Abstract
Background: Optimized stroke systems of care can enable equitable access to timely care, including endovascular thrombectomy (EVT). Yet how hospitals are connected in the care of stroke patients is not well-characterized. Given that EVT is only available in specialized centers, stroke systems and patient transfer patterns may have evolved after the 2015 publication of EVT benefit. Primary objective: to map the stroke patient transfer network in California and to determine whether it changed after 2015. Methods: We analyzed California data including every nonfederal hospital admission from pre- (2010-2014) and post-2015 (2016-2017). ICD-9, ICD-10, and DRG codes identified ischemic stroke (IS) hospitalizations. Connections between any 2 hospitals were based on the transfer of > 5 IS patients between them/year. t-tests compared the patient transfer maps pre- vs post-2015 on descriptive network measures: number of hospitals, transfer connections, and patients shared in transfer, and distance traveled in transfer. A hierarchical logistic regression model assessed whether patients were more frequently transferred to EVT-capable hospitals after 2015, adjusting for patient- and hospital-level factors, including a time-by-distance interaction. Results: Among 385,799 IS hospitalizations, 15,522 (4.0%) were transferred. After 2015, patients traveled longer distances in transfer (25.1 vs 28.4 miles, p<0.001) (Figure). The proportion of patients transferred and the number of EVT centers were stable, but, after 2015, patients were more frequently transferred to EVT centers and travelled longer distance to do so (post-2015 OR 3.0, 95% CI 2.5-3.5; distance OR 1.044/mile, 95% CI 1.04-1.05; OR for interaction 1.01, 95% CI 1.003-1.02). Conclusion: The California stroke transfer network significantly changed after the 2015 publication of benefit for EVT, with increased likelihood of transfer to EVT centers and longer distances traveled in transfer.
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