Treatment at high-volume centres more beneficial for stroke patients despite transfer effect

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In a study published in the journal Stroke, Lorenzo Rinaldo and colleagues from the Mayo Clinic, Rochester, USA, have reported that transfer of acute ischaemic stroke patients to high-volume centres is associated with reduced mortality after endovascular treatment of acute stroke compared with that at low-volume centres.

More and more interest has been given to topics such as this since the new era of mechanical thrombectomy for the treatment of large vessel occlusion began. Stroke teams are placing more attention on how the treatment process can be streamlined in order that patients can get the right care faster. The objective is to discover which workflow pattern is the most beneficial to patients, and in turn, what new processes may need to be implemented to make this a reality on a broad scale.

According to Rinaldo et al, some have argued that it may be beneficial to expand the availability of endovascular revascularisation services to lower-volume hospitals to minimise the morbidity associated with transfer to larger endovascular centres. To assess this argument, the investigators in this study compared the outcomes after revascularisation of patients directly admitted to a low-volume centre and those transferred to a high-volume centre.

To conduct the study they searched a national database of hospital-reported outcomes for patients who underwent endovascular revascularisation for acute ischaemic stroke. Hospitals were categorised as low, medium, or high procedural volume hospitals. Outcomes of inpatient admissions were collected and compared on the basis of admission source and hospital procedural volume.

A total of 118 institutions with 8,533 patients were included.

“Mortality rate (14.9% versus 18.6%; p=0.049) and mortality index (1.1 versus 1.6; p=0.048) were significantly lower among directly admitted relative to transferred patients. For all patients, there were significant differences in institutional mortality rate (low: 19.7%, medium: 14.9%, high: 9.8%; p=0.003) and mortality index (low: 1.5, medium: 1.1, high: 0.8; p=0.004) between low-, medium-, and high-volume hospitals. For transferred patients to high-volume centres, both mortality rate (high: 10% versus low: 20.4%; p=0.005) and mortality index (high: 0.8 versus low: 1.5; p=0.034) were significantly lower than that observed for directly admitted patients to low-volume hospitals,” Rinaldo and colleagues found.

With an obvious beneficial effect of treatment for patients treated at high-volume hospitals, in spite of the detrimental effects of transfer, compared to the treatment effect observed in patients who were directly admitted to low-volume hospitals, the authors of this study maintain that these findings serve as an argument for the centralisation of care.

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