Ali et. al. use the GWTG database to describe acute ischemic stroke (AIS) patients admitted to a tertiary care center (almost 50% of patients were transfers). The rationale implied by this study is that with public reporting of healthcare quality data and third party payers, there is concern that tertiary care centers will be reprimanded for higher mortality rates, explained by care of the “sicker” patients referred in.
In this single center study, patients transferred from community facilities had more severe strokes, as measured by the NIH stroke scale, and were younger on average than patients presenting through the emergency department. Many received t-PA through the “drip and ship” model. Importantly, transfer status was not independently associated with in-hospital mortality. This being said, without adjustment for medical co morbidities or stroke severity, transfer patients came in sicker, with overall increased in-patient mortality.
This study is important evidence that community hospitals are frequently giving t-PA, and utilizing the hub-and-spoke model to benefit acute treatment of stroke patients. Tertiary care centers receiving these patients are well equipped to deal with the medical complications and provide excellent specialized care. However, payers and other rating agencies must take into account metrics of stroke severity and co morbidities of patients when grading hospitals on outcomes such as in-hospital mortality.
This study is examines outcomes measures such as in-hospital mortality in a tertiary care center between transfers and non-transfers, within the environment of pay-for-performance standards. Future directions should focus on recording better metrics of patient outcomes in the GWTG database, such as modified Rankin Scale or 90-day mortality, so that we can better understand the hub-and-spoke’s impact on the community.