Higher Stroke Unit Volume Associated With Improved Quality of Early Stroke Care and Reduced Length of Stay

Svendsen, Marie Louise; Ehlers, Lars Holger; Ingeman, Annette; Johnsen, Søren Paaske

doi:10.1161/strokeaha.111.645184

Cited by 45 publications

(34 citation statements)

References 33 publications

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“…1 Other studies that have examined hospital stroke volume and outcome relationship have shown no benefit in mortality across volume categories; however, most of these studies had few small-volume hospitals, and those considered small had volumes <250. 7,8 Ogbu et al 8 found similar results to our study when hospital quartiles were categorized as small volume being considered <50 patients, and a previous Canadian study found that only the highest volume quartile shows significantly lower mortality rates compared with the lowest quartile. The inconsistent results across countries suggest that the effect of patient volumes on outcomes may differ in each country and dependent on volume categories selected.…”

Section: Discussionsupporting

confidence: 87%

Does the Volume of Ischemic Stroke Admissions Relate to Clinical Outcomes in the Ontario Stroke System?

Hall

Fang

Hodwitz

et al. 2015

Circ: Cardiovascular Quality and Outcomes

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Background— Better outcomes have been found among hospitals treating higher volumes of patients for specific surgical and medical conditions. We examined hospital ischemic stroke (IS) volume and 30-day mortality to inform regionalization planning. Methods and Results— Using a population-based hospital discharge administrative database (2005/2006 to 2011/2012), average annual IS patient volumes were calculated for 162 Ontario acute hospitals. Hospitals were ranked and classified as small (<126), medium (126–202), and large (>202). Hierarchical multivariable logistic regression was used to estimate the odds of death within 7 and 30 days to account for the homogeneity in outcomes for patients treated at the same hospital. Overall, 73 368 patients were hospitalized for IS, and 30-day mortality was 15.3%. The mean (±SD) of annual hospitalizations for IS was 29 (31) for small-volume hospitals, 156 (20) for medium-volume hospitals, and 300 (78) for high-volume hospitals. High-volume hospitals admitted younger patients (mean [±SD] age, 73.0 [13.9] years) compared with medium- and small-volume hospitals (74.0 [13.2] and 75.5 [12.5] years, respectively; P <0.0001). Patients at small-volume hospitals were more likely than patients at high-volume hospitals to die at 30 days after an acute IS (adjusted odds ratio, 1.37; 95% confidence interval, 1.14–1.65). Conclusions— Hospital IS volume is associated with 30-day mortality in Ontario. Patients admitted to hospitals with annual IS volumes <126 annually are more likely to die within 30 days than patients admitted to hospitals that see on average 300 patients annually. This finding supports centralizing care in stroke-specialized hospitals.

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Section: Discussionsupporting

confidence: 87%

Does the Volume of Ischemic Stroke Admissions Relate to Clinical Outcomes in the Ontario Stroke System?

Hall

Fang

Hodwitz

et al. 2015

Circ: Cardiovascular Quality and Outcomes

View full text Add to dashboard Cite

show abstract

“…This finding agrees with findings from a nationwide Danish study 10 but not with most other studies on stroke patient volume. [3][4][5][6][7][8][9] It seems that, in some contexts, it is possible to uphold the same quality of stroke care in small as in large hospitals.…”

Section: Discussionsupporting

confidence: 91%

Diagnostic Procedures, Treatments, and Outcomes in Stroke Patients Admitted to Different Types of Hospitals

Asplund

Sukhova

Wester

et al. 2015

Stroke

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Background and Purpose— In many countries, including Sweden, initiatives have been taken to reduce between-hospital differences in the quality of stroke services. We have explored to what extent hospital type (university, specialized nonuniversity, or community hospital) influences hospital performance. Methods— Riksstroke collects clinical data during hospital stay (national coverage 94%). Follow-up data at 3 months were collected using administrative registers and a questionnaire completed by surviving patients (response rate 88%). Structural data were collected from a questionnaire completed by hospital staff (response rate 100%). Multivariate analyses with adjustment for clustering were used to test differences between types of hospitals. Results— The proportion of patients admitted directly to a stroke unit was highest in community hospitals and lowest in university hospitals. Magnetic resonance, carotid imaging, and thrombectomy were more frequently performed in university hospitals, and the door-to-needle time for thrombolysis was shorter. Secondary prevention with antihypertensive drugs was used less often, and outpatient follow-up was less frequent in university hospitals. Fewer patients in community hospitals were dissatisfied with their rehabilitation. After adjusting for possible confounders, poor outcome (dead or activities of daily living dependency 3 months after stroke) was not significantly different between the 3 types of hospital. Conclusions— In a setting with national stroke guidelines, stroke units in all hospitals, and measurement of hospital performance and benchmarking, outcome (after case-mix adjustment) is similar in university, specialized nonuniversity, and community hospitals. There seems to be fewer barriers to organizing well-functioning stroke services in community hospitals compared with university hospitals.

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“…process-driven care. 21 The unanswered question is, does quality of patient/family discussions regarding feeding decisions suffer at the expense of efficiency? Strategies that incorporate family discussions into processes of care 22 and standardization of the approach with tools such as decision aids 23 may help to prevent overlooking key dialogues that patient's and their families may find important.…”

Section: Discussionmentioning

confidence: 99%

Timing of Percutaneous Endoscopic Gastrostomy for Acute Ischemic Stroke

George

Kelly

Albert

et al. 2017

Stroke

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Background and Purpose-Stroke guidelines recommend time-limited trials of nasogastric feeding prior to percutaneous endoscopic gastrostomy (PEG) tube placement. We sought to describe timing of PEG placement and identify factors associated with early PEG for acute ischemic stroke. Methods-We designed a retrospective observational study to examine time to PEG for ischemic stroke admissions in the Nationwide Inpatient Sample, 2001 to 2011. We defined early PEG placement as 1 to 7 days from admission. Using multivariable regression analysis, we identified the effects of patient and hospital characteristics on PEG timing. Results-We identified 34 623 admissions receiving a PEG from 2001 to 2011, 53% of which received the PEG 1 to 7 days from admission. Among hospitals placing ≥10 PEG tubes, median time to PEG for individual hospitals ranged from 3 days to over 3 weeks (interquartile range 6-8.5 days). Older adult age groups were associated with early PEG (≥85 years versus 18-54 years: adjusted odds ratio 1.68, 95% confidence interval 1.50-1.87). Those receiving a PEG and tracheostomy were more likely to receive the PEG beyond 7 days, and these patients were more often younger compared with PEG only recipients. Those admitted to high-volume hospitals were more likely to receive their PEG early (≥350 versus <150 hospitalizations; adjusted odds ratio 1.26, 95% confidence interval 1.17-1.35). Conclusions-More than half of the PEG recipients received their surgical feeding tube within 7 days of admission. The oldest old, who may benefit most from time-limited trials of nasogastric feeding for ≥2 to 3 weeks, were most likely to receive a PEG within 7 days.

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Higher Stroke Unit Volume Associated With Improved Quality of Early Stroke Care and Reduced Length of Stay

Cited by 45 publications

References 33 publications

Does the Volume of Ischemic Stroke Admissions Relate to Clinical Outcomes in the Ontario Stroke System?

Does the Volume of Ischemic Stroke Admissions Relate to Clinical Outcomes in the Ontario Stroke System?

Diagnostic Procedures, Treatments, and Outcomes in Stroke Patients Admitted to Different Types of Hospitals

Timing of Percutaneous Endoscopic Gastrostomy for Acute Ischemic Stroke

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