2 nd jurnal reading

16 th November 2017

Presenter : dr. Epa Danisa Surbakti

Moderator : dr. Haflin Soraya, Mked (Neu) Sp.S
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 Introduction

Stroke  the fifth leading cause of death

in men and the second leading cause of
death in women in the United States.

To improve stroke system of care, the

Brain Attack Coalition recommended to
establish primary stroke centers (PSCs).

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 The number of PSCs has nearly quadrupled since 2006.
Hundreds of hospitals received their initial PSC
certification in the past few years.

This shift raised a question whether PSCs at the current

time have better outcome than non-PSCs and, more
importantly, whether the action toward PSC
certification improves the outcome of stroke care.

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 To address these questions, we examined in-hospital,
30-day, and 1-year all-cause mortality in the hospitals
that received initial PSC certification between 2009 and
2013 (new PSCs), in comparison to those PSCs that
were certified before 2009 and maintained through the
study period (existing PSCs), as well as those hospitals
that have never received PSC certification (non-SCs).

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 Methods
Patient Population

inclusion criterion Excluded criterion

• Medicare fee-for-service • Elective admissions

beneficiaries aged ≥65 • Patients who were
years who were admitted transferred to or from
from the emergency another acute care facility
department between • Patients who were
January 1, 2009, to discharged and then
December 31, 2013, admitted within 1 day
• Primary discharge • those who had unknown
diagnosis of ischemic source of admission
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stroke
 Hospital Classification
Hospitals were classified
into 3 groups:

new PSC , the PSCs that received initial certification

between 2009 and 2013;

existing PSCs  the hospitals that have been certified as

PSCs before January 2009 and maintained the certification
through the study period;

non-SCs  the hospitals that have never been certified as

PSCs.
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 This study included only
those hospitals that were
categorized as general
hospitals with emergency
departments.

Rehabilitation, pediatric,
long-term care, and
federal government
hospitals (Veterans and
military hospitals) were
excluded.
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 Outcome Measures  consisted of in-
hospital, 30-day, and 1-year all-cause
mortality, length of stay of the index
hospitalization, and discharge home rates.

Covariates  Patient comorbidities were

identified using the primary and secondary
codes from claims submitted in the index
admission.
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Statistical Analysis

Patient characteristics, hospital characteristics, length of stay, discharge home rates,

and unadjusted all-cause mortality were compared among the 3 groups of hospitals

Pearson’s χ2 tests  categorical row variables

Wilcoxon rank-sum tests  continuous variables.

Generalized estimating equations accounting for within-hospital clustering were used

for in-hospital mortality, and data were expressed as odds ratio (OR; 95% confidence
9interval [CI]).
 Cox proportional models using the robust sandwich
estimator to account for within-hospital clustering were
used for 30-day and 1-year mortality, and data were
expressed as hazard ratio (95% CI).

We examined the change of in-hospital and 30-day

mortality before and after PSC certification within the new
PSC group using multivariate logistic regression for in-
hospital mortality and Cox proportional hazards model for
30-day mortality.

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 Discussion
The study showed that new PSCs had lower in-hospital and
30-day unadjusted and adjusted all-cause mortality than
existing PSCs and non-SCs.

Compared with the existing PSCs, these new PSCs were

smaller as in total number of beds and annual stroke volume
and less likely to be teaching hospitals.

The adjusted 30-day mortality, a better assessment of hospital

performance, was lower among patients who were treated at
existing PSCs than among those treated at non-SCs.

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 Our finding is slightly different from a prior
report using 2006 MEDPAR data, which found
that PSCs certified before 2006 had mildly
lower in-hospital mortality rates (4.4% versus
4.7%) than non-PSCs and a small difference in
30-day mortality (10.7% versus 11.0%).

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 Conclusions

This study showed that although PSCs as a whole had better mortality
than non-SCs,

The hospitals that obtained initial PSC certification between 2009 and
2013 had lower in-hospital and 30-day unadjusted and adjusted all-
cause mortality than the PSCs that had been certified before 2009.

These results suggest that the process of obtaining initial stroke

certification may improve the outcome of stroke care and overcome
the disadvantage of being smaller hospitals.

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 Thank you

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