Comprehensive Stroke Centers and the ‘Weekend Effect’: The SPOTRIAS Experience

Abstract

Background and Purpose: Previous studies have found mortality among ischemic stroke patients to be higher on weekends. We sought to evaluate whether weekend admission was associated with worse outcomes in a large comprehensive stroke center (CSC) cohort. Methods: Consecutive ischemic stroke patients presenting within 6 h of symptom onset were identified using the 8 CSC SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) database. Patients who received intra-arterial therapy or who were enrolled in a nonobservational clinical trial were excluded. All patients meeting the inclusion criteria were then divided into two groups: weekday admissions or weekend admissions. Weekend admission was defined as Friday 17:01 to Monday 08:59. The remainder were classified as weekday admissions. Multivariate logistic regression was used, adjusting for age, stroke severity on admission [according to the National Institutes of Health Stroke Scale (NIHSS)] and admission glucose, in order to compare the outcomes of the weekend versus the weekday groups. Results: Eight thousand five hundred and eighty-one subjects from the combined SPOTRIAS database were screened from 2002 to 2009; 2,090 (24.4%) of these met the inclusion criteria. There was no significant difference in tissue plasminogen activator treatment rates between the weekday and weekend groups (58.5 vs. 60.4%, p = 0.397). Weekend admission was not a significant independent predictor of inhospital mortality (8.4 vs. 9.9%, p = 0.056), length of stay (4 vs. 5 days, p = 0.442), favorable discharge disposition (38.0 vs. 42.2%, p = 0.122), favorable functional outcome at discharge (41.6 vs. 43.4%, p = 0.805), favorable 90-day functional outcome (54.2 vs. 46.9%, p = 0.301), or 90-day mortality (18.2 vs. 19.8%, p = 0.680) when adjusting for age, NIHSS and admission glucose. Conclusions: In this large cohort of ischemic stroke patients treated at CSCs, we did not observe the ‘weekend effect.’ This may be due to access to stroke specialists 24 h a day on 365 days a year, nurses with stroke experience and the organized system for delivering care that is available at CSCs. These results suggest that EMS protocol should be reexamined regarding the preferential delivery of weekend stroke victims to hospitals that provide all levels of reperfusion therapy. This further highlights the importance of organized stroke care.

Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care

“…Some have found evidence for reduced quality of care for patients admitted on weekends 18 , but the evidence for differences in mortality between weekend and weekday admissions has been mixed. 19,20,21 These differences might be explained by differences in how stroke care services are organised 21 , and there is evidence that low nurse staffing levels on stroke units are associated with higher mortality at weekends. 22 The limitation of much of the previous literature on the "weekend effect" is that it has typically been based on comparisons of weekends versus weekdays, or regular versus off-hours, without taking into account variation that might occur across both day of the week and time of day.…”

“…The study would have been strengthened by including more outcome measures, particularly of measures important after stroke, such as disability and quality of life. However, most of the process measures have a strong empirical rationale from good quality randomised controlled trial evidence 29,20 , and longer term outcomes data are not currently available in SSNAP. The evidence for stroke therapy interventions is generally weaker than other aspects of acute care but are widely recognised in clinical guidelines to be an essential element of acute stroke care 10 .…”

Hospital Volume and Patient Outcomes in Hepato-Pancreatico-Biliary Surgery: Is Assessing Differences in Mortality Enough?

“…[4][5][6][7] For example, comprehensive stroke centers, staffed by super-specialized care providers, have been shown to provide improved outcomes for patients presenting for treatment of acute ischemic stroke. 8,9 Similarly, improved outcomes among certain high-volume hospitals that perform bariatric surgery have led the Centers for Medicare and Medicaid Services (CMS) to designate some institutions as "centers of excellence." 10,11 For most surgical specialties, however, formal identification of super-specialization at the hospital level is rarely formalized or publically designated.…”

Off-Hours Admission and Acute Stroke Care Quality

“…Other studies have not found differences in short-term mortality when restricting to patients admitted to specialized stroke centers, indicating that organizational factors [25][26][27][28] may be important in understanding the weekend-or off-hours effect. Across patient populations, the body of scientific work supporting the existence of a weekend-or off-hour-effect is substantial.…”