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. 2014 Aug 5:349:g4757.
doi: 10.1136/bmj.g4757.

Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis

Stephen Morris  1 , Rachael M Hunter  2 , Angus I G Ramsay  3 , Ruth Boaden  4 , Christopher McKevitt  5 , Catherine Perry  4 , Nanik Pursani  6 , Anthony G Rudd  7 , Lee H Schwamm  8 , Simon J Turner  3 , Pippa J Tyrrell  9 , Charles D A Wolfe  10 , Naomi J Fulop  3
Affiliations

Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis

Stephen Morris et al. BMJ. .

Abstract

Objective: To investigate whether centralisation of acute stroke services in two metropolitan areas of England was associated with changes in mortality and length of hospital stay.

Design: Analysis of difference-in-differences between regions with patient level data from the hospital episode statistics database linked to mortality data supplied by the Office for National Statistics.

Setting: Acute stroke services in Greater Manchester and London, England.

Participants: 258,915 patients with stroke living in urban areas and admitted to hospital in January 2008 to March 2012.

Interventions: "Hub and spoke" model for acute stroke care. In London hyperacute care was provided to all patients with stroke. In Greater Manchester hyperacute care was provided to patients presenting within four hours of developing symptoms of stroke.

Main outcome measures: Mortality from any cause and at any place at 3, 30, and 90 days after hospital admission; length of hospital stay.

Results: In London there was a significant decline in risk adjusted mortality at 3, 30, and 90 days after admission. At 90 days the absolute reduction was -1.1% (95% confidence interval -2.1 to -0.1; relative reduction 5%), indicating 168 fewer deaths (95% confidence interval 19 to 316) during the 21 month period after reconfiguration in London. In both areas there was a significant decline in risk adjusted length of hospital stay: -2.0 days in Greater Manchester (95% confidence interval -2.8 to -1.2; 9%) and -1.4 days in London (-2.3 to -0.5; 7%). Reductions in mortality and length of hospital stay were largely seen among patients with ischaemic stroke.

Conclusions: A centralised model of acute stroke care, in which hyperacute care is provided to all patients with stroke across an entire metropolitan area, can reduce mortality and length of hospital stay.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work. AGR is the national clinical director of stroke in England, and London stroke clinical director. PJT was clinical lead for stroke in Greater Manchester up to 2013, and led the Greater Manchester stroke service redesign from 2007. The sponsor approved all aspects of the study protocol and any amendments thereto, but played no other role in design or conduct of the study.

Figures

None
Fig 1 Summary of acute stroke pathway in Greater Manchester and London before and after reconfiguration of acute stroke services. ASU=acute stroke unit, CSC=comprehensive stroke centre, PSC=primary stroke centre, DSC=district stroke centre. Before the centralisation of acute stroke services in both Greater Manchester and London, patients with suspected stroke were taken to the nearest emergency department to receive stroke care. They were then sent to either an acute stroke unit or a regular hospital ward for treatment before being discharged for community rehabilitation. After the reorganisation in Greater Manchester patients presenting within four hours of developing stroke symptoms are sent to the comprehensive stroke centre or a primary stroke centre for hyperacute care. Once stable, they are repatriated to a district stroke centre, a nursing home, or their own home for community rehabilitation. Patients presenting outside the four-hour window are taken to the nearest DSC, receiving similar treatment to that provided before the reorganisation. After the reorganisation in London, patients presenting with stroke symptoms at any time are taken to a hyperacute stroke unit for assessment and treatment, then repatriated to a stroke Unit, to a nursing home, or to their own home for community rehabilitation
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Fig 2 Risk adjusted mortality at 3, 30, and 90 days and length of hospital stay in Greater Manchester, London, and the rest of England by quarter. Differences between actual mortality and length of hospital stay and expected values derived from patient level risk equations are shown. In both areas some hospitals began to reconfigure their services before these dates; this is controlled for by using hospital and time fixed effects
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References

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