The Impact of Transferring Stroke Patients: An Analysis of National Administrative Data

Impact of Telestroke Implementation on Emergency Department Transfer Rate

BACKGROUND

and Purpose: Telestroke networks are associated with improved outcomes from acute ischemic stroke(AIS) patient and facilitate greater access to care, particularly in underserved regions. These networks also have the potential to influence patient disposition through avoiding unnecessary interhospital transfers. This study examines the impact of implementation of the VA National Telestroke Program (NTSP) on interhospital transfer among Veterans.

METHODS

We analyzed AIS patients presenting to the emergency department 21 VA hospitals before and after telestroke implementation. Transfer rates were determined through review of administrative data and chart review and patient and facility level characteristics were collected to identify predictors of transfer. Comparisons were made using t-test, Wilcoxon rank sum, and chi-square analysis. Multivariable logistic regression with sensitivity analyses were conducted to assess the influence of telestroke implementation on transfer rates.

RESULTS

We analyzed 3,488 stroke encounters (1,056 pre-NTSP and 2,432 post-NTSP). Following implementation, we observed an absolute 14.4% decrease in transfers across all levels of stroke center designation. Younger age, higher stroke severity, and shorter duration from symptom onset were associated with transfer. At the facility level, hospitals with lower annual stroke volume were more likely to transfer although only one hospital actually saw an increase in transfer rates following implementation. After adjusting for patient and facility characteristics, the implementation of VA NTSP resulted in a nearly 60% reduction in odds of transfer (OR = 0.39, [0.19, 0.77]).

CONCLUSIONS

In addition to improving treatment in acute stroke, telestroke networks have the potential to positively impact the efficiency of interhospital networks through disposition optimization and the avoidance of unnecessary transfers.

The Patterns and Outcomes of Inter-Hospital Transfer Among Medicare Patients with Ischemic Stroke

BACKGROUND AND PURPOSE

Inter-hospital transfer for ischemic stroke is an essential part of stroke system of care. This study aimed to understand the national patterns and outcomes of ischemic stroke transfer.

METHODS AND RESULTS

This retrospective study examined Medicare beneficiaries aged ≥65 years undergoing inter-hospital transfer for ischemic stroke in 2012. Cox proportional hazards model was used to compare 30-day and one-year mortality between transferred patients and direct admissions from the emergency department (ED admissions). Among 312,367 ischemic stroke admissions, 5.7% underwent inter-hospital transfer. Using this value as cut-off, the hospitals were classified into receiving (n = 411), sending (n = 559), and low-transfer (n = 1863) hospitals. Receiving hospitals were larger than low-transfer and sending hospitals as demonstrated by the median bed number (371, 189, and 88, respectively, p < 0.001); more frequently to be certified stroke centers (75%, 47%, and 16%, respectively, p < 0.001); and less commonly located in the rural area (2%, 7%, and 24%, respectively, p < 0.001). For receiving hospitals, transfer-in patients and ED admissions had comparable mortality at 30 days (10% vs 10%; adjusted HR [aHR]=1.07; 95% CI, 0.99-1.14) and 1 year (23% vs 24%; aHR=1.03; 95% CI, 0.99-1.08). For sending hospitals, transfer-out patients, compared to ED admissions, had higher mortality at 30 days (14% vs 11%; aHR=1.63; 95% CI, 1.39-1.91) and 1 year (30% vs 27%; aHR=1.33; 95% CI, 1.20-1.48). For low-transfer hospitals, overall transfer-in and transfer-out patients, compared to ED admissions, had higher mortality at 30 days (13% vs 10%; aHR=1.46; 95% CI, 1.33-1.60) and 1 year (28% vs 25%; aHR=1.27; 95% CI, 1.19-1.36).

CONCLUSIONS

Hospitals in the US, based on their transfer patterns, could be classified into 3 groups that shared distinct characteristics including hospital size, rural vs urban location, and stroke certification. Transferred patients at sending and low-transfer hospitals had worse outcomes than their ED admission counterpart.

Plasticity and recovery of function

The frontal lobe plays a crucial role in human motor behavior. It is one of the last areas of the brain to mature, especially the prefrontal regions. After a brief historical perspective on the perceived dichotomy between the view of the brain as a static organ and that of a plastic, constantly changing structure, we discuss the stability/plasticity dilemma including examples of documented cortical reorganization taking place at multiple spatial and temporal scales. We pose that while plasticity is needed for motor learning, stability of the system is necessary for storage and maintenance of memorized skills. We discuss how this plasticity/stability dilemma is resolved along the life span and after a brain injury. We then examine the main challenges that clinicians have to overcome to promote recovery of function in patients with brain lesions, including attempts to use neurostimulation techniques as adjuvant to training-based customary neurorehabilitation.

Ischemic Stroke Transfer Patterns in the Northeast United States

BACKGROUND

Little is known about how hospitals are connected in the transfer of ischemic stroke (IS) patients. We aimed to describe differences in characteristics of transferred versus nontransferred patients and between transferring and receiving hospitals in the Northeastern United States, and to describe changes over time.

METHODS

We used Medicare claims data, and a subset linked with the Get with the Guidelines-Stroke registry from 2007 to 2011. Receiving hospitals were those with annual IS volume greater than or equal to 120 and greater than or equal to 15% received as transfers, and transferring hospitals were nonaccepting hospitals that transferred greater than or equal to 15% of their total (ED plus inpatient) IS patient discharges. A transferring-to-receiving hospital connection was identified if greater than or equal to 5 patients per year were shared. ArcGIS 10.3.1 was used for network visualization.

RESULTS

Among 177,270 admissions to 402 Northeast hospitals, 6906 (3.9%) patients were transferred. Transferred patients were younger with more severe strokes (78 versus 81 years, P < .001; National Institutes of Health Stroke Severity 7 versus 5, P < .001), and were as likely to receive tissue plasminogen activator as nontransferred (P = .29). From 2007 to 2011, there were more patients transferred (960 [3%] to 1777 [6%], P < .001), and more transferring hospitals (46 [12%] to 91 [24%], P < .001), and receiving hospitals (6 [2%] to 16 [4%], P < .001). Most transferring hospitals were exclusively connected to a single receiving hospital.

CONCLUSIONS

From 2007 to 2011, hospitals in the United States Northeast became more connected in the care of IS patients, with increasing patient transfers and hospital connections. Yet most hospitals remained unconnected. Further characterization of this transfer network will be important for understanding and improving regional stroke systems of care.