Abstract
BackgroundTreatment of stroke patients in stroke units has increased and studies have shown improved outcomes. However, a large share of patients in Germany is still treated in hospitals without stroke unit. The effects of stroke unit service line, and total hospital quality certification on outcomes remain unclear.MethodsWe employ annual hospital panel data for 1100–1300 German hospitals from 2006 to 2014, which includes structural data and 30-day standardized mortality. We estimate hospital- and time-fixed effects regressions with three main independent variables: (1) stroke unit care, (2) stroke unit certification, and (3) total hospital quality certification.ResultsOur results confirm the trend of decreasing stroke mortality ratios, although to a much lesser degree than previous studies. Descriptive analysis illustrates better stroke outcomes for non-certified and certified stroke units and hospitals with total hospital quality certification. In a fixed effects model, having a stroke unit has a significant quality-enhancing effect, lowering stroke mortality by 5.6%, while there is no significant improvement effect for stroke unit certification or total hospital quality certification.ConclusionsPatients and health systems may benefit substantially from stroke unit treatment expansion as installing a stroke unit appears more meaningful than getting it certified or obtaining a total hospital quality certification. Health systems should thus prioritize investment in stroke unit infrastructure and centralize stroke care in stroke units. They should also prioritize patient-based 30-day mortality data as it allows a more realistic representation of mortality than admission-based data.
Highlights
Treatment of stroke patients in stroke units has increased and studies have shown improved outcomes
Our results substantiate the positive effect of Stroke unit (SU) treatment on stroke outcomes, based on a fixed effects model and large multi-year hospital sample, suggesting that hospital and health system investment in SUs improve stroke outcomes
As the first study to distinguish the potential effects of SU existence, SU certification and total hospital quality (THQ) certification, we do not find a significant effect for SU certification or THQ certification on top of the large and significant effect for SU specialization
Summary
Treatment of stroke patients in stroke units has increased and studies have shown improved outcomes. Recent data shows an incidence of about 16 million first-ever strokes annually, resulting in 5.7 million deaths, substantial long-term disabilities and significant long-term care costs [2]. The latest OECD Health Care Quality Indicator data suggest that admission-based mortality rates for ischemic stroke have decreased in the past decade, but stark cross-country outcome differences (6-fold variation) remain [5]. The study’s authors concluded a possible relation to improved primary and secondary prevention as well as increased treatment in specialized stroke units (SUs) [6]. The latter provide specialized acute and rehabilitation care with co-located and dedicated interdisciplinary teams of neurologists, internists, neuro- and vascular surgeons, and radiologists. The latter provide specialized acute and rehabilitation care with co-located and dedicated interdisciplinary teams of neurologists, internists, neuro- and vascular surgeons, and radiologists. 24/7 access to radiology
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