Rates, Characteristics, and Outcomes of Patients Transferred to Specialized Stroke Centers for Advanced Care

Background While many patients are transferred to specialized stroke centers for advanced acute ischemic stroke (AIS) care, few studies have characterized these patients. We sought to determine variation in the rates and differences in the baseline characteristics and clinical outcomes between AIS cases presenting directly to stroke centers’ front door versus Transfer-Ins from another hospital. Methods and Results We analyzed 970 390 AIS cases in the Get With The Guidelines–Stroke registry from January 2010 to March 2014 to compare hospitals with high Transfer-In rates (≥15%) versus those with low Transfer-In rates (<5%) and to compare the front-door versus Transfer-In patients admitted to those hospitals with high Transfer-In rates (high Transfer-In hospitals). Of 970 390 patients discharged from 1646 hospitals, 87% initially presented via the emergency department versus 13% were a Transfer-In from another hospital. High Transfer-In hospitals had a median 31% Transfer-In rate among all stroke discharges, were larger, had higher annual AIS volume and intravenous tPA (tissue-type plasminogen activator) rates, and were more often Midwest teaching hospitals and stroke centers. Compared with front-door, Transfer-In patients were younger, more often white, had higher median National Institutes of Health Stroke Scale scores, less often hypertension and previous stroke/transient ischemic attack, and higher in-hospital mortality (7.9% versus 4.9%; standardized difference, 12.4%). After multivariable adjustment, Transfer-In patients had higher in-hospital mortality and discharge modified Rankin scale. Conclusions There is significant regional variability in the transfer of patients with AIS. Because Transfer-In patients seem to have worse short-term outcomes, these patients have the potential to negatively influence institutional mortality rates and should be accounted for explicitly in hospital risk-profiling measures.

[1]  Christopher S Coffey,et al.  2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2015, Stroke.

[2]  Eric E. Smith,et al.  Endovascular Clot Retrieval Therapy: Implications for the Organization of Stroke Systems of Care in North America , 2015, Stroke.

[3]  Christopher S. Coffey,et al.  2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment , 2015 .

[4]  Deepak L. Bhatt,et al.  Admission heart rate and in-hospital outcomes in patients hospitalized for heart failure in sinus rhythm and in atrial fibrillation. , 2012, American heart journal.

[5]  Eric E. Smith,et al.  A Risk Score for In‐Hospital Death in Patients Admitted With Ischemic or Hemorrhagic Stroke , 2013, Journal of the American Heart Association.

[6]  Deepak L. Bhatt,et al.  Achievement of Guideline-Concordant Care and In-Hospital Outcomes in Patients With Coronary Artery Disease in Teaching and Nonteaching Hospitals: Results From the Get With The Guidelines–Coronary Artery Disease Program , 2013, Circulation. Cardiovascular quality and outcomes.

[7]  Laura G. Qualls,et al.  Associations between aldosterone antagonist therapy and risks of mortality and readmission among patients with heart failure and reduced ejection fraction. , 2012, JAMA.

[8]  A. Qureshi,et al.  Drip-and-Ship Thrombolytic Treatment Paradigm Among Acute Ischemic Stroke Patients in the United States , 2012, Stroke.

[9]  Stephen Prudhomme,et al.  Revised and Updated Recommendations for the Establishment of Primary Stroke Centers: A Summary Statement From the Brain Attack Coalition , 2011, Stroke.

[10]  S. Josephson,et al.  Quality Measures in Stroke , 2011, The Neurohospitalist.

[11]  D. Mozaffarian,et al.  Heart disease and stroke statistics--2011 update: a report from the American Heart Association. , 2011, Circulation.

[12]  Vl Roger,et al.  American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2011 update : a report from the American Heart Association , 2011 .

[13]  Eric E. Smith,et al.  Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke , 2010, Circulation. Cardiovascular quality and outcomes.

[14]  A. Rabinstein.  Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke , 2010 .

[15]  Li Liang,et al.  Get With the Guidelines–Stroke Is Associated With Sustained Improvement in Care for Patients Hospitalized With Acute Stroke or Transient Ischemic Attack , 2009, Circulation.

[16]  Christian Kukla,et al.  Comparison of Tissue Plasminogen Activator Administration Management Between Telestroke Network Hospitals and Academic Stroke Centers: The Telemedical Pilot Project for Integrative Stroke Care in Bavaria/Germany , 2006, Stroke.

[17]  R. Silverman,et al.  Tissue plasminogen activator for acute ischemic stroke: a New York city emergency medicine perspective. , 2005, The Journal of emergency medicine.

[18]  M. Hadley,et al.  Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition , 2005, Stroke.

[19]  Peter Moyer,et al.  Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association’s Task Force on the Development of Stroke Systems , 2005, Circulation.

[20]  Peter Moyer,et al.  Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association’s Task Force on the Development of Stroke Systems , 2005, Circulation.

[21]  Iva Petkovska,et al.  Virtual TeleStroke support for the emergency department evaluation of acute stroke. , 2004, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[22]  K. Grimes.  Systems of Care in North America , 2004 .

[23]  R E Latchaw,et al.  Recommendations for the establishment of primary stroke centers , 2000 .