Do Healthcare Process and Outcomes Differ for Acute Ischemic Stroke Patients Admitted to Designated Stroke Centers?

Thesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Community and Preventive Medicine, 2010.Stroke is the third leading cause of mortality and the leading cause of serious long-term disability in the Unites States. Establishment of designated stroke centers has great potential to improve acute stroke care. Despite widespread support for the stroke center concept, few studies have demonstrated improved process of care at designated stroke centers, and none has examined mortality outcomes. This dissertation uses New York Statewide Planning and Research Cooperative System data (2005-2006) to examine two research questions controlling for the non-randomized study design: (1) Do New York State designated stroke centers increase the use of thrombolytic therapy among patients with acute ischemic stroke? (2) Do designated stroke centers reduce mortality? In addition, we evaluate racial/ethnic differences in the use of thrombolytic therapy and mortality. Our studies resulted in the following observations: • Compared to patients at non-designated hospitals, patients who were treated at designated stroke centers were significantly more likely to receive thrombolytic therapy. • Receiving care at designated stroke centers was associated with significantly lower mortality, almost one percent (0.93%) lower within the hospital and 2.59%, 2.65%, 1.76%, and 2.29% lower at 30, 90, and 180 days and one year after stroke admission, respectively. • Non-Hispanic blacks were less likely than non-Hispanic whites to be treated at designated stroke centers. • Non-Hispanic blacks were less likely to receive thrombolytic therapy. • Non-Hispanic blacks had lower in-hospital mortality and lower short- and intermediate-term mortality than non-Hispanic whites. However, the survival advantage among blacks was diminishing as time after discharge increased. • Lower mortality among non-Hispanic blacks may be due to lower use of palliative care such as hospice and greater use of life-sustaining interventions including hemodialysis, gastrostomy, and enteral/parenteral nutrition. In conclusion, this dissertation validates two expected benefits of designated stroke centers, namely, increased use of thrombolytic therapy and reduced mortality. Racial disparities remain in access to quality stroke care and use of evidence-based treatment. Expanding designated stroke centers nationwide has the potential for improving quality of stroke care, reducing stroke-related health disparities, and enhancing patient outcomes