Does bypassing nearby hospitals for high-quality care reduce case fatality among inpatients who had a stroke? A retrospective study of 328 206 cases

INTRODUCTION: Patients who had a stroke often confront the trade-off between timely care at nearby hospitals and potentially higher quality but more distant care. Evidence remains limited on whether bypassing the nearest hospital in favour of a high-quality facility improves health outcomes. This study examines the causal effect of bypass behaviours on case fatality among inpatients who had a stroke and the time-bound survival benefits of bypassing behaviours directed to high-quality healthcare facilities. METHODS: A retrospective study of 328 206 inpatients who had a stroke admitted via emergency departments in Sichuan Province, China (2017-2019), using complete discharge records. Bypass behaviour was defined as patients bypassing the nearest hospital to attend a more distant facility. Inverse probability weighting and instrumental variable analyses were applied. The differential travel distance between the nearest secondary and tertiary hospitals served as the instrumental variable to evaluate the causal effect of tertiary hospital admission on case fatality for haemorrhagic and ischaemic stroke. RESULTS: Among 328 206 patients, 78% engaged in bypass behaviour. Inverse probability weighting analysis showed that receiving care at tertiary hospitals was associated with significantly lower case-fatality, regardless of whether patients bypassed the nearest facility, with ORs below 0.8 for overall, 7-day and 30-day case fatality. Bypassing to a more distant secondary hospital was not associated with differences in case fatality. Instrumental variable analysis revealed a survival benefit from treatment at tertiary hospitals, with significant reductions in overall case fatality observed among patients who had an ischaemic stroke within 30 min (OR: 0.66, 95% CI 0.46 to 0.94) and patients who had a haemorrhagic stroke within 60 min (OR: 0.23, 95% CI 0.09 to 0.61). CONCLUSIONS: Bypassing a nearby hospital to seek care at a distant tertiary hospital was associated with a lower stroke case fatality rate. Favourable outcomes were observed when tertiary hospitals were reachable within 30 min for ischaemic stroke and within 60 min for haemorrhagic stroke.