Do the Brain Attack Coalition’s criteria for stroke centers improve care for ischemic stroke?

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Abstract
Background: In 2000, the Brain Attack Coalition (BAC) recommended 11 major criteria for the establishment of primary stroke centers. The BAC relied heavily on expert opinion because evidence supporting the criteria was sparse. Objective: To assess primary stroke center elements, based on the criteria proposed by the BAC, with a questionnaire at 34 academic medical centers. Methods: Patient characteristics and outcomes were collected for all patients (n = 16,853) admitted with ischemic stroke to each hospital from 1999 to 2001. Stroke center elements were evaluated as predictors of treatment with tissue plasminogen activator (tPA) and outcomes after adjustment for patient characteristics. Results: The in-hospital mortality rate was 6.3% (n = 1,062), and 2.4% (n = 399) of patients received tPA. None of the 11 major stroke center elements was associated with decreased in-hospital mortality or increased frequency of discharge home. However, four elements predicted increased tPA use, including written care protocols, integrated emergency medical services, organized emergency departments, and continuing medical/public education in stroke (each odds ratio [OR] > 2.0, p < 0.05). Use of tPA also tended to be greater at centers with an acute stroke team, a stroke unit, or rapid neuroimaging (each OR > 2.0, p < 0.10). Institutions with a greater number of major stroke center elements used tPA more frequently. Conclusions: Of the 11 stroke center elements recommended by the BAC, 7 were associated with increased tPA use. Institutions with a greater number of these seven features used tPA more often, suggesting these key elements may be most important for primary stroke center designation, at least in terms of identifying centers that deliver IV tPA frequently.