Hospital volume and stroke outcome - Does it matter?

Background: Although hospital - outcome relationships have been explored for a variety of procedures and interventions, little is known about the association between annual stroke admission volumes and stroke mortality. Our aim was to determine whether facility type and hospital volume was associated with stroke mortality. Methods: All hospital admissions for ischemic stroke were identified from the Hospital Morbidity database ( HMDB) from April 2003 to March 2004. The HMDB is a national database that contains patient- level sociodemographic, diagnostic, procedural, and administrative information across Canada. Ischemic stroke was identified through patient's principal diagnosis recorded using the International Classification of Diseases ( 9 and 10). Multivariable analysis was performed with generalized estimating equations with adjustment for demographic characteristics, provider specialty, facility type, hospital volume, and clustering of observations at institutions. Results: Overall, 26,676 patients with ischemic stroke were admitted to 606 hospitals. Sevenday stroke mortality was 7.6% and mortality at discharge was 15.6%. Adverse outcomes were more frequent in patients treated in low- volume facilities ( < 50 strokes/ year) than in those treated in high volume facilities ( 100 to 199 and > 200 strokes patients/ year) ( for 7- day mortality: 9.5 vs 7.3%, p < 0.001; 9.5 vs 6.0%, p < 0.001; for discharge mortality: 18.2 vs 15.2%, p < 0.001; 18.2 vs 12.8%, p < 0.001). The difference persisted after multivariable adjustment or when hospital volume was divided into quartiles. Conclusions: High annual hospital volume was consistently associated with lower stroke mortality. Our study encourages further research to determine whether this is due to differences in case mix, more organized care in high- volume facilities, or differences in the performance or in the processes of care among facilities.