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Care and outcomes of patients with in-hospital stroke

Saltman AP, Silver FL, Fang J, Stamplecoski M, Kapral MK. JAMA Neurol. 2015; 72(7):749-55. Epub 2015 May 4.

Importance — A sizeable minority of strokes occur in hospitalized patients. However, little is known about the presentation, care, and outcomes of stroke in this subgroup of patients.

Objective — To examine stroke care delivery and outcomes for patients with in-hospital vs community-onset stroke.

Design, Setting, and Participants — Prospective cohort study of all patients older than 18 years with acute stroke seen in the emergency department or admitted to the hospital at participating centers (all regional stroke centers in Ontario, Canada) between July 1, 2003, and March 31, 2012, including those with stroke onset during hospitalization for another cause.

Main Outcomes and Measures — We compared processes of stroke care delivery, including time to neuroimaging and rates of thrombolysis, as well as outcomes, including death and disability, in those with in-hospital vs community-onset stroke. We used multiple logistic regression models to adjust for age, sex, comorbid conditions, and stroke type and severity.

Results — The study sample included 973 patients with in-hospital stroke and 28 837 with community-onset stroke. Patients with in-hospital stroke compared with those with community-onset stroke had significantly longer waiting times from symptom recognition to neuroimaging (median, 4.5 vs 1.2 hours; P < .001; for <2 hours, 32% vs 63%; adjusted odds ratio [AOR] = 0.21; 95% CI, 0.18-0.24), lower use of thrombolysis (12% vs 19% of those with ischemic stroke; AOR = 0.54; 95% CI, 0.43-0.67; P < .001), and longer time from stroke recognition to administration of thrombolysis (median, 2.0 vs 1.2 hours; P < .001). After adjustment for age, stroke severity, and other factors, mortality rates at 30 days and 1 year after stroke were similar in those with in-hospital stroke and community-onset stroke; however, those with in-hospital stroke had a longer median length of stay following stroke onset (17 vs 8 days; P < .001), were more likely to be dead or disabled at discharge (77% vs 65% with modified Rankin Scale score of 3-6; AOR = 1.64; 95% CI, 1.38-1.96; P < .001), and were less likely to be discharged home from the hospital (35% vs 44%; AOR = 0.76; 95% CI, 0.64-0.90;P < .001).

Conclusions and Relevance — Compared with those with community-onset stroke, patients with in-hospital stroke had delays in investigations and treatment, suggesting a need for a standardized approach to the recognition and management of in-hospital stroke, with the aim of ensuring access to rapid acute stroke care.

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Keywords: Stroke Hospitalization Health care delivery