Characteristics of academic medical centers and ischemic stroke outcomes

Background and Purpose-Data supporting the efficacy of stroke center charac teristics are limited. Methods-A questionnaire detailing stroke treatment practices was sent to 42 academic medical centers in the University Health Systems Consortium. In-h ospital mortality of all emergency department admissions for ischemic strok e at these institutions was evaluated in a database of discharge abstracts during 1997-1999. Institutional characteristics were evaluated as predictor s of in-hospital mortality after adjustment for age, sex, race, hospital tr eatment volume of ischemic stroke, and admission status (emergent, urgent, elective). Length of stay (LOS), total hospital charges, and frequency of t issue plasminogen activator (tPA) administration were evaluated as secondar y outcomes. We used a multivariable method called generalized estimating eq uations, which broadens confidence intervals to adjust for clustering of va riables at institutions. Results-Thirty-two institutions completed the questionnaire, and 29 of thes e were included in the database of discharge abstracts. In-hospital deaths occurred in 758 (7.0%) of the 10 880 ischemic stroke patients admitted thro ugh the emergency department. In-hospital deaths were less frequent at hosp itals with a vascular neurologist (odds ratio [OR] 0.51; 95% CI, 0.36 to 0. 74; P < 0.0001) and at those with guidelines stating that only neurologists could administer tPA (OR, 0.65; 95% CI, 0.49 to 0.88; P = 0.004). There wa s a trend toward fewer deaths at hospitals with a dedicated stroke team ava ilable by pager (OR, 0.76; 95% CI, 0.56 to 1.04; P = 0.09). The presence of a dedicated neurological intensive care unit, stroke unit, and written cli nical pathway for stroke were not significantly associated with in-hospital death. LOS was shorter at hospitals with a vascular neurologist (P = 0.01) . Conclusions-Academic medical centers with a vascular neurologist and those with written guidelines limiting tPA administration to neurologists had low er rates of in-hospital mortality for ischemic stroke patients.