Diagnostic procedures, treatments and outcomes in stroke patients admitted to different types of hospitals

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1 SUPPLEMENTAL MATERIAL Diagnostic procedures, treatments and outcomes in stroke patients admitted to different types of hospitals Kjell Asplund, Maria Sukhova, Per Wester, Birgitta Stegmayr for the Riks-Stroke Collaboration* Riksstroke, Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden Supplemental tables Supplemental Table I. Description of acute stroke services in Sweden with emphasis on allocation of patients to different types of hospital. Item Ownership and financing of hospitals admitting acute stroke patients Patient fees General rule of allocation of stroke patients Stroke units Description 71 hospitals publicly owned, 1 hospital privately owned but stroke care is publicly financed. Patients pay a small nominal fee for hospital stay (approximately 13 USD per day a maximum of 160 USD over a 30-day period); the fee is the same for all types of hospital. Each hospital serves a defined population (geographical catchment area); acute stroke patients are transported to or seeking this hospital. Dedicated stroke units are established in all 72 hospitals admitting acute stroke patients. The great majority are fulfilling the stroke unit criteria defined by the Stroke Unit Trialists Collaboration 15,16 and the European Stroke Initiative 17 (see Table 1). Thrombolysis Stroke thrombolysis is performed in 69 of the 72 hospitals. Patients from 1 large non-university hospital and 2 community hospitals are transferred to university hospitals for thrombolysis; after the procedure, they are usually transferred back to their home hospital. In the present study, patients are allocated to the hospital where they spent most of their hospital stay. Thrombectomy Performed in 6 of the 9 university hospitals. In 2013, 94 of 232 thrombectomies were performed in patients from another hospital s catchment area. After the intervention, patients are usually transferred back to their home hospital. In the present study, patients are allocated to the hospital where they spend most of their hospital stay. Neurosurgery Follow-up after hospital stay Selected stroke patients are transferred to one of the 6 neurosurgical facilities in Sweden for hemicraniectomy or hematoma evacuation. In 2013, 42 patients were transferred to neurosurgical clinics. In the present study, these patients are allocated to the hospital they were first admitted to. Procedures for follow-up vary by patient groups and hospitals. Nationwide, the first follow-up visit is in a hospital out-patient clinic in 34 % and in a primary health care center in 34 % (Riksstroke annual report 2013). 1

2 Supplemental Table II. Characteristics of patients treated in university, large non-university, and community hospitals between 2012 and Number of patients and percentages with 95% CIs, adjusted for clustering by generalized estimating equations (GEE). University Hospital type Specialized nonuniversity Community P value Age, mean (95% CI) 73.9 ( ) 76.0 ( ) 76.2 ( ) Sex, male Living alone ADL independent before index stroke Medical history previous stroke hypertension diabetes atrial fibrillation smoking Stroke subtype 5336 (52.8%; (50.8%; 8737 (52.2%; ) ) ) 4803 (48.0 %) (51.8 %) 8309 (49.8 %) ) ) ) 8890 (90.0%; (87.8%; (86.4%; %) %) %) 2282 (22.9%; 5465 (24.6%; 3971 (23.8%; %) %) %) 5855 (58.7%; (61.4%; (65.1%; %) %) ) 1986 (19.9%; 4661 (21.0%; 3655 (21.9%; %) %) %) 2802 (28.1%; 6491 (29.3%; 4826 (28.9%; %) )% %) 1305 (14.4%; 2885 (14.1%; 2013 (12.7%; %) %) %) ischemic 8530 (84.4%; (87.1%; (86.8%; %) %) ) Intracerebral haemorrhage 1495 (14.8%; 2567 (11.5%; 1987 (11.9%; %) %) %) undetermined 84 (0.8%; 316 (1.4%; 215 (1.3%; %) %) %) Lowered level of consciousness on admission (RLS >=2) 2071 (20.9%; 3511 (16.0%; 2825 (17.1%; %) %) %)

3 Supplemental Table III. Multivariate analysis, including also stroke patient volume, of patients treated in university, specialized non-university, and community hospitals with poor stroke outcome (dead or ADL dependent three months after stroke) as the dependent variable. Odds ratios (95% CI), adjusted for clustering by generalized estimating equations (GEE). P value OR 95 % CI Lower Upper Hospital type Community Specialized non-university University Stroke patient volume Low (Q1) Medium-low (Q2) Medium- high (Q3) High (Q4) Transfer from another hospital Yes 0,001 1,24 1,09 1,40 Sex Men Women Age group < 50 < < < < < >= 90 ADL independent before index stroke Yes < Living alone Yes Previous stroke Yes < Hypertension Yes Diabetes Yes < ,42 1,34 1,51 Atrial fibrillation Yes < ,39 1,30 1,47 3

4 Smoking Yes Stroke subtype I61 < I I63 Level of consciousness on admission RLS 4-8 < RLS 2-3 < RLS 1 Supplemental Table IV. Univariate analyses of case fatality and poor outcome in patients treated in university, specialised non-university, and community hospitals in Numbers and percentages with 95 % confidence intervals. P values adjusted for clustering by generalized estimating equations (GEE). Hospital type University Specialized nonuniversity Community P value Case fatality 7 days 3 months Poor outcome 3 months after stroke (dead or ADL dependent) 815 (8.7%; 1600 (7.7%; 1224 (7.7%; %) %) %) 1876 (21.9%; 3791 (19.4%; 2899 (19.4%; %) ( %) %) 1545 (24.1%; 3260 (22.1%; 2522 (22.6%; %) %) %)

5 Appendix. The Riksstroke Collaboration. Members of the Board Bo rrving, Lund University (chair), Peter Appelros, Örebro University Hospital, Daniela Bjarne, STROKE- Riksförbundet (patient representative), Wania Engberg, NÄL Hospital, Trollhättan, Mia von Euler, Karolinska Institute, Stockholm, Birgitta Stegmayr, Umeå University Hospital, Andreas Terént,, Uppsala University Hospital, Sari Wallin, Riksstroke office, Umeå, Mariann Ytterberg (patient representative), Västerås Working group Birgitta Stegmayr (superintendent), Sari Wallin (national coordinator), Åsa Johansson (research nurse), Fredrik Jonsson (statistician), Maria Hals Berglund (statistician), Maria Sukhova (statistician), Per Ivarsson (project administrator), Eva-Lotta Glader (research consultant), Marie Eriksson (statistical consultant). Participants Akademiska/Uppsala Hultman Anki, Lisa Jonsson Alingsås Brita Eklund, Annika Emilsson, Maria Ekholm, Anna Lindh, Ida Abrahamsson Arvika Anna Lena Wall Avesta Åsa-Lena Koivisto, Else-Marie Larsson, Bitte Pettersson, Taina Ylitalo Bollnäs Maj Fröjd, Lena Parhans Borås Hillevi Grändeby, Marianne Hjalmarsson, Elisabeth Arvidsson, Camilla Harén- Nilsson, Sibylla Carlsson Capio S:t Göran/ Stockholm Pirjo Perduv, Bo Höjeberg, Eva Rosso, Gabriella Strandberg Danderyd/Stockholm Berit Eriksson, Ann-Charlotte Laska Enköping Ann-Kristin Kinander Falun Helen Eriksson, Carin Hedlund, Monica Eriksson, Joakim Hambraeus, Ann-Jeanette Melin Gällivare Karin Johansson, Barbro Juuso Gävle Christina Andersson, Maria Smedberg Halmstad Monica Karlsson, Kerstin Larsson, Jessica ren, Christine Billfors Helsingborg Marie Mikkelsen, Annica Fristedt Hudiksvall Maj Britt Johansson Hässleholm Erika Ekholm, Anna Zenthio, Magnus Esbjörnsson Karolinska Solna Anita Hansson Tyrén Kiruna Anita Stockel Falk, Monica Sahlin, Marit Edén Kristianstad Lena Eriksson, Cia Caplander, Anna Hansson Kullbergska/Katrineholm Britt Marie Andersson, Christina Petersson Kungälv Maria Berglund, Eva Eriksson Köping Ann Hedlund, Lotta Ruin, Therese Kanthergård, Jan Saaf Landskrona Eva-Lotta Persson, Birgitta Jeppsson, Jessica Johansson Lidköping Ingrid Roland, Anita Söderholm, Kerstin Bjälkefur, Sofia Wahll Lindesberg Anette Eriksson, Vigdis Welander Linköping Caroline Nilsen, Ann-Christine Josefsson, Gunnie Green Ljungby Elisabeth Nyman, Maria Linnerö Lycksele Cecilia Ölmebäck Mora Marianne Bertilsson, Inger Boije Motala Anette Grahn, Anette Gunninge, Britt Louise Lövgren, Ulf Rosenqvist Mälarsjukhuset/Eskilstuna Yvonne Kentää, Camilla Jansson Mölndal Eva-Britt Giebner, Helen Zachrisson, Linda Alsholm SkaS Skövde Eric Bertholds, Ann Catrine Elgåsen, Björn Cederin, Eva Åkerhage Skellefteå Helena Olofsson, Ann-Charlotte Johnsson Sollefteå Solveig Velander, Inger Jonsson Sunderbyn Ann Louise Lundgren, Ulla Jarlbring Sundsvall Barbro Högvall, Ewa Edin SUS Lund Karina Hansson, Gunilla Nilsson, Hélène Pessah-Rasmussen SUS Malmö Penny Baaz, Hélène Pessah Rasmussen, Elisabeth Poromaa Södersjukhuset (SÖS)/Stockholm Cecilia Schantz-Eyre, Emma Weckström- Wadling Södertälje Inger Davidsson Torsby Anna Lena Halvardsson, Åsa Valfridsson, Corina de Wijs Trelleborg Ingela Fröjdh, Agneta Kristenssen, Ramona Vuoristo Umeå Åsa Olofsson, Maria Fransson Varberg Ing Marie Thyr, Lisa Nilsson Visby Eva Smedberg, Anna Westberg-Bysell, Åsa Lindblad, Åsa Lövgren, Susanna Grönborg Värnamo Marie Andersson, Mats Altesjö Västervik Maud Lindqvist, Britt-Marie Martinsson 5

6 Höglandssjukhuset/Eksjö-Nässjö Elisabet Olsson, Katarina Andersson Kalix Hannele Hjelm, Maria Förare Kalmar Kerstin Karlsson, Anette Danielsson, Lotten Berggren Karlshamn Anders Pettersson, Carina Larsson, Lisa Strand Karlskoga Inger Rosengren, Eva Grohp Karlskrona Boel Bingström Karlsson, Inger Berggren, Katarina Widebrant Karlstad Anna-Lena Perman, Lena Larsson Karolinska Huddinge Marie Axelsson rrköping/ Vrinnevi Marguerite Berglund, Anna Göransson rrtälje Patricia Hilland, Katarina Sjöström Nyköping Annika Kastenfalk NÄL/rra Älvsborgs Länssjukhus Anette Rosengren, Annika Jägevall, Lena Dittmer Oskarshamn Anita Svensson, Ann-Kristin Persson, Mariette Gustavsson Piteå Ulla Söderberg, Ulla Ganestig Ryhov/Jönköping Lena Sörman, Berit Krantz Sahlgrenska/Göteborg Christina Gullbratt, Lena Wernhamn Västerås Sara Östring, Eira Johansson, Lena Eriksson, Linda Jakobsson, Meeli Tarish, Elisabeth rman, Catharina Holmberg Växjö Ulla Pettersson, Linda Nilsson, Anette Borland Ystad Åsa Lindström, Gunilla Persson, Bengt Jonazon, Gull-Marie Wahlberg Ängelholm Dorit Christensen, Inger Hallenborg Örebro Marie Lokander Örnsköldsvik Marie Andersson, Ulrika Westin, Maire Johansson Östersund Kristina Ingvarsson, Åsa Persson Östra sjukhuset/göteborg Hengameh Kazemi, Linda Nilsson, Satu Kousmanen 6