Emergency medical services for acute ischemic stroke: Hub-and-spoke model versus exclusive care in comprehensive centers.

BACKGROUND: The emergent disposition of acute stroke patients remains an issue of debate. We investigated whether a hub-and-spoke model was associated with worse stroke outcomes when compared to care exclusively in comprehensive centers. METHODS: We performed a cohort study of all acute ischemic stroke patients who were hospitalized in endovascular-capable facilities, and were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2015. We examined the association of transfer status (transfer to endovascular capable hospitals versus initial treatment in these facilities) with inpatient case-fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and simulate a randomized trial. RESULTS: During the study period, 128,122 acute stroke patients met inclusion criteria. Instrumental variable analysis demonstrated that patients transferred to endovascular-capable hospitals did not have higher case-fatality (Adjusted difference, 4.4%; 95% CI, -0.1% to 9.0%), rate discharge to a facility (Adjusted difference, -2.3%; 95% CI, -5.2% to 0.6%), or longer LOS (Adjusted difference, 4.2; 95% CI, -2.2 to 10.1) in comparison to patients presenting for initial treatment in these facilities. The same associations were present when restricting the cohort to patients receiving intravenous tissue plasminogen (IV-tPA) and to patients receiving mechanical thrombectomy. CONCLUSIONS: Using a comprehensive all-payer cohort of acute ischemic stroke patients in New York State we demonstrated that patients treated in a hub-and-spoke model were not associated with worse outcomes than patients receiving care exclusively in comprehensive institutions. This needs to be taken into consideration when considering acute emergency services in this setting.

Surgical outcomes for patients diagnosed with dementia: A coarsened exact matching study.

BACKGROUND: An increasing number of elderly patients with dementia are undergoing surgical operations. Little is known about the differential impact of dementia on surgical outcomes. We investigated whether demented patients undergoing surgical operations have worse outcomes than their non-demented counterparts. METHODS: We performed a cohort study of all patients undergoing a series of surgical operations who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of dementia with inpatient case-fatality, discharge to a facility, and length of stay (LOS). Coarsened exact matching was used to balance comorbidities among the comparison groups, and mixed effect methods were used to control for clustering at the hospital level. RESULTS: During the study period, 342,075 patients underwent surgical operations that met the inclusion criteria. Multivariable logistic regression models, after coarsened exact matching, demonstrated that demented patients were not associated with higher case-fatality (OR, 0.43; 95% CI, 0.13-1.36), but were associated with higher rates of discharge to a facility (OR, 1.71; 95% CI, 1.26-2.31) and longer LOS (Adjusted difference, 31%; 95% CI, 26%-36%). These persisted in pre-specified subgroups stratified on particular operations. CONCLUSIONS: Using a comprehensive all-payer cohort of surgical patients in New York State we identified an association of dementia with increased rate of discharge to rehabilitation and longer LOS. No difference was identified in the case fatality of the two groups. Policy makers, payers, and physicians should take these findings into account when designing new policies, and when counseling patients.