Can Comprehensive Stroke Centers Erase the ‘Weekend Effect’?

Abstract

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 (1,407 site 1, 804 site 2). Thirty-six percent (800/2,211) arrived on a weekend. No significant differences were found in the ICH, IS, AIS-TPA, or TIA groups with respect to the rate of symptomatic ICH, mRS on discharge, discharge disposition, 90-day mRS, or 90-day mortality when comparing weekend and weekday groups. Using multivariate logistic regression to adjust for site, age, admission NIHSS, and blood glucose, weekend admission was not a significant independent predictive factor for in-hospital mortality in all strokes (OR = 1.10, 95% CI 0.74–1.63, p = 0.631). Conclusions: Our results suggest that comprehensive stroke centers (CSC) may ameliorate the ‘weekend effect’ in stroke patients. These results may be due to 24/7 availability of stroke specialists, advanced neuroimaging, or ongoing training and surveillance of specialized nursing care available at CSC. While encouraging, these results require confirmation in prospective studies.

Association of a higher density of specialist neuroscience providers with fewer deaths from stroke in the United States population

“…20,32 The "weekend effect" has been eliminated in comprehensive centers with around-the-clock availability of neurologists, neurosurgeons, and intensivists. 1,29 This is in agreement with the observed positive effect of more neuroscience providers in decreasing stroke mortality rates in the current analysis.…”

“…Several lines of evidence point to the value of access to appropriate health systems in the outcomes after stroke. 1,13,29 Along the same lines, telemedicine and telestroke care is increasingly used to provide timely care in stroke patients. 8,9,28 Recent studies have demonstrated increased stroke-related mortality during the weekends, potentially due to the decreased availability of specialized care providers.…”

Weekend Effect in Children With Stroke in the Nationwide Inpatient Sample

“…No such difference in mortality was observed at CSCs on weekends versus weekdays. In another study of 2 CSCs, 23 a total of 2211 adult patients were included. Patients were categorized into 4 groups: an intracerebral hemorrhage group, an arterial IS group not treated with intravenous tissue-type plasminogen activator, an arterial IS treated with tissue-type plasminogen activator, and a transient ischemic attack group.…”

Compliance with joint commission measures in state-designated stroke centers

“…15 This lack of a "weekend effect" is felt to be related to the 24/7 availability of stroke specialists, advanced neuroimaging, ongoing training, and surveillance of specialized nursing care available at CSCs. 4,16 In our study, New Jersey CSCs overall had significantly higher rates of thrombolysis compared to PSCs (19.5% vs 9.6%) when looking at the 3-hour window. This is higher overall than the national rate of 3.4% to 5.2%.…”