Clinical question: Are there any differences in care and outcomes for in-hospital versus community-onset stroke?
Background: In-hospital stroke accounts for 4%-17% of all strokes. Hospitalists and other non-neurological services have to identify and treat subsequent stroke in their patients. There is not much literature detailing the differences between hospitalized stroke patients and those admitted for stroke.
Study design: Prospective cohort study.
Setting: All regional stroke centers in Ontario, Canada.
Synopsis: During a period of nine years, 973 in-hospital and 28,837 community-acquired stroke patients were followed. Compared to community-acquired stroke patients, in-hospital stroke patients had longer time to confirmatory neuroimaging, lower use of thrombolysis, lower use of investigational tests, and longer length of stay, and they were more likely to be disabled or dead at discharge. The two cohorts had similar mortality outcomes after discharge at 30 days and one year, after adjusting for multiple factors. Interestingly, in-hospital stroke patients were more likely to be given the proper medications for secondary prevention at discharge.
The study was limited in that the authors were unable to research why in-hospital patients did not get timely diagnosis and comparable treatment. The admission diagnoses were not enough for the authors to determine if that condition mattered in care. Secondary analysis found that in-hospital stroke patients were older and had more comorbidities (i.e., diabetes, hypertension, hyperlipidemia, and atrial fibrillation). The primary reason in-hospital stroke patients did not get thrombolysis was because of a contraindication.
Bottom line: In-hospital stroke patients have increased lengths of stay and more disability compared to community-onset stroke patients.
Citation: Saltman AP, Silver FL, Fang J, Stamplecoski M, Kapral MK. Care and outcomes of patients with in-hospital stroke. JAMA Neurol. 2015;72(7):749-755.