Abstract

Variation in delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. 2017 National Audit organizational survey (Australia) linked with patient-level data from the Australian Stroke Clinical Registry (AuSCR) (2016-2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90 to 180 day readmissions and health-related quality of life (HRQoL). Models were adjusted for patient factors, including severity of stroke. 52/127 hospitals with organizational survey data were merged with 22,832 AuSCR patients with first-ever stroke/transient ischemic attack (median age 75years; 55% male; 66% ischemic). In metropolitan hospitals (N=42, 20,977 patients; 1,701 thrombolyzed; 2,395 readmitted between 90 and 180 days post stroke), a faster median door-to-needle time for thrombolysis was associated with 500+ annual stroke admissions (-15.9min, 95%CI -27.2,-4.7), annual thrombolysis >20 patients (-20.2min, 95%CI -32.0,-8.3), and having specialist stroke staff (dedicated medical lead and stroke coordinator;-12.7min, 95%CI -25.0,-0.4). A reduced likelihood of all cause readmissions between 90 and 180 days was evident in metropolitan hospitals using care pathways for stroke management (OR 0.82, 95%CI 0.67, 0.99). In regional/rural hospitals (N=10, 1,855 patients), being discharged with a care plan was also associated with use of stroke clinical pathways (OR 3.58, 95%CI 1.45, 8.82). No specific hospital resources influenced 90 to 180-day HRQoL. Relevant to all international registries, integrating information about hospital resources with clinical registry data provides greater insights into factors that influence evidence-based care.

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