A Systematic Review and Meta-Analysis Comparing Mortality between Inhospital versus Community-Onset Acute Ischemic Stroke

Abstract – Introduction: Patients who experience inhospital strokes may suffer from delays in stroke recognition, delays to acute treatment and management. We aimed to assess evidence for the difference in mortality between patients with inhospital stroke and those with community-onset stroke. Methods: We searched MEDLINE, EMBASE, and SCOPUS (from inception to October 8, 2024) to identify studies comparing mortality outcomes for inhospital and community-onset stroke patients. We collected data on study characteristics, summarized the quality of evidence, evaluated risk of bias of studies using the Newcastle-Ottawa Scale, and investigated clinical sources of heterogeneity. We performed a random-effects meta-analysis to estimate the pooled odds of mortality of inhospital stroke versus community-onset stroke patients. Results: Forty-one studies, collectively with 3, 038, 211 patients, of whom 3% experienced inhospital stroke, were included in the review. Inhospital stroke patients had an approximately 2.3-fold higher odds of inhospital mortality (pooled OR 2.27; 95% CI 1.80–2.86; 32 patient cohorts) and 1.9-fold higher odds of 3-month mortality (pooled OR 1.87; 95% CI 1.43–2.45; 14 patient cohorts) compared to community-onset stroke patients. Meta-analyses stratified by acute treatment received and study characteristics revealed consistently higher odds of death among inhospital stroke patients compared to community-onset stroke patients. Acute treatment received, study setting, geographic region, and components of study quality were significant sources of heterogeneity. Most concerns in study quality were due to potential risks of confounding. Conclusion: There was a consistently higher odds of inhospital and 3-month mortality among inhospital acute ischemic stroke patients compared to their community-onset counterparts, highlighting the need for targeted interventions to reduce this disparity.