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Original Investigation |

Primary Stroke Center Hospitalization for Elderly Patients With Stroke Implications for Case Fatality and Travel Times

Kimon Bekelis, MD1,2; Nancy J. Marth, MS, MSN2; Kendrew Wong, BS2,3; Weiping Zhou, MS2; John D. Birkmeyer, MD2; Jonathan Skinner, PhD2,4
[+] Author Affiliations
1Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
2The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
4Department of Economics, Dartmouth College, Hanover, New Hampshire
JAMA Intern Med. 2016;176(9):1361-1368. doi:10.1001/jamainternmed.2016.3919.
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Importance  Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care.

Objectives  To examine the association of case fatality with receiving care in PSCs vs other hospitals for patients with stroke and to identify whether prolonged travel time offsets the effect of PSCs.

Design, Setting, and Participants  Retrospective cohort study of Medicare beneficiaries with stroke admitted to a hospital between January 1, 2010, and December 31, 2013. Drive times were calculated based on zip code centroids and street-level road network data. We used an instrumental variable analysis based on the differential travel time to PSCs to control for unmeasured confounding. The setting was a 100% sample of Medicare fee-for-service claims.

Exposures  Admission to a PSC.

Main Outcomes and Measures  Seven-day and 30-day postadmission case-fatality rates.

Results  Among 865 184 elderly patients with stroke (mean age, 78.9 years; 55.5% female), 53.9% were treated in PSCs. We found that admission to PSCs was associated with 1.8% (95% CI, −2.1% to −1.4%) lower 7-day and 1.8% (95% CI, −2.3% to −1.4%) lower 30-day case fatality. Fifty-six patients with stroke needed to be treated in PSCs to save one life at 30 days. Receiving treatment in PSCs was associated with a 30-day survival benefit for patients traveling less than 90 minutes, but traveling at least 90 minutes offset any benefit of PSC care.

Conclusions and Relevance  Hospitalization of patients with stroke in PSCs was associated with decreased 7-day and 30-day case fatality compared with noncertified hospitals. Traveling at least 90 minutes to receive care offset the 30-day survival benefit of PSC admission.

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Figure.
Map of the United States Showing the Shortest Ground Total Time From Patient Zip Code Origin to Primary Stroke Centers Among Medicare Beneficiaries With Stroke Using Road Network Data

Alaska and Hawaii total travel times are derived from geodesic distance because of the limited road network. Green squares with a letter “H” indicate Primary Stroke Centers, while all other dots indicate zip code centroids of various total travel times to the closest Primary Stroke Center.

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