Outcomes after ischemic stroke for hospitals with and without Joint Commission-certified primary stroke centers

The role of stroke care infrastructure on the effectiveness of a hub-and-spoke telestroke model in South Carolina

OBJECTIVE

To examine the relationship between stroke care infrastructure and stroke quality-of-care outcomes at 29 spoke hospitals participating in the Medical University of South Carolina (MUSC) hub-and-spoke telestroke network.

MATERIALS AND METHODS

Encounter-level data from MUSC's telestroke patient registry were filtered to include encounters during 2015-2022 for patients aged 18 and above with a clinical diagnosis of acute ischemic stroke, and who received intravenous tissue plasminogen activator. Unadjusted and adjusted generalized estimating equations assessed associations between time-related stroke quality-of-care metrics captured during the encounter and the existence of the two components of stroke care infrastructure-stroke coordinators and stroke center certifications-across all hospitals and within hospital subgroups defined by size and rurality.

RESULTS

Telestroke encounters at spoke hospitals with stroke coordinators and stroke center certifications were associated with shorter door-to-needle (DTN) times (60.9 min for hospitals with both components and 57.3 min for hospitals with one, vs. 81.2 min for hospitals with neither component, p <.001). Similar patterns were observed for the percentage of encounters with DTN time of ≤60 min (63.8% and 68.9% vs. 32.0%, p <.001) and ≤45 min (34.0% and 38.4% vs. 8.42%, p <.001). Associations were similar for other metrics (e.g., door-to-registration time), and were stronger for smaller (vs. larger) hospitals and rural (vs. urban) hospitals.

CONCLUSIONS

Stroke coordinators or stroke center certifications may be important for stroke quality of care, especially at spoke hospitals with limited resources or in rural areas.

Heterogeneity of State Stroke Center Certification and Designation Processes

BACKGROUND

Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification.

METHODS

In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category.

RESULTS

Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6).

CONCLUSIONS

Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.

Do Quality Measures or Hospital Characteristics Predict Readmission Penalties for Hip and Knee Arthroplasty?

BACKGROUND

Quality rating systems exist to grade the value of care provided by hospitals, but the extent to which these rating systems correlate with patient outcomes is unclear. The association of quality rating systems and hospital characteristics with excess readmission penalties for total hip arthroplasty (THA) and total knee arthroplasty (TKA) was studied.

METHODS

The fiscal year 2022 Inpatient Prospective Payment System final rule was used to identify 2,286 hospitals subject to the Hospital Readmissions Reduction Program. Overall, 6 hospital quality rating systems and 5 hospital characteristics were obtained. These factors were analyzed to determine the effect on hospital penalties for THA and TKA excess readmissions.

RESULTS

Hospitals that achieved a higher Medicare Overall Hospital Quality Star Rating demonstrated a significantly lower likelihood of receiving THA and TKA readmission penalties (Cramer's V = 0.236 and Rp = -0.233; P < .001 for both). Hospitals ranked among the US News & World Report's top 50 best hospitals for orthopaedics were significantly less likely to be penalized (V = 0.042; P = .043). The remaining 4 quality rating systems were not associated with readmission penalties. Penalization was more likely for hospitals with fewer THA and TKA discharges (Rp = -0.142; P < .001), medium-sized institutions (100 to 499 beds; V = 0.075; P = .002), teaching hospitals (V = 0.049; P = .019), and safety net hospitals (V = 0.043; P = .039). Penalization was less likely for West and Midwest hospitals (V = 0.112; P < .001).

CONCLUSIONS

A higher Overall Hospital Quality Star Rating and recognition among the US News & World Report's top 50 orthopaedic hospitals were associated with a reduced likelihood of THA and TKA readmission penalties. The other 4 widely accepted quality rating systems did not correlate with readmission penalties. Teaching and safety net hospitals may be biased toward higher readmission rates.

Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence

BACKGROUND

Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally.

METHODS

A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR.

RESULTS

There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%).

CONCLUSIONS

Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.

Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach

BACKGROUND

Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer.

METHODS

This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center.

RESULTS

Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer.

CONCLUSIONS

Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.

Association of short-term hospital-level outcome metrics with 1-year mortality and recurrence for US Medicare beneficiaries with ischemic stroke

BACKGROUND

Whether stroke patients treated at hospitals with better short-term outcome metrics have better long-term outcomes is unknown. We investigated whether treatment at US hospitals with better 30-day hospital-level stroke outcome metrics was associated with better 1-year outcomes, including reduced mortality and recurrent stroke, for patients after ischemic stroke.

METHODS

This cohort study included Medicare fee-for-service beneficiaries aged ≥65 years discharged alive from US hospitals with a principal diagnosis of ischemic stroke from 07/01/2015 to 12/31/2018. We categorized patients by the treating hospital's performance on the CMS hospital-specific 30-day risk-standardized all-cause mortality and readmission measures for ischemic stroke from 07/01/2012 to 06/30/2015: Low-Low (both CMS mortality and readmission rates for the hospital were <25th percentile of national rates), High-High (both >75th percentile), and Intermediate (all other hospitals). We balanced characteristics between hospital performance categories using stabilized inverse probability weights (IPW) based on patient demographic and clinical factors. We fit Cox models assessing patient risks of 1-year all-cause mortality and ischemic stroke recurrence across hospital performance categories, weighted by the IPW and accounting for competing risks.

RESULTS

There were 595,929 stroke patients (mean age 78.9±8.8 years, 54.4% women) discharged from 2,563 hospitals (134 Low-Low, 2288 Intermediate, 141 High-High). For Low-Low, Intermediate, and High-High hospitals, respectively, 1-year mortality rates were 23.8% (95% confidence interval [CI] 23.3%-24.3%), 25.2% (25.1%-25.3%), and 26.5% (26.1%-26.9%), and recurrence rates were 8.0% (7.6%-8.3%), 7.9% (7.8%-8.0%), and 8.0% (7.7%-8.3%). Compared with patients treated at High-High hospitals, those treated at Low-Low and Intermediate hospitals, respectively, had 15% (hazard ratio 0.85; 95% CI 0.82-0.87) and 9% (0.91; 0.89-0.93) lower risks of 1-year mortality but no difference in recurrence.

CONCLUSIONS

Ischemic stroke patients treated at hospitals with better CMS short-term outcome metrics had lower risks of post-discharge 1-year mortality, but similar recurrent stroke rates, compared with patients treated at other hospitals.

Racial and Ethnic Disparities in Stroke Reperfusion Therapy in the USA

Racial and ethnic inequities in stroke care are ubiquitous. Acute reperfusion therapies, i.e., IV thrombolysis (IVT) and mechanical thrombectomy (MT), are central to acute stroke care and are highly efficacious at preventing death and disability after stroke. Disparities in the use of IVT and MT in the USA are pervasive and contribute to worse outcomes among racial and ethnic minority individuals with ischemic stroke. A meticulous understanding of disparities and underlying root causes is necessary in order to develop targeted mitigation strategies with lasting effects. This review details racial and ethnic disparities in the use of IVT and MT after stroke and highlights inequities in the underlying process measures as well as the contributing root causes. Furthermore, this review spotlights the systemic and structural inequities that contribute to race-based differences in the use of IVT and MT, including geographic and regional differences and differences based on neighborhood, zip code, and hospital type. In addition, recent promising trends suggesting improvements in racial and ethnic IVT and MT disparities and potential approaches for future solutions to achieve equity in stroke care are briefly discussed.

Stroke thrombectomy volume, rather than stroke center accreditation status of hospitals, is associated with mortality and discharge disposition

BACKGROUND

Few studies have explored the association between stroke thrombectomy (ST) volume and hospital accreditation with clinical outcomes.

OBJECTIVE

To assess the association of ST case volume and accreditation status with in-hospital mortality and home discharge disposition using the national Medicare Provider Analysis and Review (MEDPAR) database.

METHODS

Rates of hospital mortality, home discharge disposition, and hospital stay were compared between accredited and non-accredited hospitals using 2017-2018 MEDPAR data. The association of annual ST case volume with mortality and home disposition was determined using Pearson's correlation. Median rate of mortality and number of ST cases at hospitals within the central quartiles were estimated.

RESULTS

A total of 29 355 cases were performed over 2 years at 847 US centers. Of these, 354 were accredited. There were no significant differences between accredited and non-accredited centers for hospital mortality (14.8% vs 14.5%, p=0.34) and home discharge (12.1% vs 12.0%, p=0.78). A significant positive correlation was observed between thrombectomy volume and home discharge (r=0.88; 95% CI 0.58 to 0.97, p=0.001). A significant negative relationship was found between thrombectomy volume and mortality (r=-0.86; 95% CI -0.97 to -0.49, p=0.002). Within the central quartiles, the median number of ST cases at hospitals with mortality was 24/year, and the median number of ST cases at hospitals with home discharge rate was 23/year.

CONCLUSION

A higher volume of ST cases was associated with lower mortality and higher home discharge rate. No significant differences in mortality and discharge disposition were found between accredited and non-accredited hospitals.

Benefit of linking hospital resource information and patient-level stroke registry data

Variation in the delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient, and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. The 2017 National Audit organizational survey (Australia) was linked to patient-level data from the Australian Stroke Clinical Registry (2016-2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90-180-day readmissions and health-related quality of life. Models were adjusted for patient factors, including the severity of stroke. Fifty-two out of 127 hospitals with organizational survey data were merged with 22 832 Australian Stroke Clinical Registry patients with an admission for a first-ever stroke or transient ischaemic attack (median age 75 years, 55% male, and 66% ischaemic). In metropolitan hospitals (n = 42, 20 977 patients, 1701 thrombolyzed, and 2395 readmitted between 90 and 180 days post stroke), a faster median door-to-needle time for thrombolysis was associated with ≥500 annual stroke admissions [-15.9 minutes, 95% confidence interval (CI) -27.2, -4.7], annual thrombolysis >20 patients (-20.2 minutes, 95% CI -32.0, -8.3), and having specialist stroke staff (dedicated medical lead and stroke coordinator; -12.7 minutes, 95% CI -25.0, -0.4). A reduced likelihood of all-cause readmissions between 90 and 180 days was evident in metropolitan hospitals using care pathways for stroke management (odds ratio 0.82, 95% CI 0.67-0.99). In regional/rural hospitals (n = 10, 1855 patients), being discharged with a care plan was also associated with the use of stroke clinical pathways (odds ratio 3.58, 95% CI 1.45-8.82). No specific hospital resources influenced 90-180-day health-related quality of life. Relevant to all international registries, integrating information about hospital resources with clinical registry data provides greater insights into factors that influence evidence-based care.

National Patterns and Outcomes of Neurologist Care in Acute Ischemic Stroke

Background & Purpose

Specialist care of acute ischemic stroke patients has been associated with improved outcomes but is not well-characterized. We sought to elucidate the involvement and influence of neurologists on acute ischemic stroke care.

Methods

Using 100% Medicare datasets, index acute ischemic stroke admissions from 2016-2018 were identified with International Classification of Diseases, 10th Revision codes. Neurologists were identified by NPI code. Neurologist involvement in care was defined as: "neurologist involved in care"; "hospital with a neurologist"; and "percent of acute ischemic stroke treated by neurologist." Adjusted logistic regression models summarized exposure to neurologists and their association with outcomes (inpatient mortality, good outcome, and 30-day readmission).

Results

Among 647838 index AIS admissions from 2016-2018, 15.6% included a neurologist involved in care, associated with receiving intravenous thrombolysis (19.1% vs 6.5%), endovascular thrombectomy (13.2% vs 1.4%), treatment at a teaching hospital (87.7% vs 55.5%), and treatment at a hospital in the highest volume quartile (95.3% vs 75.6%). Of 4797 hospitals, 36.1% had a neurologist, among which the mean percent of admissions treated by a neurologist was 14.7% (SD 24.4). Neurologist involvement was associated with increased inpatient mortality (OR 1.81; 95% CI 1.75-1.86), decreased odds of a good outcome (OR .92; 95% CI .90-.93), and increased 30-day readmission (OR 1.04; 95% C: 1.01-1.06).

Conclusions

The minority of acute ischemic stroke admissions among the elderly in the US are treated by neurologists. Neurologist involvement in care is associated with worse outcomes, possibly from the allocation of severe cases to neurologists.

The In-Hospital Care of Patients With Peripheral Arterial Occlusive Disease

BACKGROUND

Studies from Denmark and the USA have shown differences in treatment outcomes for patients with peripheral arterial occlusive disease (PAOD) between hospitals of different size and certification status. For Germany, it is not known whether certification as a specialist center for vascular diseases or hospital size is associated with differences in the primary treatment outcome.

METHODS

Using data from the German Federal Statistical Office, all hospitalizations due to PAOD of Fontaine stage IIb or higher were included in our study and the hospitals were classified according to their size and certification status. PAOD stage, age, sex, and comorbidities were documented for each hospitalization. Univariate and multivariate logistic regressions were performed to identify independent variables that predict various treatment endpoints.

RESULTS

A total of 558 785 hospitalizations were included for analysis, of which 29% were in hospitals with certified vascular centers. In multivariate analysis, admissions to certified hospitals were associated with lower rates of major amputation (odds ratio [OR] 0.95, 95% confidence interval [0.92; 0.98], p = 0.003) and higher rates of minor amputation (OR 1.04 [1.01; 1.06], p = 0.004) with no difference observed in mortality (OR 0.99 [0.96; 1.03], p = 0.791). Admissions to larger hospitals were associated with more comorbidities, longer hospital stays, and higher rates of mortality and amputations.

CONCLUSION

Treatments in certified hospitals are associated with fewer major and more minor amputations. This may reflect intensification of therapy targeting preservation of functional limbs.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Importance

Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant.

Objective

To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities.

Design, Setting, and Participants

This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022.

Main Outcomes and Measures

Hospitals' likelihood of adopting stroke care certification.

Results

A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51).

Conclusions and Relevance

In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Prehospital triage tools across the world: a scoping review of the published literature

Background

Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics.

Methods

A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews.

Results

Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge.

Conclusions

The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01019-z.

The Bigger the Better? Center Volume Dependent Effects on Procedural and Functional Outcome in Established Endovascular Stroke Centers

Background

Mechanical thrombectomy (MT) rates for the treatment of acute ischaemic stroke due to large vessel occlusion are steadily increasing, but are delivered in heterogenic settings. We aim to investigate effects of procedural load in centers with established MT-structures by comparing high- vs. low-volume centers with regard to procedural characteristics and functional outcomes.

Methods

Data from 5,379 patients enrolled in the German Stroke Registry Endovascular Treatment (GSR-ET) between June 2015 and December 2019 were compared between three groups: high volume: ≥180 MTs/year, 2,342 patients; medium volume: 135-179 MTs/year, 2,202 patients; low volume: <135 MTs/year, 835 patients. Univariate analysis and multiple linear and logistic regression analyses were performed to identify differences between high- and low-volume centers.

Results

We identified high- vs. low-volume centers to be an independent predictor of shorter intra-hospital (admission to groin puncture: 60 vs. 82 min, β = -26.458; p < 0.001) and procedural times (groin puncture to flow restoration: 36 vs. 46.5 min; β = -12.452; p < 0.001) after adjusting for clinically relevant factors. Moreover, high-volume centers predicted a shorter duration of hospital stay (8 vs. 9 days; β = -2.901; p < 0.001) and favorable medical facility at discharge [transfer to neurorehabilitation facility/home vs. hospital/nursing home/in-house fatality, odds ratio (OR) 1.340, p = 0.002]. Differences for functional outcome at 90-day follow-up were observed only on univariate level in the subgroup of primarily to MT center admitted patients (mRS 0-2 38.5 vs. 32.8%, p = 0.028), but did not persist in multivariate analyses.

Conclusion

Differences in efficiency measured by procedural times call for analysis and optimization of in-house procedural workflows at regularly used but comparatively low procedural volume MT centers.

Exploring relationships between in-hospital mortality and hospital case volume using random forest: results of a cohort study based on a nationwide sample of German hospitals, 2016-2018

Background

Relationships between in-hospital mortality and case volume were investigated for various patient groups in many empirical studies with mixed results. Typically, those studies relied on (semi-)parametric statistical models like logistic regression. Those models impose strong assumptions on the functional form of the relationship between outcome and case volume. The aim of this study was to determine associations between in-hospital mortality and hospital case volume using random forest as a flexible, nonparametric machine learning method.

Methods

We analyzed a sample of 753,895 hospital cases with stroke, myocardial infarction, ventilation > 24 h, COPD, pneumonia, and colorectal cancer undergoing colorectal resection treated in 233 German hospitals over the period 2016–2018. We derived partial dependence functions from random forest estimates capturing the relationship between the patient-specific probability of in-hospital death and hospital case volume for each of the six considered patient groups.

Results

Across all patient groups, the smallest hospital volumes were consistently related to the highest predicted probabilities of in-hospital death. We found strong relationships between in-hospital mortality and hospital case volume for hospitals treating a (very) small number of cases. Slightly higher case volumes were associated with substantially lower mortality. The estimated relationships between in-hospital mortality and case volume were nonlinear and nonmonotonic.

Conclusion

Our analysis revealed strong relationships between in-hospital mortality and hospital case volume in hospitals treating a small number of cases. The nonlinearity and nonmonotonicity of the estimated relationships indicate that studies applying conventional statistical approaches like logistic regression should consider these relationships adequately.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07414-z.

Stroke 20 20: Implementation goals for intravenous thrombolysis

Introduction

Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis.

Material and Method

Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004.

Results

Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60-70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients.

Discussion

Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes.

Conclusion

Stroke 20-20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.

Hospital accreditation impact on healthcare quality dimensions: a systematic review

PURPOSE

To systematically review the impact of hospital accreditation on healthcare quality indicators, as classified into seven healthcare quality dimensions.

DATA SOURCE

We searched eight databases in June 2020: EBSCO, PubMed, Web of Science, Emerald, ProQuest, Science Direct, Scopus and Virtual Health Library. Search terms were conceptualized into three groups: hospitals, accreditation and terms relating to healthcare quality. The eligibility criteria included academic articles that applied quantitative methods to examine the impact of hospital accreditation on healthcare quality indicators.

STUDY SELECTION

We applied the PICO framework to select the articles according to the following criteria: Population-all types of hospitals; Intervention-hospital accreditation; Comparison-quantitative method applied to compare accredited vs. nonaccredited hospitals, or hospitals before vs. after accreditation; Outcomes-regarding the seven healthcare quality dimensions. After a critical appraisal of the 943 citations initially retrieved, 36 studies were included in this review.

RESULTS OF DATA SYNTHESIS

Overall results suggest that accreditation may have a positive impact on efficiency, safety, effectiveness, timeliness and patient-centeredness. In turn, only one study analyzes the impact on access, and no study has investigated the impact on equity dimension yet.

CONCLUSION

Mainly due to the methodological shortcomings, the positive impact of accreditation on healthcare dimensions should be interpreted with caution. This study provides an up-to-date overview of the main themes examined in the literature, highlighting critical knowledge-gaps and methodological flaws. The findings may provide value to healthcare stakeholders in terms of improving their ability to assess the relevance of accreditation processes.

Comparison of Major Clinical Outcomes between Accredited and Nonaccredited Hospitals for Inpatient Care of Acute Myocardial Infarction

Hospital accreditation programs are used worldwide to improve the quality of care and improve patient safety. It is of great help in improving the structure of hospitals, but there are mixed research results on improving the clinical outcome of patients. The purpose of this study was to compare the levels of core clinical outcome indicators after receiving inpatient services from accredited and nonaccredited hospitals in patients with acute myocardial infarction (AMI). For all patients with AMI admitted to general hospitals in Korea from 2010 to 2017, their 30-day mortality and readmissions and length of stay were compared according to accreditation status. In addition, through a multivariate model that controls various patients’ and hospitals’ factors, the differences in those indicators were analyzed more accurately. The 30-day mortality of patients admitted to accredited hospitals was statistically significantly lower than that of patients admitted to nonaccredited hospitals. However, for 30-day readmission and length of stay, accreditation did not appear to yield more desirable results. This study shows that when evaluating the clinical impact of hospital accreditation programs, not only the mortality but also various clinical indicators need to be included, and a more comprehensive review is needed.

Association between Accreditation and In-Hospital Mortality in Patients with Major Cardiovascular Diseases in South Korean Hospitals: Pre-Post Accreditation Comparison

The direct impact of hospital accreditation on patients' clinical outcomes is unclear. The purpose of this study was to evaluate whether mortality within 30 days of hospitalization for acute myocardial infarction (AMI), ischemic stroke (IS), and hemorrhagic stroke (HS) differed before and after hospital accreditation. This study targeted patients who had been hospitalized for the three diseases at the general hospitals newly accredited by the government in 2014. Thirty-day mortality rates of three years before and after accreditation were compared. Mortality within 30 days of hospitalization for the three diseases was lower after accreditation than before (7.34% vs. 6.15% for AMI; 4.64% vs. 3.80% for IS; and 18.52% vs. 15.81% for HS). In addition, hospitals that meet the criteria of the patient care process domain have a statistically lower mortality rate than hospitals that do not. In the newly accredited Korean general hospital, it was confirmed that in-hospital mortality rates of major cardiovascular diseases were lower than before the accreditation.

Development of a Joint Commission Disease-Specific Care Certification Program for Parkinson Disease in an Acute Care Hospital

BACKGROUND

Patients with Parkinson disease (PD) admitted to the hospital for any reason are at a higher risk of hospital-related complications. Frequent causes include delays in administering PD medications or use of contraindicated medications. The Joint Commission Disease-Specific Care (DSC) program has been used to establish a systematic approach to the care of specific inpatient populations. Once obtained, this certification demonstrates a commitment to patient care and safety, which is transparent to the public and can improve quality of care.

METHODS

We formalized our efforts to improve the care of hospitalized patients with PD by pursuing Joint Commission DSC. An interprofessional team was assembled to include nurses, therapists, physicians, pharmacists, performance improvement specialists, and data analysts. The team identified quality metrics based on clinical guidelines. In addition, a large educational campaign was undertaken. Application to the Joint Commission for DSC resulted in a successful June 15, 2018 site visit. To our knowledge, this is the first DSC program in PD in an acute care hospital.

CONCLUSION

Using the established platform of DSC certification from the Joint Commission, we developed a program based on relevant metrics that aims to address medication management of patients with PD admitted to the hospital. Our hope is to improve the care of this vulnerable patient population.

Hospital Volume and Mortality in Acute Ischemic Stroke Patients: Effect of Adjustment for Stroke Severity

OBJECTIVE

Stroke severity of 1 hospital is a crucial information when assessing hospital performance. We aimed to determine the effect of stroke severity in the association between hospital patient volume and outcome after acute ischemic stroke.

METHODS

Data from National Acute Stroke Quality Assessment in 2013 and 2014 were analyzed. Hospital patient volume was defined as the annual number of acute ischemic stroke patients who admitted to each hospital. Comparisons among hospital patient volume quartiles before and after adjusting age, sex, onset to arrival and stroke severity were made to determine the associations between hospital patient volume and mortality at 30 days, 90 days and 1 year. Assessments for the nonlinear associations, with treating hospital patient volume as a continuous variable, and the associations between hospital patient volume and quality of care were also made.

RESULTS

A total of 14,666 acute ischemic stroke patients admitted to 202 hospitals were analyzed. In the crude analysis, patients admitted to hospitals with lower patient volume showed higher mortality with a non-linear inverse association with a cut-off value of 227 patients/year. While the associations remained significant after adjusting age, sex and onset to arrival time (P's < .05), they disappeared when stroke severity was further adjusted (P's > .05). In contrary, hospital patient volume showed a nonlinear positive association with a plateau for summary measures of quality indicators even after adjustments for covariates including stroke severity (P < .001).

CONCLUSIONS

Our study implicates that stroke severity should be considered when assessing hospital performance regarding outcomes of acute stroke care.

Impact of disease-specific care certification on clinical outcome and healthcare performance of myocardial infarction in Taiwan

BACKGROUND

The relationship between certification for specific disease care and clinical outcome was not well known. Previous studies regarding the effect of certification for acute stroke centers were limited by their cross-sectional design. This study aimed to investigate the effect of disease-specific care (DSC) certification on healthcare performance and clinical outcome of acute myocardial infarction (AMI).

METHODS

This retrospective, longitudinal, controlled study was performed by analyzing the nationwide Taiwan Clinical Performance Indicators dataset from 2011 to 2018. Hospitals undergoing DSC certification for coronary care and reporting AMI indicators 1 year before, during, and 1 year after certification were included in group C, whereas hospitals not seeking DSC certification but reporting AMI indicators during the same period were included in group U. The primary endpoint was in-hospital mortality of AMI.

RESULTS

In total, 20 hospitals (9 in group C and 11 in group U) and up to 16 173 AMI cases were included for analysis. In-hospital mortality was similar between both groups at baseline. However, the in-hospital mortality was significantly improved during and after certification periods in comparison with that at baseline in group C (6.8% vs 8.4%, p = 0.04; 6.7% vs 8.4%, p = 0.02), whereas there was no significant change in group U, resulting in a statistically significant difference between both groups during and after certification periods (odds ratio = 0.74 [95% CI = 0.60-0.91] and 0.78 [95% CI = 0.64-0.96]). Compared with group U, the improvement in healthcare performance indicators, such as door-to-electrocardiography time <10 minutes, blood testing for low-density lipoprotein cholesterol level, prescribing a beta-blockade or a P2Y12 receptor inhibitor during hospitalization, prescribing a statin on discharge, and consultation for cardiac rehabilitation, was significant in group C.

CONCLUSION

The current study demonstrated the beneficial effect of DSC certification on clinical outcome of AMI probably mediated through quality improvement during the healthcare process.

S. Impact of accreditation on performance of healthcare organizations

Purpose

The purpose of this paper is to review the accreditation research in specific to its effect on the performance of healthcare organizations.

Design/methodology/approach

A comprehensive search and analysis of literature on the effect of healthcare accreditation were conducted between June 2017 and May 2018. The study identified 62 empirical research studies that examined the effect of healthcare accreditation programmes. Study particulars such as year of publication, objectives, focus of the study, research settings and key findings were recorded. A content analysis was performed to identify the frequency of the main themes in the literature. Knowledge gaps needing further examination were identified.

Findings

Majority of the accreditation impact studies were carried out in the developed nations (n = 49). The thematic categories, that is the impact on “patient safety and healthcare quality” (n = 26), “healthcare professionals’ views” (n = 28) and “clinical process and outcomes” (n = 17) were addressed more times. Whereas the other two thematic categories “organizational performance” and “consumers’ views or satisfaction,” each was examined less than 10 instances. This review reveals mixed views on effect of healthcare accreditation. The varied quality of studies and the availability of a few studies on consumers’ perception of accreditation effectiveness were the important limiting factors of this review.

Originality/value

The findings are valuable to healthcare managers and hospital administrators in accreditation decisions, whereas findings are of value to researchers and academicians in terms of gaps identified for future research studies pertaining to the impact of healthcare accreditation. Future studies need to consider holistic theoretical frameworks for assessing the effect of accreditation on performance of healthcare organizations to achieve precise results.

Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals

Background and Purpose: Primary stroke center (PSC) certification is associated with improvements in stroke care and outcome. However, these improvements may reflect a higher baseline level of care delivery in hospitals eventually achieving certification. This study examines whether advancements in acute stroke care at PSCs are due to certification or factors intrinsic to the hospital.

Methods: Data was obtained from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) trial with participation of 40 Emergency Medical System agencies, 315 ambulances, and 60 acute receiving hospitals in Los Angeles and Orange Counties. Subjects were transported to one of three types of destinations: PSC certified hospitals (PSCs), hospitals that were not PSCs at time of enrollment but would later become certified (pre-PSCs), and hospitals that would never be certified (non-PSCs). Metrics of acute stroke care quality included time arrival to imaging, use of intravenous tPA, and arrival to treatment.

Results: Of 1,700 cases, 856(50%) were at certified PSCs, 529(31%) were at pre-PSCs, and 315 (19%) were at non-PSCs. Mean (SD) was 33min (±76.1) at PSCs, 47(±86.6) at pre-PSCs, and 49(±71.7) at non-PSCs. Of 1,223 cerebral ischemia cases, rate of tPA utilization was 43% at PSCs, 27% at pre-PSCs, and 28% at non-PSCs. Mean ED arrival to thrombolysis was 71(±32.7) at PSC, 98(±37.6) at pre-PSC, and 95(±45.0) at non-PSCs. PSCs had improved time to imaging (p = 0.014), percent tPA use (p < 0.001), and time to treatment (p = 0.003).

Conclusions: Stroke care at hospitals prior to PSC certification is equivalent to care at non-PSCs.

Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.

Recrudescence of Old Stroke Deficits Among Transient Neurological Attacks

Background

Recrudescence of old stroke deficits (ROSD) is a reported cause of transient neurological symptoms, but it is not well characterized.

Objective

We sought to determine the prevalence, potential triggers, and clinical outcome of ROSD in a cohort of patients presenting with acute transient neurological attack (TNA) and absent acute pathology on brain imaging.

Methods

We retrospectively analyzed 340 consecutive patients who presented with TNA and no acute pathology on brain imaging that were included in an institutional stroke registry between February 2013 and April 2015. The presumed TNA cause was categorized as transient ischemic attack (TIA), ROSD, and other cause. Baseline characteristics, triggers, cardiovascular complications within 90 days, and death were recorded.

Results

The prevalence of ROSD in the studied cohort was 10% (34/340). Infectious stressors and acute metabolite derangements were more common in ROSD compared to TIA (P < .05, each). Compared to TIA and the other TNA, ROSD was more likely to have more than 1 acute stressor (P < .001). Patients with ROSD had similar vascular risk factors compared to TIA (P > .05), including hypertension, diabetes mellitus, peripheral vascular disease, hyperlipidemia, and similarly used HMG-CoA reductase inhibitor, antihypertensive, and antiplatelet medications. Among the patients with an available 90-day follow-up (n = 233), cardiovascular events were more frequent in the TIA group as compared to other TNA (P < .05).

Conclusion

ROSD is common and distinct from TIA and is associated with a triggering physiologic reaction leading to transient reemergence of prior neurologic deficits. Further study of the mechanism of this phenomenon is needed to help better identify these patients.

Association between patient outcomes and accreditation in US hospitals: observational study

OBJECTIVES

To determine whether patients admitted to US hospitals that are accredited have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by The Joint Commission (the largest and most well known accrediting body with an international presence) confers any additional benefits for patients compared with other independent accrediting organizations.

DESIGN

Observational study.

SETTING

4400 hospitals in the United States, of which 3337 were accredited (2847 by The Joint Commission) and 1063 underwent state based review between 2014 and 2017.

PARTICIPANTS

4 242 684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS).

MAIN OUTCOME MEASURES

Risk adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services and The Joint Commission.

RESULTS

Patients treated at accredited hospitals had lower 30 day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2% v 10.6%, difference 0.4% (95% confidence interval 0.1% to 0.8%), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4% v 2.4%, 0.0% (-0.3% to 0.3%), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), P<0.001) but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (-1.2% to 1.6%), P=0.75). No statistically significant differences were seen in 30 day mortality or readmission rates (for both the medical or surgical conditions) between hospitals accredited by The Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 v 3.2, 0.2 (0.1 to 0.3), P<0.001). Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 v 3.2, 0.1 (-0.003 to 0.2), P=0.06).

CONCLUSIONS

US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.

Factors associated with 1-year mortality after discharge for acute stroke: what matters?

OBJECTIVE

To evaluate factors associated with 1-year mortality after discharge for acute stroke.

METHODS

In this retrospective cohort study, we studied 305 patients with ischemic stroke or intracerebral hemorrhage discharged in 2010/2011. We linked Get With The Guidelines®-Stroke clinical data with New York State administrative data and used multivariate regression models to examine variables related to 1-year all-cause mortality poststroke.

RESULTS

The mean age was 68.6 ± 14.8 years and 51.1% were women. A total of 146 (47.9%) were discharged directly home, 96 (31.5%) to inpatient rehabilitation facilities (IRFs), and 63 (20.7%) to skilled nursing facilities (SNFs). Overall, 24 (7.9%) patients died within 1-year post-discharge. Older age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00-1.10), higher National Institutes of Health Stroke Scale (NIHSS) on admission (OR 1.10, 95% CI 1.03-1.17), and discharge destination (IRF vs. home, OR 0.10, 95% CI 0.01-0.94; and SNF vs. home, OR 2.22, 95% CI 0.71-6.95) were factors associated with 1-year all-cause mortality. When ambulation status at discharge was added to the model, ambulation with assistance and non-ambulation were significantly associated with mortality (ambulatory with assistance vs. ambulatory, OR 9.42, 95% CI 1.87-47.61; nonambulatory vs. ambulatory, OR 12.65, 95% CI 1.89-84.89).

CONCLUSIONS

While age and NIHSS on admission are important predictors of long-term outcomes, factors at discharge - ambulation status at discharge and discharge destination - are associated with 1-year mortality post-discharge for acute stroke and therefore could represent therapeutic targets to improve long-term survival in future studies.

Quality and resource efficiency in hospital service provision: A geoadditive stochastic frontier analysis of stroke quality of care in Germany

We specify a Bayesian, geoadditive Stochastic Frontier Analysis (SFA) model to assess hospital performance along the dimensions of resources and quality of stroke care in German hospitals. With 1,100 annual observations and data from 2006 to 2013 and risk-adjusted patient volume as output, we introduce a production function that captures quality, resource inputs, hospital inefficiency determinants and spatial patterns of inefficiencies. With high relevance for hospital management and health system regulators, we identify performance improvement mechanisms by considering marginal effects for the average hospital. Specialization and certification can substantially reduce mortality. Regional and hospital-level concentration can improve quality and resource efficiency. Finally, our results demonstrate a trade-off between quality improvement and resource reduction and substantial regional variation in efficiency.

Estimates and Temporal Trend for US Nationwide 30-Day Hospital Readmission Among Patients With Ischemic and Hemorrhagic Stroke

IMPORTANCE

Readmission reduction is linked to improved quality of care, saves cost, and is a desirable patient-centered outcome. Nationally representative readmission metrics for patients with stroke are unavailable to date. Such estimates are necessary for benchmarking performance.

OBJECTIVES

To provide US nationwide estimates and a temporal trend for overall, planned, and potentially preventable 30-day hospital readmission among patients with ischemic and hemorrhagic stroke; to investigate the association between hospitals' stroke discharge volume, teaching status, and 30-day readmission; and to highlight reasons for 30-day readmission and explore the association of 30-day readmission in terms of mortality, length of stay, and cost of care among patients with stroke.

DESIGN, SETTING, AND PARTICIPANTS

Cohort, year-wise analysis of the Nationwide Readmissions Database between January 1, 2010, and September 30, 2015. The setting was a population-based cohort study providing national estimates of 30-day readmission. The database represents 50% of all US hospitalizations from 22 geographically dispersed states. Participants were adult (≥18 years) patients with a primary discharge diagnosis of intracerebral hemorrhage, acute ischemic stroke, or subarachnoid hemorrhage. Hospitals were categorized by their annual stroke discharge volume and were classified as teaching hospitals if they had an American Medical Association-approved residency program or had a ratio of full-time equivalent interns and residents to beds of 0.25 or higher.

MAIN OUTCOMES AND MEASURES

Readmission was defined as any admission within 30 days of index hospitalization discharge. Using Centers for Medicare & Medicaid Services-defined algorithms, events were classified as planned or unplanned and as potentially preventable.

RESULTS

Based on study criteria, 2 078 854 eligible patients were included (mean [SE] age, 70.02 [0.07] years; 51.9% female). Thirty-day readmission was highest for patients with intracerebral hemorrhage (13.70%; 95% CI, 13.40%-13.99%), followed by patients with acute ischemic stroke (12.44%; 95% CI, 12.33%-12.55%) and patients with subarachnoid hemorrhage (11.48%; 95% CI, 11.01%-11.96%). On average, there was a 3.3% annual decline in readmission between 2010 and 2014, which was statistically significant for the period of investigation (odds ratio, 0.96; 95% CI, 0.95-0.97). Patients discharged from nonteaching hospitals with high stroke discharge volume were at a significantly higher risk of 30-day readmission, and the top 2 reasons for readmission were acute cerebrovascular disease and septicemia.

CONCLUSIONS AND RELEVANCE

This study suggests that nationally representative readmission metrics can be used to benchmark hospitals' performance, and a temporal trend of 3.3% may be used to evaluate the effectiveness of readmission reduction strategies.

A Case for Telestroke in Military Medicine: A Retrospective Analysis of Stroke Cost and Outcomes in U.S. Military Health-Care System

BACKGROUND

The development of primary stroke centers has improved outcomes for stroke patients. Telestroke networks have expanded the reach of stroke experts to underserved, geographically remote areas. This study illustrates the outcome and cost differences between neurology and primary care ischemic stroke admissions to demonstrate a need for telestroke networks within the Military Health System (MHS).

MATERIALS AND METHODS

All adult admissions with a primary diagnosis of ischemic stroke in the MHS Military Mart database from calendar years 2010 to 2015 were reviewed. Neurology, primary care, and intensive care unit (ICU) admissions were compared across primary outcomes of (1) disposition status and (2) intravenous tissue plasminogen activator administration and for secondary outcomes of (1) total cost of hospitalization and (2) length of stay (LOS).

RESULTS

A total of 3623 admissions met the study's parameters. The composition was neurology 462 (12.8%), primary care 2324 (64.1%), ICU 677 (18.7%), and other/unknown 160 (4.4%). Almost all neurology admissions (97%) were at the 3 neurology training programs, whereas a strong majority of primary care admissions (80%) were at hospitals without a neurology admitting service. Hospitals without a neurology admitting service had more discharges to rehabilitation facilities and higher rates of in-hospital mortality. LOS was also longer in primary care admissions.

CONCLUSIONS

Ischemic stroke admissions to neurology had better outcomes and decreased LOS when compared to primary care within the MHS. This demonstrates a possible gap in care. Implementation of a hub and spoke telestroke model is a potential solution.

Regional Variation in 30-Day Ischemic Stroke Outcomes for Medicare Beneficiaries Treated in Get With The Guidelines-Stroke Hospitals

BACKGROUND

We explored regional variation in 30-day ischemic stroke mortality and readmission rates and the extent to which regional differences in patients, hospitals, healthcare resources, and a quality of care composite care measure explain the observed variation.

METHODS AND RESULTS

This ecological analysis aggregated patient and hospital characteristics from the Get With The Guidelines-Stroke registry (2007-2011), healthcare resource data from the Dartmouth Atlas of Health Care (2006), and Medicare fee-for-service data on 30-day mortality and readmissions (2007-2011) to the hospital referral region (HRR) level. We used linear regression to estimate adjusted HRR-level 30-day outcomes, to identify HRR-level characteristics associated with 30-day outcomes, and to describe which characteristics explained variation in 30-day outcomes. The mean adjusted HRR-level 30-day mortality and readmission rates were 10.3% (SD=1.1%) and 13.1% (SD=1.1%), respectively; a modest, negative correlation (r=-0.17; P=0.003) was found between one another. Demographics explained more variation in readmissions than mortality (25% versus 6%), but after accounting for demographics, comorbidities accounted for more variation in mortality compared with readmission rates (17% versus 7%). The combination of hospital characteristics and healthcare resources explained 11% and 16% of the variance in mortality and readmission rates, beyond patient characteristics. Most of the regional variation in mortality (65%) and readmission (50%) rates remained unexplained.

CONCLUSIONS

Thirty-day mortality and readmission rates vary substantially across HRRs and exhibit an inverse relationship. While regional variation in 30-day outcomes were explained by patient and hospital factors differently, much of the regional variation in both outcomes remains unexplained.

Age-related differences in the rate and diagnosis of 30-day readmission after hospitalization for acute ischemic stroke

Background Little is known about the association between age and readmission within 30 days after hospitalization for acute ischemic stroke. Aim To examine the age-related differences in rate and principal reason of 30-day readmissions in patients hospitalized for acute ischemic stroke. Methods In this retrospective, population-based cohort study using State Inpatient Databases from eight US states, we identified all adults hospitalized for acute ischemic stroke. We grouped the patients into four age categories: < 65, 65-74, 75-84, and ≥85 years. Outcomes were any-cause readmission within 30 days of discharge from the index hospitalization for acute ischemic stroke and the principal diagnosis of 30-day readmission. Results We identified 620,788 hospitalizations for acute ischemic stroke. The overall 30-day readmission rate was 16.6% with an increase with advanced age. Compared to patients aged <65 years, the readmission rate was significantly higher in age 65-74 years (OR 1.19; 95% CI 1.16-1.21), in age 75-84 years (OR 1.29; 95% CI 1.27-1.31), and in ≥ 85 years (OR 1.24; 95% CI 1.22-1.27; all P<0.001). There was heterogeneity in the age-readmission rate association between men and women (P_interaction < 0.001). Overall, 45.8% of readmissions were assigned stroke-related conditions or rehabilitation care. Compared to younger adults, older adults were more likely to present with non-stroke-related conditions (46.1% in < 65 years, 50.6% in 65-74 years, 57.1% in 75-84 years, and 62.9% in ≥ 85 years; P<0.001). Conclusions Advanced age was associated with a higher 30-day readmission rate after acute ischemic stroke. Compared with younger adults, older adults were more likely to be readmitted for non-stroke-related conditions.

Stroke Administrative Severity Index: using administrative data for 30-day poststroke outcomes prediction

Aim:

Current stroke severity scales cannot be used for archival data. We develop and validate a measure of stroke severity at hospital discharge (Stroke Administrative Severity Index [SASI]) for use in billing data.

Methods:

We used the NIH Stroke Scale (NIHSS) as the theoretical framework and identified 285 relevant International Classification of Diseases, 9th Revision diagnosis and procedure codes, grouping them into 23 indicator variables using cluster analysis. A 60% sample of stroke patients in Medicare data were used for modeling risk of 30-day postdischarge mortality or discharge to hospice, with validation performed on the remaining 40% and on data with NIHSS scores.

Results:

Model fit was good (p > 0.05) and concordance was strong (C-statistic = 0.76–0.83). The SASI predicted NIHSS at discharge (C = 0.83).

Conclusion:

The SASI model and score provide important tools to control for stroke severity at time of hospital discharge. It can be used as a risk-adjustment variable in administrative data analyses to measure postdischarge outcomes.

Sex Differences in rt-PA Utilization at Hospitals Treating Stroke: The National Inpatient Sample

Background and purpose

Sex and race disparities in recombinant tissue plasminogen activator (rt-PA) use have been reported. We sought to explore sex and race differences in the utilization of rt-PA at primary stroke centers (PSCs) compared to non-PSCs across the US.

Methods

Data from the National (Nationwide) Inpatient Sample (NIS) 2004–2010 was utilized to assess sex differences in treatment for ischemic stroke in PSCs compared to non-PSCs.

Results

There were 304,152 hospitalizations with a primary diagnosis of ischemic stroke between 2004 and 2010 in the analysis: 75,160 (24.7%) patients were evaluated at a PSC. A little over half of the patients evaluated at PSCs were female (53.8%). A lower proportion of women than men received rt-PA at both PSCs (6.8 vs. 7.5%, p < 0.001) and non-PSCs (2.3 vs. 2.8%, p < 0.001). After adjustment for potential confounders the odds of being treated with rt-PA remained lower for women regardless of presentation to a PSC (OR 0.87, 95% CI 0.81–0.94) or non-PSC (OR 0.88, 95% CI 0.82–0.94). After stratifying by sex and race, the lowest absolute treatment rates were observed in black women (4.4% at PSC, 1.9% at non-PSC). The odds of treatment, relative to white men, was however lowest for white women (PSC OR = 0.85, 95% CI 0.78–0.93; non-PSC OR = 0.80, 95% CI 0.75–0.85). In the multivariable model, sex did not modify the effect of PSC certification on rt-PA utilization (p-value for interaction = 0.58).

Conclusion

Women are less likely to receive rt-PA than men at both PSCs and non-PSCs. Absolute treatment rates are lowest in black women, although the relative difference in men and women was greatest for white women.

Access disparities to Magnet hospitals for ischemic stroke patients

Access disparities to centers of excellence can have detrimental consequences for population health. We investigated the presence of racial disparities in the access of stroke patients to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC). We performed a cohort study of all ischemic stroke patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of African-American race with Magnet status hospitalization after ischemic stroke. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding. During the study period, 176,557 patients presented with ischemic stroke, and met the inclusion criteria. Overall, 4,624 (13.7%) African-Americans, and 27,468 (19.2%) non African-Americans with ischemic stroke were admitted to Magnet hospitals. Using a multivariable logistic regression, we demonstrate that African-Americans were associated with lower admission rates to Magnet institutions (OR 0.70; 95% CI, 0.68-0.73) (Table 2). This persisted in a mixed effects logistic regression model (OR 0.75; 95% CI, 0.71-0.78) to adjust for clustering at the county level, and a propensity score adjusted logistic regression model (OR 0.87; 95% CI, 0.83-0.90). Using a comprehensive all-payer cohort of ischemic stroke patients in New York State we identified an association of African-American race with lower rates of admission to Magnet hospitals.

Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization

Background and Purpose—

Primary stroke center (PSC) certification was established to identify hospitals providing evidence-based care for stroke patients. The numbers of PSCs certified by Joint Commission (JC), Healthcare Facilities Accreditation Program, Det Norske Veritas, and State-based agencies have significantly increased in the past decade. This study aimed to evaluate whether PSCs certified by different organizations have similar quality of care and in-hospital outcomes.

Methods—

The study population consisted of acute ischemic stroke patients who were admitted to PSCs participating in Get With The Guidelines-Stroke between January 1, 2010, and December 31, 2012. Measures of care quality and outcomes were compared among the 4 different PSC certifications.

Results—

A total of 477 297 acute ischemic stroke admissions were identified from 977 certified PSCs (73.8% JC, 3.7% Det Norske Veritas, 1.2% Healthcare Facilities Accreditation Program, and 21.3% State-based). Composite care quality was generally similar among the 4 groups of hospitals, although State-based PSCs underperformed JC PSCs in a few key measures, including intravenous tissue-type plasminogen activator use. The rates of tissue-type plasminogen activator use were higher in JC and Det Norske Veritas (9.0% and 9.8%) and lower in State and Healthcare Facilities Accreditation Program certified hospitals (7.1% and 5.9%) ( P <0.0001). Door-to-needle times were significantly longer in Healthcare Facilities Accreditation Program hospitals. State PSCs had higher in-hospital risk-adjusted mortality (odds ratio 1.23, 95% confidence intervals 1.07–1.41) compared with JC PSCs.

Conclusions—

Among Get With The Guidelines-Stroke hospitals with PSC certification, acute ischemic stroke quality of care and outcomes may differ according to which organization provided certification. These findings may have important implications for further improving systems of care.

Hospital Disease-Specific Care Certification Programs and Quality of Care: A Narrative Review

BACKGROUND

Disease-specific care certification (DSCC) programs have been developed to improve the quality and performance of programs or services that may be based within or associated with a hospital or other health care organization. A comprehensive summary of evidence for DSCC programs and their reported effect on the quality of care was prepared in a narrative review, the first of its kind on this topic.

METHODS

A systematic search was performed to identify articles that reported about DSCC. Any article that reported DSCC and certifications, published between 2003 and August 2015 (with an update in March 2016), and conducted in the United States was included. Databases searched included PubMed, MEDLINE, and CINAHL.

RESULTS

The articles were reviewed in terms of four topics: early development of DSCC, the journey toward DSCC, the relationship between DSCC and organizing process of care, and the relationship between DSCC and outcomes of care. Fifteen articles noted a positive relationship between DSCC programs and quality of care, only 6 of which reported empirical data. Therefore, a systematic review and meta-analysis were not warranted. Only 3 articles involved use of sophisticated statistical modeling with adequate control variables to investigate the effect of DSCC, which makes it difficult to conclude that the change in hospitals' or patients' outcomes were related to the certification.

CONCLUSIONS

The majority (13) of the articles focused on Joint Commission DSCC, with the remaining assessing Society of Cardiovascular Patient Care "accreditation" (certification). Only two studies, each study using a cross-sectional design, that empirically examined the relationship between DSCC and outcomes of care-mortality of care and readmission. More research studies are needed to evaluate the effectiveness of DSCC programs in improving outcomes of care, particularly patient-centered outcome measures, such as patient satisfaction and self-care.

Hospital Variation in Functional Recovery After Stroke

Background—

Functional status is a key patient-centric outcome, but there are little data on whether functional recovery post-stroke varies among hospitals. This study examined the distribution of functional status 3 months after stroke, determined whether these outcomes vary among hospitals, and identified hospital characteristics associated with better (or worse) functional outcomes.

Methods and Results—

Observational analysis of the AVAIL study (Adherence Evaluation After Ischemic Stroke-Longitudinal) included 2083 ischemic stroke patients enrolled from 82 US hospitals participating in Get With The Guidelines-Stroke and AVAIL. The primary outcome was dependence or death at 3 months (modified Rankin Scale [mRS] score of 3–6). Secondary outcomes included functional dependence (mRS score of 3–5), disabled (mRS score of 2–5), and mRS evaluated as a continuous score. By 3 months post-discharge, 36.5% of patients were functionally dependent or dead. Rates of dependence or death varied widely by discharging hospitals (range: 0%–67%). After risk adjustment, patients had lower rates of 3-month dependence or death when treated at teaching hospitals (odds ratio, 0.72; 95% confidence interval, 0.54–0.96) and certified primary stroke centers (odds ratio, 0.69; 95% confidence interval, 0.53–0.91). In contrast, a composite measure of hospital-level adherence to acute stroke care performance metrics, stroke volume, and bed size was not associated with downstream patient functional status. Findings were robust across mRS end points and sensitivity analyses.

Conclusions—

One third of acute ischemic stroke patients were functionally dependent or dead 3 months postacute stroke; functional recovery rates varied considerably among hospitals, supporting the need to better determine which care processes can maximize functional outcomes.

Stroke severity may predict causes of readmission within one year in patients with first ischemic stroke event

INTRODUCTION

Readmissions after stroke are costly. Risk assessment using information available upon admission could identify high-risk patients for potential interventions to reduce readmissions. Baseline stroke severity has been suspected to be a factor in readmission; however, the exact nature of the impact has not been adequately understood.

METHODS

Hospitalized adult patients with first-ever ischemic stroke were identified from a nationwide administrative database. Stroke severity was assessed using a validated claims-based stroke severity index. Cox proportional hazards models were used to investigate the relationship between stroke severity and first readmission within one year.

RESULTS

Of the 10,877 patients, 4295 (39.5%) were readmitted in one year. The cumulative risk of readmission was 34.1%, 44.7%, and 62.9% in patients with mild, moderate, and severe stroke, respectively. Patients with greater stroke severity had a significantly higher adjusted risk of first readmission for infection, metabolic disorders, neurological sequelae, and pulmonary diseases, whereas those with lesser stroke severity were prone to first readmission due to accidents. Stroke severity did not affect the risk of first readmission for recurrent stroke/transient ischemic attack, other cardiovascular events, malignancy, ulcers/upper gastrointestinal bleeding, kidney diseases, and others.

CONCLUSIONS

Stroke severity in patients with first-ever ischemic stroke not only predicts readmission but also relates to the cause of readmission. Our results might provide important information for tailoring discharge planning to prevent readmissions.

Emerging temporal trends in tissue plasminogen activator use: Results from the BASIC project

OBJECTIVE

To explore temporal trends in tissue plasminogen activator (tPA) administration for acute ischemic stroke (AIS) in a biethnic community without an academic medical center and variation in trends by age, sex, ethnicity, and stroke severity.

METHODS

Cases of AIS were identified from 7 hospitals in the Brain Attack Surveillance in Corpus Christi (BASIC) project, a population-based surveillance study between January 1, 2000, and June 30, 2012. tPA, demographics, and stroke severity as assessed by the NIH Stroke Scale (NIHSS) were ascertained from medical records. Temporal trends were explored using generalized estimating equations, and adjustment made for age, sex, ethnicity, and NIHSS. Interaction terms were included to test for effect modification.

RESULTS

There were 5,277 AIS cases identified from 4,589 unique individuals. tPA use was steady at 2% and began increasing in 2006, reaching 11% in subsequent years. Stroke severity modified temporal trends (p = 0.003) such that cases in the highest severity quartile (NIHSS > 8) had larger increases in tPA use than those in lower severity quartiles. Although ethnicity did not modify the temporal trend, Mexican Americans (MAs) were less likely to receive tPA than non-Hispanic whites (NHWs) due to emerging ethnic differences in later years.

CONCLUSIONS

Dramatic increases in tPA use were apparent in this community without an academic medical center. Primary stroke center certification likely contributed to this rise. Results suggest that increases in tPA use were greater in higher severity patients compared to lower severity patients, and a gap between MAs and NHWs in tPA administration may be emerging.

Regional Learning Collaboratives Produce Rapid and Sustainable Improvements in Stroke Thrombolysis Times

BACKGROUND

Reduction in door-to-needle (DTN) times in patients with acute ischemic stroke treated with tissue-type plasminogen activator is associated with improved outcomes. We hypothesized that a learning collaborative would rapidly reduce DTN times at Chicago's primary stroke centers.

METHODS AND RESULTS

We analyzed data from all adult patients with out-of-hospital ischemic stroke hospitalized between January 1, 2010 and March 31, 2015 and who received tissue-type plasminogen activator in the emergency department at 15 primary stroke centers in Chicago and 15 primary stroke centers in St. Louis. We implemented a structured learning collaborative in Chicago in quarter 1 of 2013 that included (1) a quality improvement leader, (2) stroke content expert, (3) multidisciplinary teams from each site, (4) a targeted goal for the program (DTN time <60 minutes in >50% of patients treated with tissue-type plasminogen activator), and (5) face-to-face meetings with on-site visits. We used interrupted time-series analysis to compare the impact of the learning collaborative on DTN times in Chicago pre- and post implementation and also concurrently versus St. Louis. We prespecified adjustment for mode of arrival, emergency medical services prenotification, and onset-to-arrival times. P values less than 0.05 were considered significant. In adjusted analysis, the reduction in DTN time within 1 quarter of implementation was 15.5 minutes (P=0.046) at Chicago sites versus 1.17 minutes at St. Louis sites (P=0.601).

CONCLUSIONS

Using a learning collaborative model at Chicago's 15 primary stroke centers, we observed major reductions in DTN times within 1 quarter of implementation. Regional collaboration and best practices sharing should be a model for rapid and sustainable system-wide quality improvement.

Primary Stroke Center Hospitalization for Elderly Patients With Stroke: Implications for Case Fatality and Travel Times

IMPORTANCE

Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care.

OBJECTIVES

To examine the association of case fatality with receiving care in PSCs vs other hospitals for patients with stroke and to identify whether prolonged travel time offsets the effect of PSCs.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of Medicare beneficiaries with stroke admitted to a hospital between January 1, 2010, and December 31, 2013. Drive times were calculated based on zip code centroids and street-level road network data. We used an instrumental variable analysis based on the differential travel time to PSCs to control for unmeasured confounding. The setting was a 100% sample of Medicare fee-for-service claims.

EXPOSURES

Admission to a PSC.

MAIN OUTCOMES AND MEASURES

Seven-day and 30-day postadmission case-fatality rates.

RESULTS

Among 865 184 elderly patients with stroke (mean age, 78.9 years; 55.5% female), 53.9% were treated in PSCs. We found that admission to PSCs was associated with 1.8% (95% CI, -2.1% to -1.4%) lower 7-day and 1.8% (95% CI, -2.3% to -1.4%) lower 30-day case fatality. Fifty-six patients with stroke needed to be treated in PSCs to save one life at 30 days. Receiving treatment in PSCs was associated with a 30-day survival benefit for patients traveling less than 90 minutes, but traveling at least 90 minutes offset any benefit of PSC care.

CONCLUSIONS AND RELEVANCE

Hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals. Traveling at least 90 minutes to receive care offset the 30-day survival benefit of PSC admission.