Does service heterogeneity have an impact on acute hospital length of stay in stroke? A UK-based multi-centre prospective cohort study

Michelle Tørnes* (Corresponding Author), David McLernon, Max Bachmann, Stanley D. Musgrave, Elizabeth A. Warburton, John F. Potter, Phyo K. Myint, On behalf of the Anglia Stroke Clinical Network Evaluation Study (ASCNES) Group

*Corresponding author for this work

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Objectives To determine whether stroke patients’ acute hospital length of stay (AHLOS) varies between hospitals, over and above case mix differences and to investigate the hospital-level explanatory factors. Design A multicentre prospective cohort study. Setting Eight National Health Service acute hospital trusts within the Anglia Stroke & Heart Clinical Network in the East of England, UK. Participants The study sample was systematically selected to include all consecutive patients admitted within a month to any of the eight hospitals, diagnosed with stroke by an accredited stroke physician every third month between October 2009 and September 2011. Primary and secondary outcome measures AHLOS was defined as the number of days between date of hospital admission and discharge or death, whichever came first. We used a multiple linear regression model to investigate the association between hospital (as a fixed-effect) and AHLOS, adjusting for several important patient covariates, such as age, sex, stroke type, modified Rankin Scale score (mRS), comorbidities and inpatient complications. Exploratory data analysis was used to examine the hospital-level characteristics which may contribute to variance between hospitals. These included hospital type, stroke monthly case volume, service provisions (ie, onsite rehabilitation) and staffing levels. Results A total of 2233 stroke admissions (52% female, median age (IQR) 79 (70 to 86) years, 83% ischaemic stroke) were included. The overall median AHLOS (IQR) was 9 (4 to 21) days. After adjusting for patient covariates, AHLOS still differed significantly between hospitals (p<0.001). Furthermore, hospitals with the longest adjusted AHLOS’s had predominantly smaller stroke volumes. Conclusions We have clearly demonstrated that AHLOS varies between different hospitals, and that the most important patient-level explanatory variables are discharge mRS, dementia and inpatient complications. We highlight the potential importance of stroke volume in influencing these differences but cannot discount the potential effect of unmeasured confounders.
Original languageEnglish
Article numbere024506
JournalBMJ Open
Issue number4
Publication statusPublished - 3 Apr 2019

Bibliographical note

We thank the stroke database team and stroke research team staff from all participating sites who contributed to data collection. We also would like to acknowledge the contribution of Anglia Stroke Clinical Network Evaluation Study (ASCNES) Group.

Supplementary data


  • acute hospital
  • health services research
  • length of stay
  • outcome
  • stroke


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