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Transferred patients with stroke at increased risk for poorer outcomes
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Compared with regular admissions, patients with stroke who were transferred to another hospital had an increased risk for in-hospital mortality and complications, according to new data published in Circulation Cardiovascular Quality Outcomes.
Adrienne V. Nickles, MPH , from the Michigan Department of Community Health, and colleagues compared the characteristics and outcomes of patients with stroke who were transferred to hospitals participating in the Michigan Coverdell Stroke Registry vs. patients with were regular hospital admissions. In-hospital complications included deep vein thrombosis, urinary tract infections and hospital-acquired pneumonia.
Transfer vs. regular admission
Overall, 19% of the 16,202 stroke admissions to 36 hospitals (13,453 ischemic, 631 subarachnoid hemorrhage, 2,118 intracerebral hemorrhage) recorded in the registry from 2009 to 2011 were transferred from another hospital. The average age of patients was 69 years. More than half of the patients were female and white, and 83% had experienced an ischemic stroke. According to the Cochrane-Armitage test, the number of patients transferred to another hospital increased during the 3-year study period, from 16% in the first quarter of 2009 to 22.4% in the last quarter of 2011 (P < .0001).
Transferred status was associated with younger age, greater stroke severity (median NIH Stroke Scale, 5 vs. 4; P < .0001) and hemorrhagic stroke compared with regular admission status. Patients with a history of stroke were less likely to be transferred. Of the 2,749 patients with hemorrhagic stroke, 77% had intracerebral hemorrhage and 33% had subarachnoid hemorrhage. More patients with subarachnoid hemorrhage were transferred than patients with intracerebral hemorrhage (53.9% vs. 32.7%; P < .0001).
Primary stroke centers vs. teaching hospitals
Sixty percent of hospitals in the registry were teaching hospitals and the remainder were primary stroke centers. Fourteen hospitals were classified as both primary stroke centers and teaching hospitals. Most hospitals (72%) received at least one transferred stroke patient, with 92% of patients transferred to a primary stroke center and 96% to a teaching hospital.
Of the 13,453 ischemic stroke admissions, more transferred patients received tissue plasminogen activator (tPA) therapy (16.1%) compared with regular admissions (8.4%). Approximately 85% of the transferred patients treated with tPA received IV administration. More than 92% of those who received IV tPA received it as part of “drip-and-ship” protocol.
In-hospital mortality and complications
More than 7% of all patients with stroke died in the hospital; the rate of in-hospital death was higher among patients with hemorrhagic stroke (22.4%) compared with patients with ischemic stroke (4.4%). In-hospital mortality was higher in transferred patients compared with those who were regular admissions (12% vs. 6.4%; P < .001).
Transfer status was a predictor of in-hospital mortality, even after adjustment for potential confounders (adjusted OR = 1.32; 95% CI, 1.12-1.56). However, this relationship varied by stroke type. Patients with ischemic stroke who were transferred had double the risk of patients with ischemic stroke who were regular admissions (adjusted OR = 2.14; 95% CI, 1.69-2.72). For patients with hemorrhagic stroke, however, the risk for in-hospital mortality was similar between patients that were transferred and those considered regular admissions.
Approximately 14% of all patients had at least one complication, with more patients experiencing urinary tract infection (9.9%) than deep vein thrombosis (2%) or hospital-acquired pneumonia (4%). The likelihood of complications while in the hospital was greater for transferred patients than for regular admissions (18.4% vs. 12.8%; P < .001).
“As stroke systems of care continue to evolve, registries need to expand their data collection efforts to provide a more complete understanding of the relative benefits and risk of transferring patients for acute stroke care ... including the timing and reasons for the decision to transfer, and the initial stroke severity at the time of the first medical evaluation,” Nickles and colleagues wrote. – by Tracey Romero
Disclosure: The researchers report no relevant financial disclosures.
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