Designated Stroke Centers Mitigate 'Weekend Effect'

Pauline Anderson

August 25, 2011

August 25, 2011 — New research shows that patients with stroke admitted to hospitals on Saturdays, Sundays, or holidays have a 5% higher risk for death by 90 days than those admitted during the work week.

This discrepancy has been described previously and dubbed the "weekend effect." However, researchers found no such difference in mortality in stroke patients admitted to comprehensive stroke centers (CSCs) on weekends or weekdays.

The results also showed a rising rate of tissue plasminogen activator (tPA) usage and fewer stroke admissions to hospital over the course of about a decade, but the increased weekend mortality rate at some centers was disappointing, said lead author James S. McKinney III, MD, assistant professor, Neurology, University of Medicine and Dentistry of New Jersey, New Brunswick. "It's a little bit disturbing that there is, as late as 2007, a weekend effect in stroke care."

This suggests that there still may be a lapse in quality or spectrum of care on weekends at some smaller hospitals, said Dr. McKinney. The good news, he said, is that the lack of a dip in weekend survival rates at CSCs reflects recent efforts to coordinate and improve stroke care.

The study was published online August 25 in the journal Stroke.

Weekend Mortality

Researchers used the Myocardial Infarction Data Acquisition System database, which contains demographic and clinical information on patients discharged from New Jersey hospitals with a primary diagnosis of cerebral infarction. The database includes information on treatment with intravenous thrombolysis and on coexisting medical conditions. Researchers also accessed data on out-of-hospital deaths from state death registration files.

The study included 134,441 stroke patients admitted between 1996 and 2007 to 88 hospitals in New Jersey. Of these, 23.4% were admitted to 12 CSCs, 51.5% to 43 primary stroke centers, and 25.1% to 33 nonstroke centers; 27.8% were weekend admissions. There was a 27.9% decline in stroke admissions during the study period

The overall 90-day mortality for patients admitted with stroke was 16.7%. Mortality was significantly higher for patients admitted on weekends (17.2% vs 16.5% on weekdays; P = .002). Ninety-day stroke mortality declined throughout the study period for both weekend and weekday admissions (New Jersey introduced legislation to designate stroke centers in 2004).

After adjusting for confounding variables, 90-day mortality remained significantly higher for patients admitted on weekends compared with on weekdays (hazard ratio, 1.05; 95% confidence interval, 1.02 - 1.09)

In contrast, there was no increase in adjusted 90-day mortality in patients admitted to CSCs on weekends (hazard ratio, 1.01; 95% confidence interval, 0.95 - 1.08)

Intravenous thrombolysis rates were higher for stroke patients admitted on weekends (1.6% vs 1.3% on weekdays). Dr. McKinney called these rates "pretty abysmal," although they were much better than when the study started.

"At the end of study, you were 10 times more likely to be treated with tPA than at the beginning of the study," he noted. "I think that speaks to physician comfort with using the drug, and patient and community awareness that there is treatment for stroke."

Forced to Use 911

The higher rate of tPA use on weekends could be a result of more patients being eligible to receive this drug because of fewer delays in arriving at the hospital, or because of faster access to diagnostic imaging and neurological evaluation. Or, patients who suffer a stroke on a weekend may not have a choice in how they are admitted to hospital, said Dr. McKinney.

"Some people who have neurological symptoms during the week will call their primary care doctor and make an appointment, and by the time they actually get to a hospital, they may be outside any time treatment windows; we have 3, maybe 4 and a half hours to treat most strokes. But on weekends, primary care doctors' offices are closed, and people are almost forced to use 911 and emergency medical services to access healthcare."

Even if their use of tPA may increase on weekends, some hospitals are faced with reduced staff. "There may be disparities in hospital care on weekends," said Dr. McKinney. "Unfortunately, some smaller hospitals may not have the staffing, whether it's [computed tomography] scan technicians, or even physical or occupational therapists."

However, the study has many "positives," said Dr. McKinney. "On the whole, the mortality rates after stroke are decreasing across the board, which is good, and the number of stroke admissions decreased over the study period. So I think primary care doctors, neurologists, cardiologists, and other caregivers are doing a better job at preventing initial stroke. At the same time, tPA usage rates are going up, which means we're doing a better job at identifying strokes, and patients are getting to the hospital sooner, so they're eligible for tPA."

The study findings are another indication that CSCs are the way to go to streamline stroke care. "Financially, it probably doesn't make sense — and from a healthcare resource allocation standpoint, it probably doesn't make sense — for every hospital to be a comprehensive stroke center, but there should be a comprehensive stroke center serving a larger community," as stroke is the third leading cause of death in the United States and the leading cause of adult permanent disability, said Dr. McKinney.

A Major Effect

Approached for a comment on the study, Ralph L. Sacco, MD, chairman, Neurology; executive director, McKnight Brain Institute; and chief of neurology, University of Miami, Florida, said the study was interesting and showed that the weekend disparity does not exist at CSCs.

Even though the difference in 90-day mortality at other centers was small, the study "adds to the evidence that treating patients at designated stroke centers can improve outcomes after stroke," said Dr. Sacco in an email to Medscape Medical News.

"Data from the [American Heart Association's] Get With the Guidelines stroke centers have also shown improvements in stroke performance indicators and increased use of tPA over time," noted Dr. Sacco. "Other studies have also shown better outcomes among stroke centers. Improved organization of care with primary and comprehensive stroke centers can have a major impact in improving the outcomes of our stroke patients."

The authors have disclosed no relevant financial relationships.

Stroke. Published online August 25, 2011. Full text


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