Abstract 2260: Interhospital Transfers in the Colorado Stroke System
Background: Stroke systems have been called a “critical next step in improving patient outcomes.” A desired feature is for hospitals unable to function as primary stroke centers to transfer appropriate patients for timely acute care. Recommendations imply that systems should be deliberately designed, but in Colorado an informal system is emerging without coordinated statewide action. We sought to assess the performance of this system with regard to hospital transfers.
Methods: The Colorado Stroke Registry (CSR), a Get With The Guidelines-Stroke® database, shared by 39 hospitals, captures clinical data for ∼70% of Colorado strokes. Using data from CSR and the Colorado Hospital Association, we examined transfers during 2007-2009 to assess the effect of transfer on acute thrombolysis and to gain insight into factors that may determine whether transfer occurs.
Results: 12,241 records had stroke-events during 2007-2009. Ischemic strokes (IS) were 56.7% of these. Transient ischemic attacks (TIA), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and non-specified stroke accounted for 23.7%, 4.6%, 11.3%, and 3.7%, respectively. Hospital transfers were noted in 1,487 records (12.1%). Nearly 80% of transfers were to only 6 (15%) of the 39 hospitals. The likelihood of transfer to a hospital was significantly correlated with hospital volume (P = 0.0045). Compared to IS, transfer was less likely for TIA but more likely for ICH and SAH (OR: 0.28, 1.59, 4.37, respectively; P <0.0001 for each). Transfer was more likely for: men than women (13.4% v 11.0%, P <0.0001); whites than blacks (11.8% v 5.3%, P <0.0001); and Hispanics than non-Hispanics (13.3% v 12.1%, P=0.002). Transfers were younger with higher NIHSS scores (mean age: 63.9 v 70; mean NIHSS 9.7 v 7.1, P <0.0001 for both). Transfer was less likely if additional medical problems were recorded (11% v 20.1%, P< 0.0001) or if primary insurance was Medicare rather than commercial (5.9% v 10.1%, P<0.0001). Day of week did not predict transfer. In a multivariate logistic model of transfer for IS, these variables were independently predictive: age, NIHSS and absence of additional problems. IS transfers were more likely to receive IV tPA (22.9% v 10.7%, P<0.0001) and more likely to die in-hospital (8.6% v 4.5%, P<0.0001), but no more likely to have clinically significant ICH following tPA (3.7% v 5.7%, P=0.324).
Conclusions: Without centralized planning, a system of acute stroke care is evolving in Colorado. In the system, transfers are common for IS, SAH, and ICH. 15% of hospitals receive nearly 80% of transfers. Transfer is more common for IS patients who: are younger, have higher NIHSS scores and lack additional problems. Transferred IS patients are more likely to receive IV tPA but not to have clinically significant ICH after thrombolysis.
- © 2012 by American Heart Association, Inc.