Hospital’s efforts and resources matter, not designation.
I want to remind readers what the question is: Does a "stroke center" designation – not the centers themselves, but the designation – improve patient outcomes?
I want to address three separate questions. First, do some centers provide better stroke care than do others? Second, does care improve at primary stroke centers? Third, does a stroke center designation improve patient outcomes? Most of what Dr. Alberts discussed addresses the first two questions.
Dr. S. Claiborne Johnston
I concede the first question completely. There definitely is evidence that care differs among hospitals. Many medical centers had elements of primary stroke centers prior to certification, and some of these elements were associated with better outcomes.
In our 2005 study of 16,853 patients at 34 academic centers in the United States before the start of stroke center designations, several components of stroke centers were already present at different hospitals. Centers that had these components were more likely to give TPA. The more components a hospital already had, the more likely they were to give TPA. This says nothing about designation. It just says that those components tend to associate with providing better care. Some of the components also were associated with reduced mortality.
I also concede the second question: Does care improve at primary stroke centers? In studies that looked at care improvements at stroke centers, care got better. Just the fact of looking makes a difference. That occurs in part because of stroke center designation, but how well could we do if we just tracked our own outcomes and we weren’t certified as primary stroke centers? We’d probably do a lot better, compared with baseline, regardless of the designation.
We did a cluster randomized trial of 14 Kaiser hospitals in Northern California and randomized them to an intervention group (standardized discharge orders) or a control group. We took one specific element that’s in all of our stroke centers and worked hard to make that happen in seven hospitals, but not in the other seven. Even before we started the trial, "optimal treatment" (defined as our combined outcome of blood pressure control, statin use, and anticoagulation if atrial fibrillation was present) improved from 15% to 32% of patients systemwide. During the trial of 3,360 patients, optimal treatment rates remained statistically stable in the control group (from 32% at baseline to 34% at 6 months) and improved at the intervention hospitals (from 31% at baseline to 38%).
The bottom line is that you don’t need stroke center certification to improve care. Care improves for a variety of reasons. Sometimes other steps are much more cost effective to implement than stroke center certification would be.
The last and only real question in this debate is whether stroke center designation improves patient outcomes. The recently published New York study in JAMA that Dr. Alberts cited showed lower mortality in designated stroke centers than in non–stroke center hospitals, but there are differences between those groups: Stroke centers tended to treat younger patients and those in urban areas, with more teaching hospitals and larger hospitals. The investigators tried to control for those factors, but one thing they couldn’t control for was the fact that hospitals chose to become primary stroke centers. They had the capabilities, and it was feasible at those centers to become primary stroke centers. Already, they were at an advantage.
There is just no solid evidence that the designation improves outcomes for patients. Care differs among hospitals prior to certification. Care improves when you watch it, and was improving well before the certification process began. Some elements of stroke centers are associated with better care, but certification as a stroke center is not required to pursue those elements. Hospitals that elect to become certified are more likely to provide better stroke care before certification, and are already committed to improving care.
I want to pose a different question: Does society benefit from stroke center certifications? I think the answer is "Yes." The system of certifying stroke centers provides a framework for regionalization. With stroke center certification, we can convince our EMS teams that they need to bypass the noncertified hospitals and bring stroke patients to hospitals that provide better stroke care. Getting patients to hospitals that provide better care definitely will improve overall care on a societywide level.
Dr. Johnston is professor of neurology and epidemiology and director of the stroke service at the University of California, San Francisco. He said he has no relevant conflicts of interest.