Does admission to hospital improve the outcome for stroke patients?

Objectives: to identify the factors associated with hospital admission and the differences in management and outcome of stroke patients between hospital and home. Design: a prospective community stroke register (1995–8) with multiple notification sources. Setting: an inner city multi‐ethnic population of 234 533 in South London, UK. Participants: 975 subjects with first in a lifetime strokes, whether or not they were admitted to hospital. Patients dying suddenly and those already hospitalized at the time of stroke were excluded. Main outcome measures: factors associated with hospital admission; differences in management in the acute phase of stroke; mortality and dependency assessed by the Barthel index 3 months post‐stroke. Results: 812 patients were admitted to hospital for stroke; 163 were managed in the community. Factors independently associated with hospital admission included stroke severity, pre‐stroke independence, atrial fibrillation, having an intracranial haemorrhage and having a non‐lacunar infarction. Computed tomography scan rates were higher in admitted (78%) than non‐admitted patients (63%; P=0.001). By 3 months, 285 (35%) of the admitted patients had died compared with 13 (8%) of non‐admitted patients (P<0.001). Of the admitted patients, 241 (47%) had a Barthel index ≥18 compared with 106 (72%) of those who were not admitted (P<0.001). After adjusting for case‐mix variables, the odds ratios for death and dependency (Barthel index<18) in admitted and non‐admitted patients were 2.21 (0.96–5.12) and 2.39 (1.35–4.22) respectively. Conclusion: patients with clinical indicators for a more severe stroke were more likely to be admitted to hospital. Hospitalized stroke patients may have poorer survival and disability rates than those who remain at home, even after adjustment for case mix. There may be some aspects of acute hospital care that may be detrimental to outcome in certain groups of stroke patients. This requires further investigation