Beyond the numbers: understanding inter-center variation in recanalization therapy rates

This study aimed to investigate the inter-center differences in recanalization therapy (RT) utilization between Estonia's two largest comprehensive stroke centers and to assess whether variation in the management of patient subgroups is associated with differences in short-term neurological and functional outcomes.

We performed a retrospective two-center study including all acute ischemic stroke (AIS) patients admitted between January-June 2021. Mild AIS or mild stroke was defined as National Institutes of Health Stroke Scale (NIHSS) ≤ 5. Demographic, treatment, NIHSS, and modified Rankin Scale (mRS) data were analyzed using nonparametric and categorical tests. Multivariable logistic regression evaluated predictors of RT use in AIS and predictors of stroke outcome.

Among 635 AIS patients, RT was administered more frequently at Tartu University Hospital (TUH) than at North Estonia Medical Centre (NEMC) (45.2% vs. 30.7%, p < 0.001; aOR 0.49, 95% CI 0.33-0.74). A total of 301 (47.5%) patients had mild stroke. RT use in mild stroke was substantially higher at TUH (33.1% vs. 10.0%, p < 0.001). Descriptive analysis showed greater neurological improvement in RT-treated mild stroke patients than non-RT-treated patients [median NIHSS reduction 2.0 (IQR 0.8-3.0) vs. 1.0 (IQR 0.0-2.0), respectively; Wilcoxon rank-sum test, p < 0.001], whereas good functional outcome did not differ by RT exposure. After adjustment, neurological improvement was independently associated with treatment center and baseline NIHSS category but not with RT exposure (aOR 0.94, 95% CI 0.43-2.06).

RT was also not independently associated with good functional outcome. Inter-center variation in RT utilization was primarily driven by the management of mild stroke patients. Comparable stroke-care infrastructure did not ensure uniform RT utilization.