Direct admission to specialist stroke centres has no clear benefit over initial treatment at a local hospital

Pickering A, Harnan S, Cooper K, et al.  Acute ischaemic stroke patients - direct admission to a specialist centre or initial treatment in a local hospital? A systematic review Journal of Health Services Research & Policy. 2015 May.

Review question

Are mortality rates decreased when stroke patients bypass local, non-specialist hospitals in favour of specialist stroke centres?

Background

Treating patients with a suspected stroke is a time-critical concern, and there is uncertainty regarding the benefit of directly transferring patients to a specialist stroke centre rather than beginning therapy at a local, non-specialist hospital.

Current guidelines recommend that stroke patients be admitted directly to stroke centres, but therapy can begin in a local, non-specialist hospital under appropriately trained staff before transfer to a specialist centre.

Due to the time-sensitive nature of treating someone who has had a stroke, the best treatment option may be at the closest, local hospital.

How the review was done

A detailed search of a number of electronic databases for studies published from 1988 to 2012 was conducted. Studies that compared direct admission of stroke patients to a specialist centre with admission of stroke patients to a non-specialist centre (with the potential to transfer), were included in the review.

A total of 14 studies were included in the review after assessment for eligibility.

This review was funded by the National Institute for Health Research Service Delivery and Organization Programme.

What the researchers found

The review found that stroke mortality rates were no different when patients began therapy at local hospitals and then transferred to stroke centres, as compared to direct admission to a stroke centre.

When patients were assessed for complications after discharge from the hospital, outcomes were the same for those who transferred directly to a stroke centre and those who transferred from a local hospital.

The included studies showed that there is uncertainty as to whether time to therapy is longer when patients were admitted directly to a stroke centre compared to receiving treatment first at a non-specialist local hospital.

Conclusion

This review found that health outcomes are the same for patients who are transferred directly to a specialist centre and those who are treated at a non-specialist local hospital before being transferred to a specialist centre. However, the authors cite poor data and study quality as major limitations to the generalizability of these findings, and more evidence is needed to support the current guidelines of transferring all stroke patients to specialist stroke centres for treatment.