Hospital size, remoteness and stroke outcome

Introduction: Previous studies have shown an association between number of stroke admissions and outcomes. Small hospitals often support more remote areas and we studied national data to determine if an association exists between hospital remoteness and stroke care. Methods: Data from the Irish National Audit of Stroke (INAS) on average stroke admissions, adjusted mortality for ischaemic stroke, thrombolysis rate and proportion with door to needle (DTN) ≤45 min were analysed. Hospital remoteness was quantified by distance to the next hospital, nearest neurointerventional centre and location within 10 km of the national motorway network. Results: Data for 23 of 24 stroke services were evaluated. Median number of strokes admitted per year was 186 (range 84-497). Nine hospitals (39%) admitted ≥200 stroke patients per year (mean 332). Average adjusted mortality (7.0 vs. 7.3, P = 0.67 t-test), mean thrombolysis rate (12.1% vs. 9.2%, P = 0.09) and mean proportion of patients treated ≤45 min (40.4% vs. 31.3%, P = 0.2) did not differ significantly between higher and lower volume hospitals.Hospitals close to the motorway network (n = 15) had a higher mean thrombolysis rate (11.9% vs. 7.5%, P = 0.01 t-test) and proportion DTN ≤45 min (43.7-18.4%, P Conclusion: Remoteness of hospitals is associated with worse measures of stroke outcome and management.</p

Response to: Relationship between hospital size, remoteness and stroke outcome

We thank Dr Liu and Dr Wang for their consideration of our paper. In response to some of their comments, as the paper makes clear, the study was conducted in only Ischaemic strokes (1). Because of the small size of some of the participating hospitals and the smaller proportion of haemorrhagic strokes calculations of adjusted mortality rate are less precise in the haemorrhagic stroke population. There are also fewer effective acute interventions for intracerebral haemorrhage thus measures of process such as thrombolysis rate and door to needle time would not be pertinent to them. Subsequent analyses of the data have found that in fact Remote hospitals in Ireland see a lower proportion of haemorrhagic strokes and care for a slightly older population (2) but both of these factors were controlled for in the study.</p