Comparative effectiveness of medical care for patients with in-hospital ischemic stroke in primary stroke units and regional comprehensive stroke centers

BACKGROUND: In-hospital ischemic stroke is a severe competing condition associated with a high rate of adverse outcomes.

AIM: This work aimed to compare the effectiveness of medical care for patients with in-hospital ischemic stroke in facilities with a primary stroke unit versus a regional comprehensive stroke center.

METHODS: A retrospective analysis was performed, evaluating quality of care and outcomes in 389 patients with in-hospital ischemic stroke across 12 healthcare facilities in Saint Petersburg during 2015–2024: eight hospitals with a regional comprehensive stroke center and one federal medical organization providing 24/7 endovascular care for in-hospital ischemic stroke (n = 268); and three multidisciplinary hospitals with a primary stroke unit (n = 121).

RESULTS: In-hospital ischemic stroke occurred more frequently in internal medicine patients in primary stroke units (66.9% vs 33.1%), whereas in regional comprehensive stroke centers it was more common in surgical patients (56.7% vs 43.3%; p < 0.001). Patients with in-hospital ischemic stroke treated in primary stroke units were older (77.0 ± 13.0 vs 69.0 ± 12.0 years; p < 0.001), had higher comorbidity burden by Charlson Comorbidity Index (8.9 ± 3.7 vs 7.1 ± 2.8; p < 0.001), and were more often admitted urgently (85% vs 57%; p < 0.001). In-hospital ischemic stroke in primary stroke units was associated with more severe neurological deficits (13 ± 7 vs 12 ± 8; p = 0.025), poorer functional outcomes (p < 0.001), and higher in-hospital mortality (53% vs 29%; p < 0.001) compared with regional comprehensive stroke centers. At diagnosis of in-hospital ischemic stroke, angiographic (11% vs 57%; p < 0.001) and perfusion (0.8% vs 5.4%; p < 0.001) neuroimaging studies were performed less frequently in hospitals with primary stroke units than in regional comprehensive vascular centers; emergency reperfusion methods were also used less often (0.8% vs 16.4%; p < 0.001).

CONCLUSION: Differences in functional capacity between primary stroke units and regional comprehensive stroke centers with regard to reperfusion treatment approaches should not adversely influence the timeliness and completeness of diagnostic work-up in patients with in-hospital ischemic stroke. Angiographic and perfusion neuroimaging allows for the use of systemic thrombolytic therapy under expanded indications in primary stroke units, and also enables determination of indications for endovascular interventions to facilitate transfer to the nearest regional comprehensive stroke center in accordance with routing protocols.