Preventing death one stroke at a time

IN THE 21ST CENTURY, PREVENTING DEATHS DUE TO MEDIcal illness is an increasingly difficult task. Much of the lowhanging fruit has already been harvested; improvements in medical care are now measured as prevention of subsequent morbidities, not prevention of deaths. For example, the use of coronary artery stenting vs angioplasty alone does not reduce overall mortality. Use of intravenous tissue plasminogen activator (IV-TPA) for acute ischemic stroke improves neurologic outcomes but does not prevent death. Among symptomatic patients, carotid endarterectomy vs medical therapy does not prevent death. However, in this issue of JAMA, a report from Xian and colleagues using data from New York State found that patients with acute ischemic stroke (n=15 297) who were admitted to a designated primary stroke center (PSC) had a statistically significant 2.5% absolute reduction in adjusted 30-day all-cause mortality compared with patients admitted to nondesignated hospitals (n=15 650). This finding is important for several reasons. Each year, almost 800 000 new or recurrent strokes occur in theUnitedStatesalone, andworldwideabout16million individualshaveastroke. A2%to3%absolutereductionindeath wouldsuggest that16 000 to24 000 livescouldbesaved in the United States by having stroke patients cared for at a PSC. Many aspects of care at a PSC might contribute to the mortality reduction reported by Xian et al. A key component of a PSC is the stroke unit (an inpatient unit that provides coordinated multidisciplinary care with specific protocols and a well-trained, experienced medical staff). Prior studies have shown that care in a stroke unit vs a general medical ward is associated with a 3% absolute reduction in deaths, which is consistent with the findings reported in the study by Xian et al. Studies using the New York database have shown that care at a PSC was associated with reduced times to physician contact and brain imaging, increased TPA use, and more than a doubling of patients admitted to a stroke unit. Having a neurologist involved in the care of patients with a stroke is also associated (in some studies) with almost an 8% absolute risk reduction in death. Another finding reported by Xian et al was that admission to a PSC was associated with reduced mortality at 1 day, 7 days, 30 days, and 1 year after admission. Such a consistent and lasting result is likely to be due to a combination of factors, such as medical expertise, processes of care, and specific but heterogeneous medical interventions. This is based on the fact that different care approaches and interventions are involved in medical care at 1 day, 7 days, and 30 days, and the adjusted reductions in mortality increased with time from admission. It is possible but not proven that some aspects of care (eg, stroke unit protocols) used early in the hospitalization helped prevent subsequent deaths. A common misperception is that PSCs focus mainly on increasing the use of IV-TPA as an acute therapy. Although IV-TPA remains an important therapy for ischemic stroke, it is used in only a small number of all patients. It is unlikely that the increased use of IV-TPA seen in the current study (4.8% at the PSCs vs 1.7% at nondesignated hospitals) could account for the reduced mortality observed because rates of IV-TPA use were quite low, and prior studies have failed to show that IV-TPA use reduces mortality. Primary stroke centers likely achieve much of their benefit from improved diagnosis and measures to prevent peristroke complications. How does the care and improved outcomes at a PSC compare with other studies of PSCs and other systemic advances in acute medical care? A national study of patients with acute ischemic stroke in Finland found that care at a comprehensive stroke center (CSC) was associated with a 2.4% reduction in mortality compared with a non-CSC hospital. For a PSC, the reduction in mortality was 1.5% compared with a non-PSC hospital. Thus, the results seen in New York are consistent with other large studies, even in other parts of the world. One concern, however, is that even though death rates were reduced, the net outcome was keeping patients alive but with severe disabilities. This seems unlikely because 30-day readmission rates and rates of discharge to a skilled nursing facility were roughly equal in the stroke center and nondesignated hospital groups in the study by Xian et al. Other studies have also shown improved overall outcomes at a PSC.