analyses revealed that DSC status was related with reduced mortality for both ICH (OR 0.7, 95% CI 0.5-0.8) and SAH patients (OR 0.4, 95% CI 0.3-0.7). DSC remained a significant predictor of lower in-hospital mortality for SAH patients (OR 0.6, 95% CI 0.3-0.9) but not for ICH patients (OR 0.8, 95% CI 0.6-1.0) after adjusting for patient demographic characteristics, comorbidities, hospital size, teaching status and location. Conclusions: Admission to a DSC was independently associated with reduced in-hospital mortality for SAH patients but not for those with ICH. Other patient and hospital characteristics may explain the benefits of DSC status on outcomes after ICH. For conditions with clear treatments such as ischemic stroke and SAH, being treated in a DSC improves outcomes, but this trend was not observed in those with strokes, in those who did not have clear treatment guidelines. Identifying hospital-level factors associated with ICH and SAH represents a means to identify and improve gaps in stroke systems of care.

Stroke in-hospital survival and its predictors: the first results from Tabriz Stroke Registry of Iran

“…It has been shown that regardless of the individual predictors of in-hospital mortality, being admitted to a designated stroke center could improve survival after intracerebral hemorrhage. 3 The overall case-fatality proportion was 12.5% in current study. It reached up to 25.1% in Imam Reza University Hospital vs only 1.7% in Razi University Hospital.…”

“… 1 Hemorrhagic stroke ranks the highest with respect to in-hospital fatality among stroke subtypes, with a range of about 24%–28% reported based on various studies. 1 – 3 It is also considered a major public health problem with high morbidity and mortality in low- and middle-income countries, including Iran, with rates exceeding that in high-income countries. 4 – 8 …”

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

“…The effect of hospital characteristics and health systems of care—including physician expertise, case volumes, and care provision in dedicated neurocritical care units—on outcomes for patients with aSAH has been described in large nonrandomized studies. 67–69,71,75–77 Specifying exact case volumes for what should constitute a high-volume center versus a low-volume center is particularly challenging given the heterogeneity of studies. Thus, specific case numbers are not included in Recommendation 1; instead, the case numbers used in the 2012 aSAH guideline are included in the Synopsis for historical reference.…”

“…72,75 Stroke center designation has been associated with reduced in-hospital mortality for patients with aSAH. 71 Timely arrival of patients with aSAH in hospitals where they can receive both aneurysm treatment and neurocritical care is relevant given the risks for aneurysm rerupture and DCI. 70,73,74 According to US Nationwide Inpatient Samples, factors associated with treatment delay in aSAH were older age, non-White race, Medicaid payer status, surgical clipping, and admission to low-surgical-volume hospitals.…”

Association between Clinical and Laboratory Markers and 5-year Mortality among Patients with Stroke

“…Red blood cell count (RCC) 8 , mean corpuscular volume (MCV) 8 , mean platelet volume 9 , low diastolic blood pressure 10 during admission, pyrexia 10 , and severe obesity 11 were factors associated with post-stroke mortality in patients with ischemic stroke. In addition, anemia 12 and hospital size 13 influence post-stroke mortality in patients with hemorrhagic stroke. Moreover, white blood cell count 14 , serum creatinine levels 14 , hyperglycemia 15 , hyponatremia 16 , red cell distribution width (RDW) 17 , systolic blood pressure 14 , hyperthermia 18 , and residential environment 19 influence post-stroke mortality in patients with combined ischemic and hemorrhagic stroke.…”