Hospital and Demographic Characteristics Associated With
Advanced Primary Stroke Center Designation
Catherine M. McDonald, MS; Steven Cen, PhD; Lucas Ramirez, MD; Sarah Song, MD;
Jeffrey L. Saver, MD; William J. Mack, MD; Nerses Sanossian, MD
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
Background and Purpose—Despite evidence that primary stroke center (PSC) certification is associated with improvements
in care and outcome, only a minority of hospitals have achieved this certification. We sought to determine hospital-based
factors associated with achievement of PSC certification.
Methods—We used the 2011 American Hospital Association survey and the 2010 national census for population and
household data to identify potential hospital and demographic factors influencing certification as a PSC by the Joint
Commission, Healthcare Facilities Accreditation Program, and DNV Healthcare.
Results—Of the 3696 hospitals to complete the survey, 3069 fulfilling study criteria included 908 PSC (31%) and 2161 nonPSC. Independent hospital characteristics associated with PSC certification were Joint Commission accreditation (odds
ratio [OR], 3.5; 95% confidence interval [CI], 2.4–5.0), increasing size (per quartile in number of beds; OR, 2.5; 95% CI,
2.1–3.1) and inpatient neurological services (OR, 3.2; 95% CI, 2.4–4.6), number of households per zip code (per 1000
households; OR, 1.1; 95% CI, 1.0–1.2), increasing Hispanic population (by 10% increase; OR, 1.1; 95% CI, 1.0–1.2),
and income per household (per $10 000; OR, 1.2; 95% CI, 1.1–1.3). Designation as a sole community provider (OR, 0.22;
0.10–0.47) or governmental hospital control (0.61; 0.44–0.84) was associated with noncertification.
Conclusions—Less than 1 in 3 hospitals has achieved certification as an PSC. Potential areas of improvement include
increasing certification of governmental-controlled hospitals. (Stroke. 2014;45:3717-3719.)
Key Words: certification ◼ hospitals ◼ quality improvement
See related article, p 3499.
Healthcare Facilities Accreditation Program, and DNV Healthcare
websites. Comprehensive and PSC certifications were combined
for this analysis. We determined regional emergency medical services routing policy by survey.4 We obtained demographic information by linking the hospitals participating in the American Hospital
Association survey to the 2010 national census for population and
household using the hospital address.
Only hospitals with ≥25 beds (smallest hospital to achieve PSC) and
24-hour emergency departments were evaluated. Data were analyzed
using SAS. We performed univariate analysis for each individual factor’s association with advanced stroke certification using t test for continuous and χ2 for categorical variables. Factors found to be associated
with achievement of certification (P<0.010) were evaluated by logistic
regression to determine a final model of independent association.
I
n 2000, the Brain Attack Coalition published recommendations for the establishment of primary stroke centers (PSCs)
to improve and advance acute stroke care.1 Based on these
requirements, hospitals began applying for PSC certification
starting in 2003. PSC certification has been associated with
higher compliance with national guideline proven care, higher
rates of acute stroke therapy, and, most importantly, improved
clinical stroke outcomes.2,3
In an attempt to identify possible factors affecting PSC
certification, we sought to determine hospital-based characteristics associated with successful achievement of certification. Understanding these factors could assist in a targeted
approach to increasing stroke center certification, improving
the delivery of emergent stroke care in the United States.
Results
Of 5723 hospitals meeting American Hospital Association criteria in the United States, 3696 completed the 2011 survey. Of
these, 3069 fulfilled study criteria of potentially becoming a
PSC including 908 PSC (31%) and 2161 non-PSC (Table 1).
PSCs were typically larger (mean 354 beds versus 136
beds), had busier EDs (56 000 visits versus 24 000 visits/y),
were more often affiliated with Accreditation Council for
Methods
Using the 2011 American Hospital Association annual survey, we
identified hospital-related factors potentially affecting PSC certification (listed in Table 1). PSC certification status for each hospital
through January 2013 was determined via the Joint Commission (JC),
Received July 29, 2014; final revision received July 29, 2014; accepted August 19, 2014.
From the Keck School of Medicine (C.M.M., S.C., L.R., W.J.M., N.S.), Departments of Neurology (S.C., L.R., N.S.) and Neurosurgery (W.J.M.), and
Roxanna Todd Hodges Comprehensive Stroke Clinic (S.C., W.J.M., N.S.), University of Southern California, Los Angeles; Department of Neurology, Rush
University, Chicago, IL (S.S.); and UCLA Stroke Center (J.L.S.).
Guest Editor for this article was Eric E. Smith, MD, MPH.
Correspondence to Nerses Sanossian, MD, Keck School of Medicine, University of Southern California, 1520 San Pablo St, Suite 3000, Los Angeles,
CA 90033. E-mail [email protected]
© 2014 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.114.006819
3717
3718 Stroke December 2014
Table 1. Demographics and Characteristics
Factor
ACGME
PSC,
n (%)
Non-PSC,
n (%)
939
2545
402 (43%)
396 (14%)
Significance
(P Value)
Table 2. Results of Multivariate Analysis: Independent
Associations With Primary Stroke Certification
Factor
Odds
Ratio
95% Confidence
Interval
<0.0001
Joint Commission certification
3.5
2.4–5.0
0.22
0.10–0.47
AMA affiliation
480 (51%)
556 (21%)
<0.0001
Sole community provider
AAMC
168 (18%)
136 (5%)
<0.0001
Governmental hospital control
0.61
0.44–0.84
Increasing bed size (per quartile)
2.5
2.1–3.1
Hospital-based neurological services
3.2
2.4–4.6
<0.0001
1000 households
1.1
1.0–1.2
<0.0001
10% increase in Hispanic population
1.1
1.0–1.2
Household income increase of $10 000
1.2
1.1–1.3
JC accredited
Rural referral CTR
Sole community provider
892 (95%)
1727 (65%)
<0.0001
38 (4%)
118 (4%)
0.606
8 (1%)
247 (9%)
Type of hospital
Federal
Governmental (NF)
1 (0%)
63 (2%)
91 (10%)
643 (24%)
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
For profit
152 (16%)
372 (14%)
NP church
169 (18%)
251 (10%)
NP nonchurch
526 (56%)
1325 (50%)
Teaching affiliation
485 (52%)
564 (21%)
Bed number (mean, SD)
354 (226)
136 (157)
<0.0001
Large (>500 bed) hospital
184 (20%)
81 (3%)
<0.0001
<0.0001
Trauma center
513 (55%)
995 (38%)
<0.0001
Neurological services
879 (94%)
1208 (46%)
<0.0001
486 (52%)
1073 (40%)
<0.0001
ED visits/y
EMS routing
55 833 (32 025)
24 051 (26 385)
<0.0001
Population of area
29 316 (15 281)
20 901 (15 970)
<0.0001
73% (20%)
80% (20%)
<0.0001
Percent white
Percent black
16% (19%)
12% (16%)
<0.0001
Percent Hispanic
15% (17%)
11% (16%)
<0.0001
52 112 (24 150)
46 262 (17 633)
<0.0001
Median house income
AAMC indicates Association of American Medical Colleges; ACGME,
Accreditation Council for Graduate Medical Education; AMA, American Medical
Association; CTR, center; ED, emergency department; EMS, emergency medical
service; JC, Joint Commission; NF, non-Federal; NP, nonprofit; and PSC, primary
stroke center.
Graduate Medical Education (ACGME) residency programs
(43% versus 14%), AMA medical schools (51% versus 21%),
JC-accredited (95% versus 65%), had inpatient neurological
services (94% versus 46%) and trauma centers (55% versus
38%). PSCs were less likely to be governmental (federal/state/
county 10% versus 26%) and designated as the sole community provider (1% versus 9%).
Independent hospital characteristics associated with PSC
certification were JC accreditation (odds ratio [OR], 3.5; 95%
confidence interval [CI], 2.4–5.0), sole community provider
(OR, 0.22; 95% CI, 0.10–0.47), hospital type (governmental
versus nongovernmental, 0.61; 95% CI, 0.44–0.84), increasing size (per quartile in number of beds; OR, 2.5; 95% CI,
2.1–3.1), and inpatient neurological services (OR, 3.2; 95%
CI, 2.4–4.6; Table 2).
Although controlling for hospital-based factors, the demographic and regional factors independently associated with
hospital PSC designation were number of households per
zip code (per 1000 households; OR, 1.1; 95% CI, 1.0–1.2),
increasing Hispanic population (every 10% increase; OR, 1.1;
95% CI, 1.0–1.2), and increasing income per household (per
$10 000; OR, 1.2; 95% CI, 1.1–1.3; Table 2).
Governmental hospitals were the less likely to achieve PSC
certification, and rates varied depending on controlling body
(Table 3). Hospitals administered by states and hospital districts were more often PSC, whereas county-administered hospitals had extremely low rates of certification. The low rates of
certification in the 294 county facilities drove the association
of governmental control with low rates of advanced stroke
certification.
Discussion
We found that larger hospitals with JC certification who
offered neurological services were most likely to be accredited, whereas sole community provider hospitals and governmental hospitals, particularly county facilities, were much less
likely to be certified. Demographic characteristics of hospitals achieving PSC certification included increased number
of households, increasing Hispanic population, and wealthier neighborhoods. Hospital size is a recognized barrier, but
smaller hospitals can successfully achieve stroke center certification,5 often using telemedicine to link to larger hospitals
or regional stroke networks for the resources needed for acute
stroke care.
Many factors drive hospitals to become stroke centers,
including the desire to improve care. Factors working against
certification include lack of coordination, financial constraints,
inadequate available medical expertise, and increasing administrative complexity because of hospital regulations.6 We
recently described the positive effect of regional emergency
Table 3. Governmental Control Type and Primary Stroke
Center Certification
Control Type
n
Percent
Certified, %
Federal government
68
1.5
City
80
5
County
294
5
Hospital district
422
12
18
22
873
32
Both city and county
State
McDonald et al Hospital Characteristics of Stroke Centers 3719
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medical services diversion to certified stroke centers in driving hospital certification.7
The most striking result in our analysis is that hospitals controlled by governmental entities were significantly less likely
to be certified as stroke centers. This was most evident in the
group of county facilities, in which 1 in 20 achieved certification. County hospitals have an important role as safety net
for uninsured and underinsured, often providing care to the
indigent and underserved. This population is at particularly
high risk for stroke and in great need of stroke education and
acute stroke care.
There are limitations to this study, including incomplete
participation (65%) of hospitals nationwide in the survey.
The hospitals that did not participate are more likely to be
smaller and resource-poor, and it is possible that we may have
overestimated the rate of stroke centers nationwide. Survey
results may not reflect actual practices in the hospitals. We
were unable to take into account state-based acute stroke certification systems, which several states use. For example, in
2004, the Massachusetts Department of Public Health began
designating primary stroke service hospitals, independently of
the JC certification program, using criteria based on the Brain
Attack Coalition recommendations.5 The American Hospital
Association survey data used in this study reflected only PSCs
that had been certified by the JC, DNV, and the Healthcare
Facilities Accreditation Program. Another limitation is the
data’s inability to reflect which hospitals tried and failed to
achieve PSC certification. These survey data give us a snapshot of certification at only 1 point in time. A longitudinal
analysis could provide a different perspective because hospital certification is not a static process; the number of hospitals
seeking certification change all the time.
Sources of Funding
This work was supported by the 2013 American Heart Association
Student Scholarship in Cerebrovascular Diseases and Stroke (C.M.
McDonald), Roxanna Todd Hodges Foundation (W.J. Mack, N.
Sanossian), and Joachim Splichal (N. Sanossian).
Disclosures
Dr Saver is a member of the Get with the Guidelines steering committee and is an employee of the University of California. The University
of California, Regents receive funding for Dr Saver’s services as a
scientific consultant on trial design and conduct to Covidien, CoAxia,
Stryker, BrainsGate, and St. Jude Medical. Dr Saver has served as
an unpaid site investigator in multicenter trials run by Lundbeck for
which the UC Regents received payments on the basis of clinical trial
contracts for the number of subjects enrolled. Dr Saver serves as an
unpaid consultant to Genentech advising on the design and conduct
of the Potential of rtPA for Ischemic Strokes With Mild Symptoms
(PRISMS) trial; neither the University of California nor Dr Saver
received any payments for this voluntary service. The University of
California has patent rights in retrieval devices for stroke. The other
authors report no conflicts.
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Hospital and Demographic Characteristics Associated With Advanced Primary Stroke
Center Designation
Catherine M. McDonald, Steven Cen, Lucas Ramirez, Sarah Song, Jeffrey L. Saver, William J.
Mack and Nerses Sanossian
Downloaded from http://stroke.ahajournals.org/ by guest on July 31, 2017
Stroke. 2014;45:3717-3719; originally published online November 11, 2014;
doi: 10.1161/STROKEAHA.114.006819
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2014 American Heart Association, Inc. All rights reserved.
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