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(Stroke. 2008;39:2522.)
© 2008 American Heart Association, Inc.

Original Contributions

Escalating Levels of Access to In-Hospital Care and Stroke Mortality

Gustavo Saposnik, MD, MSc, FAHA; Jiming Fang, PhD; Martin O'Donnell, MB, MRCPI; Vladimir Hachinski, MD, DSc, FRCPC; Moira K. Kapral, MD, MSc, FRCPC; Michael D. Hill, MD, MSc, FRCPC on behalf of the Investigators of the Registry of the Canadian Stroke Network (RCSN) for the Stroke Outcome Research Canada (SORCan) Working Group

From the Stroke Research Unit, Division of Neurology, Department of Medicine (G.S.), St. Michael’s Hospital, University of Toronto, Ontario, Canada; the Institute of Clinical Evaluative Sciences (J.F.), Toronto, Ontario, Canada; the Department of Medicine (M.O.), McMaster University, Ontario, Canada; the Stroke Program, Department of Clinical Neurological Sciences (V.H.) London Health Sciences Center, University of Western Ontario, Canada; the Department of Health Policy (G.S., M.K.K.), Management and Evaluation, University of Toronto, Ontario, Canada; the Division of General Internal Medicine and Clinical Epidemiology (M.K.K.), Department of Medicine, University Health Network, Toronto, Ontario, Canada and University Health Network Women’s Health Program Toronto, Ontario, Canada; and Stroke Unit, Departments of Clinical Neurosciences/Medicine/Community Health Sciences (M.D.H.), University of Calgary, Alberta, Canada.

Correspondence to Dr Gustavo Saposnik, 55 Queen St East, Suite 931, St Michael’s Hospital, University of Toronto, Toronto, M5C 1R6, Canada. E-mail saposnikg{at}smh.toronto.on.ca

Background and Purpose— Organized stroke care is an integrated approach to managing stroke to improve stroke outcomes by ensuring that optimal treatment is offered. However, limited information is available comparing different levels of organized care. Our aim was to determine whether escalating levels of organized care can improve stroke outcomes.

Methods— Cohort study including patients with acute ischemic stroke between July 2003 and March 2005 in the Registry of the Canadian Stroke Network (RCSN). The RCSN is the largest clinical database of patients with acute stroke patients seen at selected acute care hospitals in Canada. As stroke unit admission does not automatically imply receipt of comprehensive care, we created the organized care index to represent different levels of access to organized care ranging from 0 to 3 as determined by the presence of occupational therapy/physiotherapy, stroke team assessment, and admission to a stroke unit. The primary end point was early stroke mortality. Secondary end points include 30-day and 1-year mortality.

Results— Overall, 3631 ischemic stroke patients were admitted to 11 hospitals. Seven day stroke mortality was 6.9% (249/3631), 30-day stroke mortality was 12.6% (457/3631), and 1-year stroke mortality was 23.6% (856/3631). Risk-adjusted 7-day mortality was 2.0%, 3.2%, 7.8%, and 22.5% for organized care index of 3, 2, 1, and 0. Higher level of care was associated with lower adjusted mortality (for organized care index 3, OR 0.03, 95% CI 0.02 to 0.07 for 7-day mortality; OR 0.09, 95% CI 0.05 to 0.17 for 30-day mortality; and OR 0.40, 95% CI 0.25 to 0.64 for 1-year mortality).

Conclusions— Higher level of access to care was associated with lower stroke mortality rates. Establishing a well-organized and multidisciplinary system of stroke care will help improve the quality of service delivered and reduce the burden of stroke.

Key Words: outcome research • access to care • organized care • health policy • stroke team

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