Acute stroke treatment at a primary stroke center is associated with a 7-day and 30-day survival benefit compared to non-certified centers, according to data published in JAMA Internal Medicine.
The adage “time is brain” has grown in relevance as health care providers try to improve stroke outcomes. Primary stroke centers certified by the Joint Commission have been developed to provide more timely evaluation for thrombolytics, endovascular procedures, and neurosurgical care. However, the question remains if the benefits of a certified primary stroke center are offset by the potential increased travel time to receive specialized care during an acute stroke.
Kimon Bekelis, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, NH and colleagues retrospectively analyzed data from a cohort of Medicare beneficiaries to assess the 7- and 30-day mortality of patients receiving stroke care at a primary stroke center compared to local care. Further analysis investigated the effect of travel time on outcomes. Travel time was assessed based on home address zip code and road network data.
The study included 865,184 Medicare patients (mean age 78.9 years; 55.5% female). More than half of participants (53.9%) received care at a primary stroke center, of which 24% of patients lived closest to. Ischemic stroke patients were more likely to receive thrombectomy (1% vs 0.2%) and intravenous tissue plasminogen activator (6% vs 2.8%) if treated at a primary stroke center than a non-specialized hospital.
In primary stroke centers, 16.5% of participants died in the first 7 days and 30.8% died at day 30 compared to 13.3% and 26.3% at non-specialized hospitals, respectively. After controlling for socioeconomic factors, health status, and travel time, the investigators found that stroke care at a primary stroke center was associated with lower 7-day (-1.8%, 95% CI: -2.1% to -1.4%) and 30-day (-1.8%, 95% CI: -2.3% to -1.4%) case fatality. For every 56 stroke patients treated at a primary stroke center, there was 1 life saved at day 30.
The investigators observed a greater 30-day survival benefit with shorter travel time to a primary stroke center. For instance, a travel time of less than 20 minutes improved survival by 2.7% (95% CI: 1.5% to 3.9%, NNT 37 patients) to 1.7% for a 60 to 89-minute travel time (95% CI: 0.2% to 2.4%, NNT 59 patients). However, a travel time greater than 90 minutes did not appear to have a survival benefit at 30 days, whereas travel greater than 60 minutes did not improve survival at 7 days.
The study had several limitations, including no data on stroke severity and estimated travel times with the potential to under- and overestimate travel time.
In an accompanying editorial, Lee Schwamm, MD, of Massachusetts General Hospital in Boston, pointed out that the Joint Commission relies heavily on infrastructure and less on performance.
“The most cost-effective sorting and allocation strategies will occur in the context of a unified stroke system of care that brings together centers of varying capability that are publicly reporting their performance data, engaged in continuous quality improvement and focused on what is best for patients,” Dr. Schwamm wrote.
The study was funded by a grant from the National Institute on Aging and the National Institutes of Health Common Fund. The authors report no disclosures.
- Bekelis K, Marth NJ, Wong K. Primary Stroke Center Hospitalization for Elderly Patients With Stroke: Implications for Case Fatality and Travel Times. JAMA Intern Med. 2016; doi:10.1001/jamainternmed.2016.3919.
- Schwamm LH. Admitting the Patient With Acute Stroke to the Right House-Lessons From the Sorting Hat of Hogwarts. JAMA Intern Med. doi:10.1001/jamainternmed.2016.3930.