Outcomes of studies detail benefits of designation.
There are some key components of primary stroke centers that appear to make a big difference. Acute stroke teams reduce time delays and increase treatment by IV tissue plasminogen activator (TPA). Stroke units have repeatedly been shown to improve outcomes, reduce deaths, and reduce complications. Care protocols improve the efficiency of care, improve outcomes, and reduce mistakes.
A meta-analysis of data from 18 well-done, relevant studies showed that stroke unit care was associated with a significant 21% reduction in death and a 13% reduction in the combined end point of death or poor outcome.
A separate 2005 study by Dr. S. Claiborne Johnston and associates of 16,853 patients with acute ischemic stroke at 34 medical centers looked at whether the Brain Attack Coalition’s criteria for stroke centers improved care. Use of an acute stroke team reduced the risk of mortality by 24%. Emergency medical services (EMS) activation of a stroke team reduced mortality risk by 19%. The rate of TPA use at centers that had the most characteristics of primary stroke centers was close to 5% of strokes – double the rate at other centers (Neurology 2005;64:422-7).
Data from the National Institute of Neurological Disorders and Stroke and numerous studies throughout the world show that timely administration of TPA after stroke improves patient outcomes. This is a very important point: If stroke centers did nothing more than increase the use of IV TPA, their effect on patient outcomes would be profound.
A 2006 report from New York State followed 32 hospitals, 14 of which became designated primary stroke centers. They instituted preferential triage, in which ambulances had to bypass non–stroke centers, if possible, to take patients to a stroke center. The rate of TPA utilization nearly doubled. Stroke unit admissions skyrocketed from a little more than 15% to nearly 40%.
In a new study, we looked at TPA use at stroke centers that are certified by the Joint Commission and have gone through either one cycle or three cycles of certification. The rate of IV TPA administration to eligible patients significantly increased in relation to the length of time a hospital had been a stroke center. The more experienced stroke centers also achieved higher rates of compliance with other care paradigms, including higher rates of discharge on statins and stroke education. These make a difference in preventing subsequent strokes, MIs, and vascular deaths.
A Finnish study included huge numbers of patients – 20,045 at comprehensive stroke centers, 10,749 at primary stroke centers, and 30,891 at general hospitals. Compared with 1-year death rates at general hospitals, rates were 11% lower at primary stroke centers and 16% lower at comprehensive stroke centers. Rates of institutional care were lower at the stroke centers, and the proportions of patients who could go home at 1 year increased by 16% and 22% at the two types of stroke centers, respectively (Stroke 2010;41:1102-7).
A second project in New York State looked at 30,947 patients with acute ischemic stroke in 2005-2006, 15,297 of whom were admitted to a designated primary stroke center. As an internal control group, the study looked at 39,000 patients who were admitted for GI hemorrhage and 40,000 who were admitted for MI to see if these were just better hospitals or if the "stroke center" designation made a difference.
Mortality was significantly lower at primary stroke centers compared with other hospitals at four follow-up time points (0.3% lower within 1 day, 1.3% lower at 7 days, 2.5% lower at 30 days, and 3% lower at 1 year). This is a hard end point. This benefit was consistent in analyses comparing subgroups of hospitals by location or by race or ethnicity (JAMA 2011;305:373-380).
A 2%-3% reduction in deaths from strokes in the United States would mean 16,000-24,000 fewer deaths. There are very few medical interventions that reduce deaths. Trauma centers reduce deaths, and we have molded the stroke center concept after that of the trauma center.
Stroke centers are beneficial for patients and improve outcomes in many ways. They reduce death, and few things do. They improve clinical outcomes and increase the use of TPA. They provide more efficient care and are more effective in starting secondary prevention medications. There are more than 800 hospitals designated as primary stroke centers by the Joint Commission – they can’t all be wrong!
Dr. Alberts is professor of neurology, director of the stroke program, and chief of the division of stroke and cerebrovascular disease at Northwestern University, Chicago. He has received honoraria from Genentech, which makes TPA. Dr. Alberts and Dr. Johnston debated this topic at the American Stroke Association’s International Stroke Conference 2011.