Geographic differences in acute stroke care in Catalunya: impact of a regional interhospital network.

Abstract

UNLABELLED:

Limited resources prevent specialized care in community hospitals (CH) challenging geographical equity. We studied the impact of a regional interhospital network based on urgent transfer from 4 CH to a referral stroke center (RSC).

METHODS:

During 2006, all stroke patients admitted to the 5 networked hospitals (4 CH, 1 RSC) were studied: clinical pathways and stroke interventions were recorded. Physicians at CH decided emergent transfer under their clinical judgment. Quality therapeutic measures where defined: urgent expert neurological evaluation, stroke unit admission and thrombolytic treatment. For patients receiving tissue plasminogen activator, demographic and outcome data were recorded: clinical improvement (decrease > or =4 National Institute of Health Stroke Scale points at discharge), total recovery (3-month modified Rankin Scale score > or =1).

RESULTS:

From a total of 1,925 acute stroke patients, 1,587 were admitted to the RSC (1,396 primarily). Of 529 primarily admitted to CH, 191 (36.1%) were emergently transferred. Patients primarily admitted to the RSC were more frequently evaluated by a neurologist (100 vs. 34%; p < 0.001) and admitted to a stroke unit (22.7 vs. 11.7%; p < 0.001). However, the rate of thrombolytic treatment was similar (4.4 vs. 5.1%; p = 0.491). After initial assessment at the RSC, 92 (48.2%) transfers were considered unnecessary. Transferred patients accounted for 27/88 (30.7%) thrombolyses performed in the RSC. Baseline characteristics were similar, except a longer time to treatment (164 vs. 211 min; p = 0.004) and more frequent early ischemia CT signs among transferred patients (23 vs. 53%; p = 0.037). Clinical improvement (62 vs. 50%; p = 0.273) and symptomatic hemorrhagic transformation (6.8 vs. 3.8%; p = 0.596) were similar. However, among transferred patients, the degree of total recovery was lower (44 vs. 22%; p = 0.05).

CONCLUSION:

An interhospital network based on transfers to an RSC does not warrant geographical equity: equal access to best therapeutic interventions is only partially achieved at the expense of a high proportion of unnecessary transfers.

• Authors: Marc Ribo, Carlos A Molina, Angels Pedragosa, Carme Sanclemente, Estevo Santamarina, Marta Rubiera, Raquel Delgado-Mederos, Olga Maisterra, Manuel Quintana, Jose Alvarez-Sabin
• Journal: Cerebrovascular diseases (Basel, Switzerland) (Cerebrovasc Dis) Vol. 26 Issue 3 Pg. 284-8 ( 2008) ISSN: 1421-9786 [Electronic] Switzerland
• PMID: 18648202 (Publication Type: Comparative Study, Evaluation Study, Journal Article, Multicenter Study, Research Support, Non-U.S. Gov't)
• Copyright: Copyright 2008 S. Karger AG, Basel.

Topics

• Acute Disease
• Aged
• Aged, 80 and over
• Community Networks (organization & administration)
• Critical Pathways (organization & administration)
• Female
• Health Services Accessibility
• Healthcare Disparities
• Hospitals, Community (organization & administration)
• Hospitals, University (organization & administration)
• Humans
• Male
• Middle Aged
• Neurologic Examination
• Outcome and Process Assessment, Health Care
• Patient Transfer
• Program Evaluation
• Regional Health Planning
• Residence Characteristics
• Spain
• Stroke (diagnosis, therapy)
• Thrombolytic Therapy
• Treatment Outcome