Introduction: In this study, we utilized information provided in the Nationwide Inpatient Sample (NIS) to study the impact of transferring stroke patients from one facility to a center where they received some form of active stroke intervention (intravenous tissue plasminogen activator, thrombectomy, or a combination of both therapies).For the first time we incorporated the patient clinical condition(APR-DRG) in our analysis. It is important to understand the advantages in transferring a patient to a comprehensive stroke center as recent trials (MR CLEAN, EXTEND-IA, ESCAPE and SWIFT PRIME ) has shown the superiority of intra-arterial treatment of stroke.

Methods: We analyzed patient demographic and hospital factors obtained from 2008–2010 acute stroke NIS data. Discharge-disposition, hospitalization cost, and mortality were the dependent variables studied. Univariate analysis and multivariate binary logistic regression analysis were performed. We focused our data analysis on the cohort of acute stroke patients who received some form of active intervention (55,913 of 1,311,511 patients in the NIS).

Results: When overall outcome was considered, transferred patients had a significantly higher number of other-than-routine (OTR, meaning other than discharge to home without home healthcare) discharge dispositions (p<0.0001). In multivariate-regression analysis including pertinent patient and hospital factors, transfer-in patients had significantly worse OTR discharge disposition (p<0.0001, OR 2.575, CI 2.341–2.832). Mean hospitalization cost including an intervention was $70,325.11 for direct admissions and $97,546.92 for transferred patients. Transfer from another facility (p<0.001, OR 1.677, CI 1.548–1.817) was associated with higher hospitalization cost.

Conclusions: Our study showed that hospital cost for acute stroke intervention is significantly higher for a transferred patient than for a direct admission. Moreover, the frequency of OTR discharge was significantly higher among transferred patients than direct admissions. Future strategies should focus on ways and means of transporting patients appropriately and directly to stroke centers.

Patient Care: 1. Its a landmark study, that shows that patients taken directly to stroke centers have lesser mortality, morbidity and lesser hospitalization costs.

Learning Objectives: 1. Patents that are directly admitted to comprehensive stroke centers do better, than those who are transferred from an intermediary hospital. 2. Cost of hospital;assertion is less in patents that are directly admitted to comprehensive stroke centers than those who are transferred from an intermediary hospital

References: References 1. Adamczyk P, Attenello F, Wen G, He S, Russin J, Sanossian N, et al: Mechanical thrombectomy in acute stroke: utilization variances and impact of procedural volume on inpatient mortality. J Stroke Cerebrovasc Dis 22:1263-1269, 2013 2. Attenello FJ, Adamczyk P, Wen G, He S, Zhang K, Russin JJ, et al: Racial and socioeconomic disparities in access to mechanical revascularization procedures for acute ischemic stroke. J Stroke Cerebrovasc Dis 23:327-334, 2014 3. Bateman BT, Schumacher HC, Boden-Albala B, Berman MF, Mohr JP, Sacco RL, et al: Factors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients: an analysis of the nationwide inpatient sample 1999 to 2002. Stroke 37:440-446, 2006 4. Bhattacharya P, Mada F, Salowich-Palm L, Hinton S, Millis S, Watson SR, et al: Are racial disparities in stroke care still prevalent in certified stroke centers? J Stroke Cerebrovasc Dis 22:383-388, 2013 5. Brinjikji W, Rabinstein AA, Kallmes DF, Cloft HJ: Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke: a study of the national inpatient sample: 2006 to 2008. Stroke 42:1648-1652, 2011 6. Chalela JA, Kasner SE, Jauch EC, Pancioli AM: Safety of air medical transportation after tissue plasminogen activator administration in acute ischemic stroke. Stroke 30:2366-2368, 1999 7. Choi JH, Bateman BT, Mangla S, Marshall RS, Prabhakaran S, Chong J, et al: Endovascular recanalization therapy in acute ischemic stroke. Stroke 37:419-424, 2006 8. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al: Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation 127:e6-e245, 2013 9. Gupta R, Horev A, Nguyen T, Gandhi D, Wisco D, Glenn BA, et al: Higher volume endovascular stroke centers have faster times to treatment, higher reperfusion rates and higher rates of good clinical outcomes. J Neurointerv Surg 5:294-297, 2013 10. Hoh BL, Chi YY, Waters MF, Mocco J, Barker FG, 2nd: Effect of weekend compared with weekday stroke admission on thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay in the Nationwide Inpatient Sample Database, 2002 to 2007. Stroke 41:2323-2328, 2010 11. Kimball MM, Neal D, Waters MF, Hoh BL: Race and income disparity in ischemic stroke Care: Nationwide Inpatient Sample database, 2002 to 2008. J Stroke Cerebrovasc Dis 23:17-24, 2014 12. McNeill L, English SW, Borg N, Matta BF, Menon DK: Effects of institutional caseload of subarachnoid hemorrhage on mortality: a secondary analysis of administrative data. Stroke 44:647-652, 2013 13. Qureshi AI, Suri MF, Nasar A, Kirmani JF, Ezzeddine MA, Divani AA, et al: Changes in cost and outcome among US patients with stroke hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001. Stroke 38:2180-2184, 2007 14. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al: Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation 125:e2-e220, 2012 15. Russo CA, Andrews RM: Hospital stays for stroke and other cerebrovascular diseases, 2005: Statistical brief #51. Available at http://www.ncbi.nlm.nih.gov/books/NBK56044/. Accessed July 10, 2014, in Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Health Care Policy and Research (US), 2008 16. Silbergleit R, Scott PA, Lowell MJ: Cost-effectiveness of helicopter transport of stroke patients for thrombolysis. Acad Emerg Med 10:966-972, 2003 17. Sonig A, Khan IS, Wadhwa R, Thakur JD, Nanda A: The impact of comorbidities, regional trends, and hospital factors on discharge dispositions and hospital costs after acoustic neuroma microsurgery: a United States nationwide inpatient data sample study (2005-2009). Neurosurg Focus 33:E3, 2012 18. U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. Household Component Summary Data Tables: Available at http://meps.ahrq.gov/data_stats/tables_compendia_hh_interactive.jsp?File=HCFY2010&Table=HCFY2010_CNDXP_C&TCOPT1=&TCOPT2=&ModPopCheck=Yes&ModPop=Yes&_Debug=&DDAGELOW=&DDAGEHIGH=&Action.x=179&Action.y=19. Accessed July 10, 2014 19. Wormer BA, Fleming GP, Christmas AB, Sing RF, Thomason MH, Huynh T: Improving overtriage of aeromedical transport in trauma: a regional process improvement initiative. J Trauma Acute Care Surg 75:92-96, 2013 Figure Legend Figure 1. A, Box plot shows hospitalization charges (in US dollars) associated with acute stroke intervention for transferred-in versus nontransferred patients. B, Box plot shows length of stay (in days) associated with acute stroke intervention for transferred-in versus nontransferred patients.