ABSTRACT
Background The thrombectomy-capable stroke center (TSC) is a recently introduced intermediate tier of accreditation for hospitals caring for patients with acute ischemic stroke (AIS). The comparative quality and clinical outcomes of reperfusion therapies at TSCs, primary stroke centers (PSCs), and comprehensive stroke centers (CSCs) has not been well delineated.
Methods We conducted a retrospective, observational, cohort study from 2018-2020 that included patients with AIS who received endovascular (EVT) and/or intravenous (IVT) reperfusion therapies at CSC, TSC, or PSC. Participants were recruited from Get With The Guidelines–Stroke registry. Study endpoints included timeliness of IVT and EVT, successful reperfusion, discharge destination, discharge mortality, and functional independence at discharge.
Results Among 84,903 included patients, 48,682 received EVT, of whom 73% were treated at CSCs, 22% at PSCs, and 4% at TSCs. The median annual EVT volume was 76 for CSCs, 55 for TSCs, and 32 for PSCs. Patient differences by center status included higher NIHSS, longer onset-to-arrival time, and higher transfer-in rates for CSC/TSC/PSC, respectively. In adjusted analyses, the likelihood of achieving the goal door-to-needle time was higher in CSCs compared to PSCs (OR 1.39; 95% CI 1.17-1.66) and in TSCs compared to PSCs (OR 1.45; 95% CI 1.08-1.96). Similarly, the odds of achieving the goal door-to-puncture time were higher in CSCs compared to PSCs (OR 1.58; 95% CI 1.13-2.21). CSCs and TSCs also demonstrated better clinical efficacy outcomes compared to PSCs. The odds of discharge to home or rehabilitation were higher in CSCs compared to PSCs (OR 1.18; 95% CI 1.06-1.31), while the odds of in-hospital mortality/discharge to hospice were lower in both CSCs compared to PSCs (OR 0.87; 95% CI 0.81-0.94) and TSCs compared to PSCs (OR 0.86; 95% CI 0.75-0.98). There were no significant differences in any of the quality-of-care metrics and clinical outcomes between TSCs and CSCs.
Conclusions In this study representing national US practice, CSCs and TSCs exceeded PSCs in key quality-of-care reperfusion metrics and outcomes, whereas TSCs and CSCs demonstrated similar performance. Considering that over one-fifth of all EVT procedures during the study period were conducted at PSCs, it may be desirable to explore national initiatives aimed at facilitating the elevation of eligible PSCs to a higher certification status.
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
The Get With The Guidelines®-Stroke (GWTG-Stroke) program is provided by the American Heart Association/American Stroke Association. GWTG-Stroke is sponsored, in part, by Novartis, Boehringer Ingelheim and Eli Lilly Diabetes Alliance, Novo Nordisk, Sanofi, AstraZeneca, Bayer and Alexion Pharmaceuticals.
Author Declarations
I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.
Yes
The details of the IRB/oversight body that provided approval or exemption for the research described are given below:
IQVIA is the data coordination center. The Duke Clinical Research Institute is the statistical coordinating center and analyzes deidentified data under an institutional review board-approved protocol.
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Yes
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Data Availability
Data types: Deidentified participant data How to access data: Data were collected by the American Heart Association (the steward of the data according to contracts between the American Heart Association and participating hospitals) and are stored securely at the Duke Clinical Research Institute (DCRI). Given that data were collected for clinical care and quality improvement, rather than primarily for research, data sharing agreements require an application process for other researchers to access the data. Interested researchers can submit proposals to utilize Get With The Guidelines for research purposes, including for validation purposes. Proposals can be submitted at http://www.heart.org/qualityresearch. Additional information regarding the statistical analysis plan and analytic code may also be available from DCRI upon request. When available: With publication Who can access the data: Given that data were collected for clinical care and quality improvement, rather than primarily for research, data sharing agreements require an application process for other researchers to access the data. Interested researchers can submit proposals to utilize Get With The Guidelines for research purposes, including for validation purposes. Proposals can be submitted at http://www.heart.org/qualityresearch. Additional information regarding the statistical analysis plan and analytic code may also be available from DCRI upon request.