Characteristics of Academic Medical Centers Associated with Ischemic Stroke Outcome
Background: Data supporting the efficacy of stroke center characteristics are limited. Methods: A questionnaire detailing stroke treatment practices was sent to 42 academic medical centers in the University Health Systems Consortium participating in a quality improvement project. In-hospital mortality of all emergency-department admissions for ischemic stroke at these institutions was evaluated in a large administrative database from 1997 through 1999. We used a multivariable method called generalized estimating equations, which broadens confidence intervals to adjust for clustering of variables at institutions. Using this technique, institutional characteristics were evaluated as predictors of in-hospital mortality after adjusting for age, gender, race, hospital treatment volume of ischemic stroke, and admission status (emergent, urgent, elective). Results: Thirty-two institutions completed the questionnaire and 29 of these were included in the administrative database. In-hospital deaths occurred in 758 (7.0%) of the 10,880 ischemic strokes admitted through the emergency department. In-hospital deaths were less frequent at hospitals with a vascular neurologist (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.36–0.74, p<0.001), and at those with guidelines stating that only neurologists could administer tPA (OR 0.65, 95% CI 0.49–0.88, p=0.004). There was a trend toward fewer deaths at hospitals with a dedicated stroke team available by pager (OR 0.76, 95% CI 0.56–1.04, p=0.09). The presence of a dedicated neurological intensive care unit, stroke unit, and written clinical pathway for stroke were not significantly associated with in-hospital death. Conclusions: Academic medical centers with a vascular neurologist and those with written guidelines limiting tPA administration to neurologists had lower rates of in-hospital mortality for ischemic stroke patients.