Two leading researchers agree that designated stroke centers provide better stroke care than other hospitals, but they disagree on the reasons for this difference.
LOS ANGELES—Does stroke center designation improve patient outcomes? It depends on whom you ask, according to Mark J. Alberts, MD, and S. Claiborne Johnston, MD, PhD, who debated the issue at the 2011 International Stroke Conference.
“Stroke centers are beneficial for patients and improve outcomes in many ways,” said Dr. Alberts, Professor of Neurology and Director of the Stroke Program at Northwestern University’s Feinberg School of Medicine and Northwestern Memorial Hospital in Chicago. “They reduce death, and few medical interventions do that. They improve clinical outcomes, and few things do that. They increase the use of t-PA, which is the only FDA-approved medical care in use for acute ischemic stroke. They reduce length of stay. They are more effective in starting secondary medications, which we know is very beneficial. And there are more than 800 hospitals designated as primary stroke centers by the Joint Commission [on Accreditation of Healthcare Organizations]. They can’t all be wrong!”
“There’s just no solid evidence that the designation improves outcomes for patients,” countered Dr. Johnston, Director of the University of California, San Francisco (UCSF), Stroke Service. “Hospitals electing to become certified are more likely to provide better stroke care before and are already committed to improving care. And this is the bottom line—you can’t disentangle those things.”
Benefits of Stroke Centers—Assessing the Evidence
Primary and comprehensive stroke centers—which are designated by the Joint Commission on Accreditation of Healthcare Organizations based on criteria developed by the Brain Attack Coalition—provide better stroke care than do non–stroke centers, the presenters agreed. Only Dr. Alberts described this care as resulting from the stroke center designation, however.
The four key components of primary stroke centers—acute stroke teams, stroke units, care protocols, and treatment with IV t-PA—all have been associated with improved patient outcomes, he noted. “If stroke centers did nothing more than increase the use of IV t-PA, their effect on patient outcomes would be profound,” Dr. Alberts added.
In addition, he described a study involving 32 hospitals in New York State, 14 of which received primary stroke center designation during the study period. Emergency medical services (EMS) were required to take stroke patients to the stroke centers if possible, bypassing the other hospitals. Following the designations, the rate of t-PA administration increased from 20% to 40%, stroke unit admissions increased from about 15% to about 40%, and door-to-physician time decreased among these hospitals.
A more recent study in New York studied 30,947 patients with acute ischemic stroke, 15,297 of whom were admitted to a primary stroke center, said Dr. Alberts.
Compared with patients admitted to non–stroke centers, those admitted to stroke centers had 0.3% lower mortality at one day, 1.3% lower mortality at seven days, 2.5% lower mortality at 30 days, and 3% lower mortality at one year, he said.
“What is the impact of reduced patient death rates?” Dr. Alberts asked. “A 2% to 3% reduction in deaths from strokes in the United States means 16,000 to 24,000 fewer deaths per year. Globally, this means 300,000 to almost half a million fewer deaths throughout the world. Granted, there are some parts of the world that do not have stroke centers, but this is our challenge—to get more of the world on board with the stroke center concept.”
A Noncausative Link?
Better stroke care at stroke centers may result from factors other than stroke center designation, Dr. Johnston suggested. He noted that in the more recent New York study, stroke centers tended to treat younger patients and to be located in more urban areas, with more teaching hospitals and larger hospitals, compared with the non–stroke centers.
“The investigators tried to control for those factors as best they could, but you can’t control for these differences based on binary variables,” Dr. Johnston said. “And 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. So already, they were at an advantage.”
He also suggested that tracking the outcomes at designated stroke centers may cause, rather than simply reflect, an improvement in care.
“Just the fact of looking makes a difference,” said Dr. Johnston. “How good would we do if we just tracked our own outcomes and we weren’t certified as primary stroke centers? We’d do a lot better.
Stroke Centers and Society
Despite their differences, Dr. Johnston and Dr. Alberts agreed that the stroke center system encourages better overall care by establishing a clear stroke-care hierarchy among regional facilities.