Stroke Unit Care and Trends of In-Hospital Mortality for Stroke in Germany 2005–2010

Abstract

In Germany, the financing of stroke unit care was implemented into the hospital reimbursement system in 2006. Since then, many acute care hospitals newly implemented stroke units. Simultaneous, in-hospital mortality for stroke declined. The study aims to analyze the association of mortality trends for stroke with the increasing provision of stroke unit care in German hospitals. Hospitalizations for acute stroke from 2005 to 2010 are identified in the nationwide German Diagnosis Related Groups statistics. Trends of risk-adjusted in-hospital mortality are studied stratified by existence of a stroke unit in the admitting hospital, as well as stratified by cohorts of hospitals defined by the respective period of stroke unit implementation. Overall, mortality in patients admitted to stroke unit hospitals is lower (crude 9.2%; adjusted 9.8%) compared to patients admitted to nonstroke unit hospitals (12.7%; 11.6%). The longitudinal analysis revealed a general secular trend of declining mortality in all cohorts of hospitals. However, while all stroke unit-providing hospital cohorts converge to a quite similar level of mortality in 2010, mortality in hospitals without stroke unit remains significantly higher. Reduction of mortality in hospitals with early provision of stroke unit care seems to be attributable to the secular trend. A reduction of mortality exceeding the secular trend was observed in hospitals with late stroke unit implementation. The earlier stroke unit implementations might represent rather 'formal' inceptions in experienced hospitals with preexisting appropriate stroke care, whereas late implementations seem to have caused extra improvements. Overall, stroke patients are more likely to survive when admitted to an stroke unit-providing hospital. A more stringent assignment of acute stroke patients to stroke unit-providing hospitals could possibly further reduce stroke mortality in Germany.