Bekelis Kimon, Missios Symeon, Coy Shannon, Mayerson Bruce, MacKenzie Todd A
Neuroscience Service Line, Catholic Health Services of Long Island, Melville, NY, United States; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, United States; Population Health Research Institute of New York at CHS, Melville, NY, United States; Geisel School of Medicine at Dartmouth, Hanover, NH, United States.
Population Health Research Institute of New York at CHS, Melville, NY, United States; Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
J Clin Neurosci. 2019 Feb;60:12-16. doi: 10.1016/j.jocn.2018.10.031. Epub 2018 Oct 19.
The emergent disposition of acute stroke patients remains an issue of debate. We investigated whether a hub-and-spoke model was associated with worse stroke outcomes when compared to care exclusively in comprehensive centers.
We performed a cohort study of all acute ischemic stroke patients who were hospitalized in endovascular-capable facilities, and were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2015. We examined the association of transfer status (transfer to endovascular capable hospitals versus initial treatment in these facilities) with inpatient case-fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and simulate a randomized trial.
During the study period, 128,122 acute stroke patients met inclusion criteria. Instrumental variable analysis demonstrated that patients transferred to endovascular-capable hospitals did not have higher case-fatality (Adjusted difference, 4.4%; 95% CI, -0.1% to 9.0%), rate discharge to a facility (Adjusted difference, -2.3%; 95% CI, -5.2% to 0.6%), or longer LOS (Adjusted difference, 4.2; 95% CI, -2.2 to 10.1) in comparison to patients presenting for initial treatment in these facilities. The same associations were present when restricting the cohort to patients receiving intravenous tissue plasminogen (IV-tPA) and to patients receiving mechanical thrombectomy.
Using a comprehensive all-payer cohort of acute ischemic stroke patients in New York State we demonstrated that patients treated in a hub-and-spoke model were not associated with worse outcomes than patients receiving care exclusively in comprehensive institutions. This needs to be taken into consideration when considering acute emergency services in this setting.
急性中风患者的紧急处置仍然是一个有争议的问题。我们调查了与仅在综合中心接受治疗相比，“中心-辐射”模式是否与更差的中风预后相关。
我们对所有在具备血管内治疗能力的机构住院，并于2009年至2015年在纽约州全州规划与研究合作系统（SPARCS）数据库中登记的急性缺血性中风患者进行了队列研究。我们检查了转运状态（转至具备血管内治疗能力的医院与在这些机构接受初始治疗）与住院病死率、出院至某机构以及住院时间（LOS）之间的关联。使用工具变量分析来控制未测量的混杂因素并模拟随机试验。
在研究期间，128,122例急性中风患者符合纳入标准。工具变量分析表明，与在这些机构接受初始治疗的患者相比，转至具备血管内治疗能力医院的患者并没有更高的病死率（调整差异，4.4%；95%置信区间，-0.1%至9.0%）、出院至某机构的比例（调整差异，-2.3%；95%置信区间，-5.2%至0.6%）或更长的住院时间（调整差异，4.2；95%置信区间，-2.2至10.1）。当将队列限制为接受静脉注射组织纤溶酶原（IV-tPA）的患者和接受机械取栓的患者时，同样的关联也存在。
通过对纽约州急性缺血性中风患者的一个全面的全付费者队列进行研究，我们证明，与仅在综合机构接受治疗的患者相比，采用“中心-辐射”模式治疗的患者预后并不更差。在考虑这种情况下的急性紧急服务时，这一点需要被考虑在内。
