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Following recommendations from the Brain Attack Coalition (BAC) for implementing a hospital-based stroke system of care, the number of certified stroke centers in the U.S. increased, yet fewer than 15% of acute care hospitals nationwide have this designation. Whether achieving stroke center designation meaningfully affects stroke outcomes remains unclear. To examine this issue, researchers conducted an observational study, comparing mortality at New York State hospitals with and without designated stroke centers; the hospitals admitted a total of 30,947 patients with acute ischemic stroke (15,297 to designated stroke centers) during 1 year.
Short- and long-term mortality rates after the index stroke were modestly better at hospitals with stroke centers than at those without (10.1% vs. 12.5% at 30 days; 22.3% vs. 26.0% at 1 year; P<0.001 for both comparisons). The difference remained significant after adjustments for stroke risk factors and for differential distance to hospitals (i.e., whether patients lived closer to a hospital with than without stroke center designation). Furthermore, the outcome differences seemed specific for stroke: Hospitals with and without stroke centers had similar 30-day all-cause mortality rates among patients with gastrointestinal (GI) hemorrhage or acute myocardial infarction (AMI).
Xian Y et al. Association between stroke center hospitalization for acute ischemic stroke and mortality. JAMA 2011 Jan 26; 305:373.
Comment
These findings show that admission to a stroke center is associated with a modestly better survival rate than admission to a nondesignated hospital. However, extrapolating this finding to suggest that implementing a BAC-recommended stroke system of care is associated with improvement in clinical outcome may be premature. First, evidence suggests that hospitals that voluntarily join certification programs already provide superior care compared with noncertified hospitals. Therefore, the better outcomes observed in this cross-sectional study are not clearly attributable to obtaining certification. Second, the outcome difference might stem from the Pygmalion effect, in which greater expectation placed upon individuals (e.g., hospital employees in designated stroke centers) leads to better performance. Indeed, this phenomenon may account for the relatively lower mortality after stroke, but not after GI hemorrhage or AMI, at hospitals with stroke centers. Convincing skeptics will require longitudinal studies specifically designed to prove the value of a BAC-based stroke center designation program in improving care. Ideally, these studies would compare outcomes before and after stroke center designation and would incorporate other endpoints important to stroke patients and caregivers, such as neurological status, disability, and quality of life.