Clinical characteristics, in-hospital management, and outcomes of patients with in-hospital vs. community-onset ischaemic stroke: a hospital-based cohort study

BACKGROUND: Lack of high-quality national-level data on in-hospital ischaemic stroke hinders the development of tailored strategies for this subgroup's identification, treatment, and management. METHODS: We analyzed and compared clinical characteristics, in-hospital management measures, and outcomes, including death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACEs), disability at discharge, and in-hospital complications between in-hospital and community-onset ischaemic stroke enrolled in the Chinese Stroke Center Association registry from August 2015 to December 2022. FINDINGS: The cohort comprised 14,948 in-hospital and 1,366,898 community-onset ischaemic stroke patients. In-hospital ischaemic stroke exhibited greater stroke severity, higher prevalence of comorbidities, more pre-admission medications, and had suboptimal management measures, for example, the onset-to-needle time within 4.5 h (83.3% vs. 93.1%; difference, −9.8% [−11.4% to −8.3%]), and antithrombotics at discharge (78.6% vs. 90.0%; difference, −11.4% [95% CI, −12.1% to −10.7%]). After adjusting for covariates, in-hospital ischaemic stroke remains associated with higher risks of unfavorable outcomes, including in-hospital death/DAMA (13.9% vs. 8.6%; adjusted risk difference [aRD], 2.2% [95% CI, 1.8%–2.7%]; adjusted odds ratio [aOR], 1.35 [95% CI, 1.25–1.45]), MACE (12.6% vs. 6.5%; aRD, 4.1% [95% CI, 3.5%–4.7%]; aOR, 1.68 [95% CI, 1.52–1.85]), and complications (23.7% vs. 12.1%; aRD, 6.5% [95% CI, 5.1%–7.9%]; aOR, 1.72 [95% CI, 1.64–1.80]), except for disability at discharge (41.1% vs. 33.1%; aRD, 0.4% [95% CI, −1.7% to 2.5%]; aOR, 0.99 [95% CI, 0.88–1.11]). INTERPRETATION: In-hospital ischaemic stroke demonstrated more severe strokes, worse vascular risk profiles, suboptimal management measures, and worse outcomes compared to community-onset ischaemic stroke. This emphasizes the urgent need for improved hospital systems of care and targeted quality improvement initiatives for better outcomes in in-hospital ischaemic stroke. FUNDING: 10.13039/501100012166National Key R&D Programme of China and Beijing Hospitals Authority.