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When Does Transport to a Distant Primary Stroke Center Make Sense?

LEBANON, NH – It’s a frequent dilemma when stroke occurs: Should the patient be transported to a primary stroke center (PSC), which offers specialized care, or will the extra travel time mitigate the benefits?

An article published online by JAMA Internal Medicine provides a fairly straightforward answer: Hospitalization of patients with stroke in PSCs was associated with decreased seven-day and 30-day case fatality compared with noncertified hospitals.

Yet, the Dartmouth-Hitchcock Medical Center-led study suggests that traveling at least 90 minutes to receive care offsets the 30-day survival benefit of PSC admission. To reach that conclusion, researchers analyzed data for a national group of Medicare beneficiaries and calculated travel time.

With stroke a leading cause of death and long-term disability in the United States, PSCs certified by The Joint Commission have been established to ensure adherence to guidelines and the efficient delivery of disease-specific care. Yet, incentives to direct patients with stroke to regional PSCs can affect travel times and outcomes, according to the report.

Using a study period from 2010 through 2013, researchers focused on 865,184 Medicare fee-for-service beneficiaries, average age nearly 79 years, who presented with a stroke. Slightly more than half of the patients, 53.9%, were treated at one of 976 PSCs across the country, with about 24% of them living closer to a PSC than to a non-PSC facility.

Results indicate that admission to a PSC was associated with a 1.8% lower seven-day and 30-day death rate, but that traveling at least 90 minutes to a PSC appears to offset any mortality benefits. Presented another way, the study suggests 56 patients with stroke need to be treated in PSCs to save one life at 30 days. For seven-day outcomes, the study posits that 60 minutes of travel time for a PSC admission could be the offsetting factor.

"Further investigations are necessary to identify the best combination of approaches to improve access to centers of excellence and stroke outcomes," the authors conclude.

In a related commentary, Lee H. Schwamm, MD, of Massachusetts General Hospital and Harvard Medical School, both in Boston, writes that, “Within the limits of their Medicare (Centers for Medicare & Medicaid Services) fee-for-service claims data source, [researchers] did an elegant job of trying to control for measured and unmeasured confounding introduced by the nonrandom allocation of patients.”

“The most cost-effective sorting and allocation strategies will occur in the context of a unified stroke system of care that brings together centers of varying capability that are publicly reporting their performance data, engaged in continuous quality improvement, and focused on what is best for patients,” Schwamm adds. “Smartphone apps or similar methods are needed that can factor in the onset time, degree of stroke severity, travel times, hospital door-to-needle and door-to-puncture times, rates of recanalization success, patient preference, and in-hospital mortality to determine the best possible destination for each patient.”