Are 90 day outcomes for spontaneous ICH patients with same risk subset associated with level of care? What is the comparative effectiveness for management of spontaneous ICH patients at a higher level of care? The Lone Star Stroke Consortium, with its network of hub and spoke hospitals, provides a unique opportunity to answers these questions.
Intracerebral hemorrhage (ICH) accounts for about 10 – 15% of all strokes annually. It is associated with high mortality (30-day mortality up to 50%) and morbidity (up to 80% patients failing to achieve functional independence.) There are no specific modalities to treat ICH. Only a limited number of hospitals have well-developed critical pathways for ICH management. The health care systems research as well as research for development of new therapies lags behind ischemic stroke.
Lack of evidence for appropriate level of care for ICH patients: The American Heart Association / American Stroke Association guidelines for management of spontaneous ICH were updated in 2015 and include a new class 1 level B recommendation stating “initial monitoring of ICH patients should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise”. The evidence to support this recommendation is primarily provided by three observational studies. These studies represent data between 1998 and 2005 with two of them conducted in Canada and Sweden. Furthermore, these studies are secondary analyses on data from registries for heterogeneous group of critical care patients, looking at in-patient or day-30 mortality outcomes as measures of benefit.
The evolving model of stroke care delivery can be regarded as a sum of concurrent and overlapping changes seen during the past decade like standardization and certification of a growing number of regional stroke care facilities, legislation around preferential routing of stroke patients to centers with higher level of stroke care, integration of pre-hospital services with the overall system of care, improvements in hospitals’ quality of care processes, and expanding use of telemedicine technologies. These changes have complex interactions, with wide ranging regional variations. The individual or collective contribution of these changes to the overall reduction in stroke mortality and specifically for ICH mortality remains unclear. However, any recommendations for level of care of ICH patients need to be sensitive to these system changes.
It is also pertinent to note that the decline in overall stroke and ICH mortality has not been coupled with a reduced incidence. This translates into greater prevalence and burden of disease, and makes it imperative that any new guidelines for the appropriate level of care of ICH patients provide evidence-based recommendations taking into account outcomes beyond in-patient or 30-day mortality. A study from 2006 found a reduction in 30-day mortality for ICH patients treated at PSC hospitals, however, there was no difference in 30-day readmission rates. Another recent analysis did not reveal significant differences in all cause 90-day mortality between ICH patients treated at CSC vs. non-CSC hospitals. Finally, the impact of non-discriminant transfer of ICH patients to higher level of care (HLOC) needs evaluation in terms of healthcare costs and resource utilization. There is a lack of evidence in this realm.
It is likely that the decision to transfer ICH patients from a community hospital to a certified stroke center is an interplay of multiple patient, clinical, caregiver, physician, policy, and resource factors. It is also probable that there is a considerable facility-wide and regional variation in the practice of transferring ICH patients. Therefore, the first logical step towards developing evidence based recommendations is to study the regional patterns of care for ICH patients. Regional data are imperative to obtain detailed and granular information on in-patient and long term outcomes like resource utilization and functional and quality of life for ICH patients treated both at CSCs and non-certified community hospitals. These data are also necessary to study various transfer related decision parameters.