In-Hospital Stroke Quality and Outcomes in the Mechanical Thrombectomy Era: Get With The Guidelines-Stroke, 2016 to 2023

BACKGROUND: In-hospital stroke is associated with delayed recognition and worse outcomes compared with community-onset stroke. Contemporary national data in the mechanical thrombectomy (MT) era are limited. METHODS: We performed a retrospective cohort study of adult ischemic stroke admissions in the Get With The Guidelines-Stroke registry from January 2016 to December 2023 (the MT era). In-hospital stroke was compared with community-onset stroke as the primary analysis. A secondary descriptive analysis comparing in-hospital patients with stroke from January 2006 to April 2012 and January 2016 to December 2023 was also performed. Primary outcomes were in-hospital mortality, discharge home, and independent ambulation at discharge. Multivariable logistic regression with generalized estimating equations accounted for within-hospital clustering and adjusted for demographics, vascular risk factors/comorbidities, and hospital characteristics. Temporal trends in MT use were assessed with the Cochran-Armitage trend test. RESULTS: Among 4 996 392 ischemic stroke admissions from 2016 to 2023, 191 355 (3.8%) were in-hospital, and 4 805 037 (96.2%) were community onset. In-hospital patients presented with greater severity (National Institutes of Health Stroke Scale score >20: 14.5% versus 7.9%; National Institutes of Health Stroke Scale score, 0–4: 43.3% versus 60.4%) had worse outcomes including higher in-hospital mortality (adjusted odds ratio, 2.27 [95% CI, 2.18–2.36]; P <0.001), lower likelihood of discharge home (adjusted odds ratio, 0.46 [95% CI, 0.45–0.48]; P <0.001), and lower independent ambulation at discharge (adjusted odds ratio, 0.52 [95% CI, 0.50–0.53]; P <0.001). Recognition-to-computed tomography time was longer for in-hospital (median 51 [interquartile range, 16–269] versus 18 [10–39] minutes; P <0.001). MT rates increased significantly from 2016 to 2023 in both in-hospital and community-onset patients (4.47%–9.54% and 2.35%–5.55%, respectively; P <0.001). Quality metrics and outcomes significantly improved in the MT era, independent of treatment modality. CONCLUSIONS: In patients with in-hospital stroke, MT rates increased over time, and improvements in quality metrics were observed regardless of treatment modality. A higher level of stroke severity and worse outcomes persists.