Effect of a provincial system of stroke care delivery on stroke care and outcomes

Background:

Systems of stroke care delivery have been promoted as a means of improving the quality of stroke care, but little is known about their effectiveness. We assessed the effect of the Ontario Stroke System, a province-wide strategy of regionalized stroke care delivery, on stroke care and outcomes in Ontario, Canada.

Methods:

We used population-based provincial administrative databases to identify all emergency department visits and hospital admissions for acute stroke and transient ischemic attack from Jan. 1, 2001, to Dec. 31, 2010. Using piecewise regression analyses, we assessed the effect of the full implementation of the Ontario Stroke System in 2005 on the proportion of patients who received care at stroke centres, and on rates of discharge to long-term care facilities and 30-day mortality after stroke.

Results:

We included 243 287 visits by patients with acute stroke or transient ischemic attack. The full implementation of the Ontario Stroke System in 2005 was associated with an increase in rates of care at stroke centres (before implementation: 40.0%; after implementation: 46.5%), decreased rates of discharge to long-term care facilities (before implementation: 16.9%; after implementation: 14.8%) and decreased 30-day mortality for hemorrhagic (before implementation: 38.3%; after implementation: 34.4%) and ischemic stroke (before implementation: 16.3%; after implementation: 15.7%). The system’s implementation was also associated with marked increases in the proportion of patients who received neuroimaging, thrombolytic therapy, care in a stroke unit and antithrombotic therapy.

Interpretation:

The implementation of an organized system of stroke care delivery was associated with improved processes of care and outcomes after stroke.Stroke is a leading cause of death and disability worldwide.^1,2 Guidelines recommend that eligible patients receive care in a stroke unit, undergo neuroimaging and receive thrombolytic therapy, antithrombotic agents and screening for carotid stenosis.^3–6 Many of these interventions require specialized resources, including clinicians with expertise in stroke care and rapid access to brain and vascular imaging; however, wide interfacility variations exist in the availability of such resources.^7–10To address regional disparities in resources and care, organizations such as the Canadian Stroke Network and the American Stroke Association have recommended the implementation of organized systems of stroke care delivery.^11,12 Such systems are designed to facilitate access to optimal stroke care across an entire region and to promote the use of evidence-based therapies.¹¹ However, little is known about the effect of stroke systems of care on outcomes in patients with stroke.The province of Ontario was the first large jurisdiction in Canada, and in North America, to implement an integrated regional system of stroke care delivery. A system of coordinated stroke care, known as the Ontario Stroke System, was launched in 2000 and fully implemented in 2005, resulting in a major transformation in the delivery of stroke care across the province.¹³ We used population-based administrative and clinical data to evaluate the effect of the system’s implementation on stroke care and outcomes.