Can Comprehensive Stroke Centers Erase the ‘Weekend Effect’?

Background: Prior epidemiological work has shown higher mortality in ischemic stroke patients admitted on weekends, which has been termed the ‘weekend effect’. Our aim was to assess stroke patient outcomes in order to determine the significance of the ‘weekend effect’ at 2 comprehensive stroke centers. Methods: Consecutive stroke patients were identified using prospective databases. Patients were categorized into 4 groups: intracerebral hemorrhage (ICH group), ischemic strokes not treated with IV t-PA (intravenous tissue plasminogen activator; IS group), acute ischemic strokes treated with IV t-PA (AIS-TPA group), and transient ischemic attack (TIA group). Weekend admission was defined as the period from Friday, 17: 01, to Monday, 08: 59. Patients treated beyond the 3-hour window, receiving intra-arterial therapy, or enrolled in nonobservational clinical trials were excluded. Patient demographics, NIHSS scores, and admission glucose levels were examined. Adverse events, poor functional outcome (modified Rankin scale, mRS, 3–6), and mortality were compared. Results: A total of 2,211 patients were included Received: February 26, 2008 Accepted: July 23, 2008 Published online: November 28, 2008 Sean I. Savitz, MD Vascular Neurology Program, Department of Neurology University of Texas Health Science Center-Houston 6431 Fannin St, MSB-7.124, Houston, TX 77030 (USA) Tel. +1 713 500 7083, Fax +1 713 500 0692, E-Mail sean.i.savitz@uth.tmc.edu © 2008 S. Karger AG, Basel Accessible online at: www.karger.com/ced Albright et al. Cerebrovasc Dis 2009;27:107–113 108 logical work has shown higher mortality rates for weekend admissions compared with weekday admissions [1] . Recent work by Kostis et al. [2] found that patients with myocardial infarction have higher mortality rates and lower numbers of invasive cardiac procedures performed when admitted on weekends, suggesting that improving access to care on weekends could improve patient outcome. This difference in outcomes related to patient admission during the weekend has come to be known as the ‘weekend effect.’ More recently, Saposnik et al. [3] found the ‘weekend effect’ to have a significant negative impact on discharge disposition, 7-day case fatality, and in-hospital mortality in ischemic stroke patients. Analysis of the Swedish Hospital Discharge Register and the Nationwide Inpatient Sample of Healthcare Cost and Utilization Project data confirmed this excess mortality for weekend admissions [4, 5] . Using the Get with the Guidelines data, Reeves et al. [5] recently reported increased in-hospital mortality in weekend admissions for both patients with infarct and intracerebral hemorrhage [6] . Though patients treated in hospitals with stroke units have improved outcome, evidence from the UK suggests that stroke patients admitted on weekends were less likely to be admitted to stroke units and less likely to receive the same quality of care when compared to weekday admissions [7–12] . Contrary to these findings, Ensminger et al. [13] found no statistically significant difference in hospital mortality between weekend and weekday admissions when examining an 8-year cohort of general ICU patients admitted to a tertiary care academic medical center. This study differed from previous studies in that the facility was staffed by fellows and residents 24 h a day, 7 days a week, and intensivists were available at all times. Further, the authors suggested that this level of staffing and the continuous availability of diagnostic and therapeutic modalities may be responsible for preventing the weekend effect. Given these contradictory findings, we hypothesized that centers with continuous availability of expert stroke teams, necessary diagnostic and therapeutic modalities, and stroke-nursing expertise could modify the ‘weekend effect’ in acute ischemic stroke (AIS) patients. Our aim was to examine both the individual and combined experiences of 2 comprehensive stroke centers (CSC) in the USA, and determine the presence and significance of a ‘weekend effect’ in AIS patients treated with IV t-PA (intravenous tissue plasminogen activator). Acute ischemic stroke patients treated with IV t-PA were chosen, as these patients require the highest need for immediate services and immediate intervention. In addition, it is often the post-t-PA AIS patients that are at greatest risk of adverse events.