Highlights
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Compared to community-onset stroke patients, in-hospital stroke patients have higher mortality rates, longer hospital stays and increased in-hospital complications.
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In-hospital stroke patients experience major delays in diagnosis and treatment and are less likely to receive thrombolysis.
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Thrombectomy may offer greater reduction in mortality and pneumonia for in-hospital stroke patients.
Introduction
In-hospital strokes or strokes occurring during hospitalization represent between 2.2 and 17% of all stroke cases. Reference Nouh, Amin-Hanjani and Furie1–Reference Chen, Singh, Kamal and Hill3 Patients with in-hospital strokes are shown to have higher mortality rates, greater functional impairment and longer hospital stays compared to community-onset stroke patients. Reference Bekelis, Missios, Coy and MacKenzie4–Reference Schürmann, Nikoubashman and Falkenburger10 In-hospital acute ischemic strokes are also less likely to receive acute reperfusion therapies. Reference Cumbler, Wald and Bhatt11–Reference El Husseini and Goldstein13 Proposed reasons behind this disparity in outcomes include differences in patient characteristics and potential suboptimal care in patients with in-hospital strokes. Reference Nouh, Amin-Hanjani and Furie1–Reference Chen, Singh, Kamal and Hill3,Reference Cumbler, Murphy, Jones, Wald, Kutner and Smith12
Compared to community-onset stroke patients, in-hospital stroke patients have increased rates of comorbidities, including atrial fibrillation, coronary artery disease, cardiomyopathy, diabetes mellitus and cancer. Reference Dulli and Samaniego14–Reference Aly, McDonald, Leathley, Sharma and Watkins17 Additionally, up to half of in-hospital strokes occur perioperatively. Reference Benesch, Glance and Derdeyn18–Reference Ganesh20 These characteristics result in more complex medical profiles and management challenges, including delayed stroke detection and barriers to acute treatment. Reference Nouh, Amin-Hanjani and Furie1–Reference Chen, Singh, Kamal and Hill3,Reference Cumbler, Wald and Bhatt11,Reference El Husseini and Goldstein13 While multiple quality improvement initiatives have successfully reduced treatment delays for community-onset strokes, similar efforts targeting in-hospital strokes have lagged behind. Reference Chen, Singh, Kamal and Hill3,Reference Bekelis, Missios, Coy and MacKenzie4,Reference Liu, Han and Wu21
We compared patients with in-hospital strokes and those with community-onset strokes in Alberta with respect to the following: clinical characteristics, clinical outcomes, specifically length of stay, in-hospital mortality and in-hospital complications, and workflow metrics among treated acute ischemic stroke patients. Our findings aim to inform targeted strategies to address care gaps and improve outcomes in this high-risk population.
Methods
Study design
We performed a retrospective cohort study (INPATIENTS: IN-hosPitAl sTrokes In AlbErta iNcidence and ouTcomeS) including patients aged 18 years and older with in-hospital and community-onset strokes in Alberta, Canada between January 1, 2018 to December 31, 2022. The recent 5–year period was selected to ensure an adequate sample size, anticipating at least 1,000 in-hospital strokes to have occurred and to reflect current stroke care practices. Reference Elbayomy, Kim, Ammanuel, Traverzo, Battula and Ahmed22 As of 2022, Alberta Health Services operated 106 acute care hospitals with 8,523 acute care beds serving an adult population of around 2.83 million. 23 Alberta has two comprehensive stroke centers (CSCs) and 15 primary stroke centers (PSCs). 23 PSCs are equipped with CT scanners, offer intravenous thrombolysis (IVT) and have access to specialists via remote consultation. CSCs provide advanced stroke care, including endovascular thrombectomy (EVT) and on-site stroke neurology, neuro-interventional and neurosurgical expertise. 23
Data sources
The cohorts were identified on the Discharge Abstract Database (DAD), a nationwide database that captures clinical and demographic information on all hospital discharges. 24 Using the episode of care, we linked the DAD to the Quality Improvement and Clinical Research Alberta Stroke Program (QuICR) registry that includes all acute ischemic strokes treated with IVT and/or EVT in the province.
Cohort definition
In-hospital stroke was defined as a post-admission comorbidity of stroke during an inpatient episode of care, while community-onset stroke was defined as a most responsible diagnosis, pre-admission comorbidity diagnosis (Diagnosis type 1 requiring active management and contributing to resource use during the episode of care) or transfer service diagnosis of stroke on the first admission. The unit of analysis was the episode of care or contiguous admissions across facilities for the same patient. Patients may have multiple episodes of care during the study period. Acute ischemic strokes were identified by the International Classification of Diseases, 10th revision codes H34.1, I63.x and I64, while hemorrhagic strokes were identified by codes I61.x. (See Supplementary Table 1.) We excluded patients with transient ischemic attacks, venous infarcts, subarachnoid hemorrhage, invalid identifiers and those from out-of-province. Electronic chart reviews by five neurologists and two students with a background in healthcare research supplemented missing data for the in-hospital stroke cohort, including stroke symptom recognition times and confirmation of in-hospital stroke type.
Standard protocol approvals, registrations, and patient consents
The study was approved by the University of Calgary Conjoint Health Research Ethics Board (REB23-0864) and did not require patient consent due to its retrospective design and use of de-identified, minimal-risk data. We adhered to the STROBE Guidelines for cohort studies and the RECORD reporting guidelines for routinely collected health data.
Outcomes and exposure
The primary outcomes were in-hospital mortality, duration of hospital stay and the occurrence of the following in-hospital complications: acute kidney injury, cardiac arrest, deep venous thromboembolism (DVT) or pulmonary embolism (PE), gastrointestinal (GI) bleeding, pneumonia, respiratory failure and urinary tract infection (UTI), collected from the DAD. (See Supplementary Table 2.) For acute ischemic stroke patients who received treatment, the following workflow metrics were recorded as outcomes: time from presentation to neuroimaging, time from presentation to IVT administration and time from presentation to groin puncture for EVT. The time of presentation was defined as stroke symptom recognition by healthcare staff for in-hospital strokes and as hospital arrival for community-onset strokes, reflecting the point at which the hospital stroke response was activated in each cohort. The exposure of interest was stroke onset location, classified as in-hospital or community-onset.
Demographic and clinical variables collected
Variables collected for both cohorts included age, sex, year of admission, type of admitting facility, stroke type, neuroimaging performed and baseline stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS). (See Supplementary Table 3.) Pre-existing comorbidities within five years were also collected, including atrial fibrillation, cancer, chronic renal disease, coronary artery disease, diabetes, heart failure, hypertension, and previous stroke or transient ischemic attack. (See Supplementary Table 4.) Workflow metrics and NIHSS were only available for patients treated with IVT and/or EVT within the QuICR registry.
Statistical analysis
We compared baseline demographic and clinical characteristics between in-hospital and community-onset strokes using descriptive statistics. We conducted multivariable regression analysis to determine the association between stroke onset location and the following primary outcomes: prolonged hospital stay – defined as hospital stay greater than the median length of hospital stay, in-hospital mortality and the occurrence of each in-hospital complication. Models were adjusted for age, sex, the presence of each medical comorbidity, stroke facility type (non-stroke center, primary stroke center and comprehensive stroke center) and admission year. NIHSS was excluded from the models due to a high degree of missing data (>80%).
Among acute ischemic strokes, we tested for effect modification by IVT/EVT using interaction terms between treatment type and stroke onset location in adjusted models. Stratum-specific odds ratios were reported when interaction p-values were <0.05.
We computed standardized median differences (SMDs), the difference in medians divided by the pooled interquartile ranges, to compare workflow metrics between treated patients. SMDs <0.5, 0.5 to <0.8 and ≥0.8 were considered small, medium and large effect sizes, respectively. Reference Sun and Cheung25 Negative binomial regression was used to estimate rate ratios comparing treated in-hospital and community-onset stroke workflow times, adjusting for the same covariates as above. Analyses were based on stroke classification from administrative data, except for the comparison of workflow metrics, where stroke type was verified by chart review. Two-tailed tests with p < 0.05 were considered significant. STATA v17.0 software was used for all analyses.
Data availability
Data supporting the findings of this study are available from the corresponding author upon reasonable request.
Results
Study sample
A total of 24,039 hospital admissions for ischemic and hemorrhagic strokes were identified in Alberta from 2018 to 2022. Of these, 2,545 (10.6%) were in-hospital strokes. Ischemic strokes represented around 87% of each cohort. The majority of patients from the community-onset stroke cohort were identified using the most responsible diagnosis, 18,728 (87.13%), while 2,221 (10.33%) were identified using a pre-admission comorbidity diagnosis, and 545 (2.54%) were identified using a transfer service diagnosis of stroke. Among 2,224 patients identified as having in-hospital acute ischemic stroke based on administrative data, 2,115 (95.1%) were confirmed by manual chart review. (See Figure 1.)
Study flowchart and classification of stroke types based on administrative data and manual chart review.
Comparing baseline characteristics between in-hospital and community-onset strokes
Table 1 shows the baseline characteristics of in-hospital strokes and those with community-onset strokes. Median age and sex distribution were similar. Over half of admissions occurred at CSCs, with stable volumes over time. In-hospital strokes had higher rates of atrial fibrillation, cancer, kidney disease, coronary disease, diabetes and heart failure, while hypertension was slightly more common in community-onset strokes. Among acute ischemic strokes, in-hospital strokes were less likely to receive IVT alone (2.43% vs 9.92%, p < 0.001) or IVT and EVT (0.27% vs 3.81%, p < 0.001), though the proportion of EVT treatment was similar between groups (4.27% vs 4.22%, p = 0.910). Among patients with available NIHSS scores, the median score was higher in those with in-hospital strokes (15, IQR 11–20; n = 100) compared to community-onset strokes (9, IQR 5–16; n = 2,534). The majority (73.55%) of in-hospital stroke patients received acute treatment at CSCs and PSCs, while a minority were transferred from non-stroke centers for advanced therapies. Specifically, 26 patients (16.77% of treated in-hospital strokes) were transferred to CSCs for EVT, and 15 patients were transferred to PSCs or CSCs (9.67% of treated in-hospital strokes) for IVT.
Baseline characteristics of in-hospital and community-onset strokes
CT = computed tomography; EVT = endovascular thrombectomy; IVT = intravenous thrombolysis; MRI = magnetic resonance imaging; *first neuroimaging performed during admission not necessarily first neuroimaging performed related to stroke symptoms in in-hospital strokes; **available in 2,634 patients only: 100 in-hospital strokes and 2,534 community-onset strokes.
Comparing outcomes of in-hospital and community-onset strokes
In-hospital strokes had significantly higher rates of complications and longer hospital stays (median 22 vs 7 days; p < 0.001) compared to community-onset strokes. In-hospital mortality was higher among in-hospital strokes (36.62% vs 13.87%; p < 0.001). ICU admission at any time point, as well as gastrostomy and tracheostomy procedures, was more common in in-hospital strokes while dysphagia screening was performed less frequently (See Table 2).
Comparison of outcomes between in-hospital and community-onset strokes
DVT/PE = deep venous thrombosis or pulmonary embolism; EVT = endovascular thrombectomy; ICU = intensive care unit; IVT= intravenous thrombolysis; *ICU admission not necessarily due to stroke; **missing in 14,318: 1,577 in in-hospital strokes, 12,741 in community-onset strokes.
In-hospital strokes had a significantly higher odds of adverse clinical outcomes compared to community-onset strokes (See Table 3). After adjusting for age, sex, comorbidities, facility type and admission year, the odds of mortality for in-hospital strokes were 3-fold higher compared to community-onset strokes (adjusted OR [aOR] 3.09; 95% CI 2.80–3.41). In-hospital strokes also had 6-fold higher odds of prolonged hospitalization compared to community-onset strokes (aOR 5.5; 95% CI 4.9–6.1). Mixed-effects logistic regression models accounting for clustering by stroke facility type and admission year showed similar effect estimates compared to fixed-effects models (Supplementary Table 5), indicating that neither facility type nor admission year significantly influenced the outcomes. Sensitivity analyses excluding patients without neuroimaging (Supplementary Table 6) yielded findings consistent with the primary analyses.
Unadjusted and adjusted odds ratios for primary outcomes comparing in-hospital to community-onset strokes
* Odds ratios adjusted for age, sex, the presence of each medical comorbidity, stroke facility type and admission year; DVT/PE = deep venous thrombosis or pulmonary embolism.
Among acute ischemic strokes, effect modification was observed for in-hospital mortality and pneumonia, specifically in those receiving EVT with or without IVT, but not for IVT alone. In-hospital strokes who received EVT with or without IVT had a 46% lower odds of in-hospital mortality compared to non-treated strokes (aOR 0.46, 95% CI: 0.28–0.75; p-interaction = 0.002). They also had a 38% lower odds of pneumonia compared to non-treated strokes (aOR 0.38, 95% CI: 0.20–0.71; p-interaction = 0.003). These findings suggest that the benefit of EVT with or without IVT is greater among in-hospital strokes compared to community-onset strokes for these outcomes. (See Supplementary Table 7).
Comparing workflow metrics of treated acute ischemic in-hospital and community-onset strokes
All workflow metrics were prolonged among in-hospital acute ischemic strokes compared to community-onset strokes (See Table 4). The time from presentation to neuroimaging was approximately four times longer, and the times from presentation to IVT and to EVT were approximately twice as long for in-hospital strokes. (See Table 5).
Comparison of workflow metrics between in-hospital and community-onset acute ischemic strokes that received acute treatment
EVT = endovascular thrombectomy; IVT = intravenous thrombolysis; IQR = interquartile range; *Standardized median difference ≥8 considered large effect size; **standardized median difference 0.5 to <0.8 considered medium effect size; †missing in 180: 12 in in-hospital cohort, 168 in community-onset cohort; ††missing in 57: 15 in in-hospital cohort, 42 in community-onset cohort; †††missing in 51: 6 in in-hospital cohort, 45 in community-onset cohort.
Unadjusted and adjusted rate ratios for workflow metrics comparing treated in-hospital and community onset acute ischemic strokes
EVT = endovascular thrombectomy; IVT = intravenous thrombolysis; IQR = interquartile range; *rate ratios adjusted for age, sex, the presence of each medical comorbidity, stroke facility type and admission year.
Discussion
Our findings show that in-hospital strokes experience worse clinical outcomes, including higher mortality rates, longer hospital stays and increased in-hospital complications, compared to community-onset strokes. In-hospital acute ischemic strokes were less likely to receive IVT and experienced significant delays in management. The majority of treated in-hospital stroke patients received acute treatment at CSCs or PSCs, while only a small percentage of patients were transferred from non-stroke centers. In-hospital acute ischemic strokes may derive greater benefit from EVT compared to community-onset strokes, particularly in reducing in-hospital mortality and pneumonia.
In-hospital strokes represented 10.6% of all stroke admissions in Alberta from 2018 to 2022, with the majority being ischemic. While this falls within the prevalence range (2.2 to 17%) reported in prior studies, direct comparisons are challenging due to variations in institutional practices, patient populations and healthcare systems. Reference Kimura, Minematsu and Yamaguchi7,Reference Dulli and Samaniego14,Reference Blacker26
Observed differences in baseline characteristics between in-hospital and community-onset strokes highlight the distinct clinical profiles of these two groups. There was a higher prevalence of atrial fibrillation, cancer, chronic kidney disease, diabetes and heart failure among in-hospital strokes, supporting the existing literature that in-hospital stroke patients have a greater burden of pre-existing comorbidities. Reference Dulli and Samaniego14–Reference Aly, McDonald, Leathley, Sharma and Watkins17 Interestingly, hypertension was more common among community-onset strokes. This could reflect differing risk profiles where hypertension plays a more prominent role among community-onset strokes.
The odds of in-hospital mortality were 3-fold higher for in-hospital strokes compared to community-onset strokes in Alberta. This is consistent with prior studies reporting higher mortality in in-hospital strokes attributed to older age, more severe comorbidities, greater stroke severity, and potential delays in recognition, diagnosis and treatment. Reference Cumbler2–Reference Bekelis, Missios, Coy and MacKenzie4,Reference El Husseini and Goldstein13,Reference Farooq, Reeves, Gargano, Wehner, Hickenbottom and Majid27–Reference Moradiya and Levine29 While it is difficult to determine whether this reflects a true treatment effect or selection bias – such as preferential EVT treatment of patients with better baseline function – our findings suggest that the mortality gap may be partially modifiable for some patients through acute treatment. In a recent systematic review and meta-analysis, in-hospital stroke was associated with a two-fold higher odds in mortality compared to community-onset stroke, but this difference was attenuated among patients receiving EVT, highlighting the potential role of treatment and patient selection in influencing outcomes. Reference Ignacio, Waraich and Khan30 Among acute ischemic stroke patients, the benefit of EVT appeared greater for in-hospital strokes compared to community-onset strokes particularly in reducing in-hospital mortality and pneumonia; however, data on this relationship remain limited, and further research is needed to better understand this potential association.
In-hospital strokes were associated with longer hospital stays, increased complication rates and lower rates of dysphagia screening compared to community-onset strokes. These findings may reflect differences in patient profiles and healthcare delivery, including management delays and reduced adherence to guideline-recommended care. Reference Bekelis, Missios, Coy and MacKenzie4,Reference Cumbler, Wald and Bhatt11,Reference Aly, McDonald, Leathley, Sharma and Watkins17,Reference Liu, Han and Wu21,Reference Farooq, Reeves, Gargano, Wehner, Hickenbottom and Majid27,Reference Emmett, Douiri and Marshall31,Reference Chapman, Kennedy, Bradley and Harbison32 In-hospital ischemic strokes also had lower rates of IVT, likely due to more frequent contraindications as in prior studies. Reference Cumbler, Wald and Bhatt11–Reference El Husseini and Goldstein13 Meanwhile, EVT rates were similar in our cohorts but have varied across studies – reported as higher or lower, compared to community-onset strokes – reflecting differences in institutional practices, workflows, available expertise and resource availability. Reference Farooq, Reeves, Gargano, Wehner, Hickenbottom and Majid27,Reference Akbik, Xu and Xian33,Reference Gu, Wang and Yang34
Key workflow metric delays were observed in the in-hospital stroke cohort, possibly resulting from challenges in stroke recognition, delays in response and logistical issues, e.g. patient transport. Reference Nouh, Amin-Hanjani and Furie1–Reference Chen, Singh, Kamal and Hill3,Reference El Husseini and Goldstein13,Reference Aly, McDonald, Leathley, Sharma and Watkins17,Reference Chapman, Kennedy, Bradley and Harbison32 Time to EVT was less prolonged, suggesting a more streamlined workflow for EVT-treated strokes. This could be due to clearer symptom presentation or more favorable characteristics among these patients. A study conducted in Taiwan reported comparable workflow metrics among EVT-treated cohorts, concluding that workflow metric targets can be achieved in well-equipped centers. Reference Lu, Chen and Yeh35 While we identified delays, we were unable to assess the association between workflow metrics and outcomes in adjusted models due to the small number of treated in-hospital patients and limited availability of workflow data. Future studies are needed to evaluate the impact of workflow efficiency on outcomes in this population.
In our cohort, most treated in-hospital stroke patients received acute care at CSCs or PSCs, with a minority transferred from non-stroke centers for advanced therapies. These findings underscore the need for future research to assess treatment patterns across different hospital types, monitor trends over time, and ensure that workflow optimization strategies and policy recommendations are applicable beyond high-resource CSCs.
It was not possible to determine eligibility rates for IVT or EVT in our study because key clinical criteria – such as stroke severity, imaging findings, timing of symptom recognition and contraindications – are not captured in retrospective administrative data. Eligibility for acute stroke treatments is highly individualized and depends on multiple factors and clinical judgment, which these data cannot assess. As such, observed treatment rates reflect those who received therapy and should be interpreted as representing real-world, population-level treatment patterns rather than definitive estimates of eligibility. In addition, the study period spanned the COVID-19 pandemic, but our analysis found no significant impact of the pandemic on main outcomes.
This study has a number of strengths. First, it includes a large sample size of both in-hospital and community-onset strokes across the province over a 5–year period. This comprehensive dataset enabled robust comparisons of clinical outcomes, workflow metrics, and treatment patterns between the two groups. Second, confounding was minimized through multivariable adjustment for important covariates, including age, sex, comorbidities, admission year and type of stroke center. Third, our findings are consistent with existing literature supporting their broader relevance. Finally, the study addresses an important knowledge gap by characterizing clinical outcomes and workflow metrics of in-hospital stroke patients, offering actionable insights for future quality improvement efforts.
This study has several limitations. Its retrospective design and reliance on administrative health data may have been subject to coding errors and misclassification of exposures and outcomes. Administrative data also lack clinical granularity and are missing important variables. For example, modified Rankin Scale was not available, precluding the analysis of functional outcomes. We were also unable to adjust for comorbidity burden using validated indices, such as the Charlson or Elixhauser comorbidity indices. Baseline NIHSS was not included in the analyses of primary outcomes due to a high proportion of missing data. Additionally, goals of care designations and decisions to withhold resuscitative measures were not available in our dataset. Findings may also have limited generalizability beyond Alberta due to differences in healthcare systems and stroke care delivery. Finally, selection bias may be present, particularly in the analyses of treated patients, as sicker or more complex patients may have been systematically excluded from treatment decisions.
Our study demonstrated that in-hospital stroke patients have unique characteristics and risk profiles compared to community-onset stroke patients. In examining quality of care metrics, we found that in-hospital strokes suffered from significant delays in management and, possibly, suboptimal care. While it is challenging to determine the contributions of non-modifiable patient-related factors and potentially modifiable system-level factors to these outcomes, what is perhaps the more important question is how these poorer outcomes can be mitigated. In 2022, the AHA/ASA released a scientific statement entitled Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke detailing a path to optimizing care for patients with in-hospital strokes. Reference Nouh, Amin-Hanjani and Furie1 In their review, they highlighted the importance of implementing formal protocols to identify and respond to in-hospital strokes. Reference Nouh, Amin-Hanjani and Furie1
Calgary, Alberta, implemented a hospital-wide standardized inpatient stroke response protocol in 2024. This protocol involves early stroke recognition using the BEFAST mnemonic, mandatory notification of the Most Responsible Health Practitioner and prompt paging of the on-call stroke team, followed by expedited neuroimaging and acute management of stroke patients. 36 Future studies comparing pre- and post-implementation outcomes will be crucial for assessing its effectiveness and identifying areas for improvement.
Conclusion
Our study highlights significant disparities in clinical outcomes and delays in workflow metrics between in-hospital and community-onset strokes in Alberta. In-hospital acute ischemic strokes were less likely to receive IVT, but EVT rates were comparable, suggesting similar treatment potential. These findings reinforce existing literature and emphasize the need for targeted quality improvement efforts to address care gaps and improve outcomes in this high-risk population.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/cjn.2025.10431.
Acknowledgements
None.
Author contributions
KI contributed to the study concept and design, acquisition, analysis, interpretation of the data and drafting and revising the manuscript. RA contributed to data acquisition and data cleaning, critical revision of the manuscript. CK contributed to data acquisition and data cleaning, critical revision of the manuscript. MM contributed to data acquisition and data cleaning. AA contributed to data acquisition and data cleaning. DN contributed to data acquisition. JS contributed to data acquisition. RM contributed to data acquisition. MA contributed to data acquisition. BA contributed to data acquisition. JKH contributed to the study concept and design, analysis, interpretation of the data, critical revision of the manuscript and supervision. BM contributed to the study concept and design, analysis, interpretation of the data, critical revision of the manuscript and supervision. MDH contributed to the study concept and design, analysis, interpretation of the data, critical revision of the manuscript and supervision. MAA contributed to the study concept and design, acquisition, analysis, interpretation of the data, critical revision of the manuscript and supervision.
Funding statement
KI is supported by the Alberta Innovates Graduate Student Scholarship.
Competing interests
CK received honoraria for lectures including Daiichi-Sankyo (Thailand), Thai Otsuka Pharmaceutical Co. Ltd and Boehringer Ingelheim (Thailand) Ltd MDH received grants for the ESCAPE-NA1, ESCAPE-NEXT, ESCAPE-MeVO and TEMPO-2 studies; received consulting fees for Sun Pharma Brainsgate Inc; has patents licensed to Circle NVI and private stock ownership at Circle Inc., Basking Biosciences. KI, RA, MM, AA, DN, KS, RM, MA, BA, JKH, BM, and MAA have nothing to disclose.
Open access
Target article
INPATIENTS: Comparing Clinical Characteristics and Outcomes of Adults with In-Hospital and Community-Onset Strokes
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Reviewer Comment on Ignacio et al. “INPATIENTS: Comparing Clinical Characteristics and Outcomes of Adults with In-Hospital and Community-Onset Strokes”