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Deaths Higher for Strokes Treated at Night, on Weekends

Two new studies again suggest that stroke mortality is higher in patients who are admitted to the hospital during nights and on weekends.

The results were presented during the International Stroke Conference 2008.

In 1 report, researchers led by Matthew J. Reeves, PhD, associate professor of neurology at Michigan State University, in East Lansing, researchers found that the risk for in-hospital mortality was higher for all patients who presented after hours and on weekends, but particularly so for hemorrhagic stroke patients.

The other study, with lead author David S. Liebeskind, MD, associate professor of neurology at the University of California, Los Angeles, showed that mortality was higher for patients with any stroke admitted to the hospital on a weekend vs a weekday.

The findings, both researchers speculated, may reflect differences in the quality of care offered to stroke patients during these off-hours. "There are differences here that shouldn’t be," Dr. Liebeskind told reporters here. These findings "set the course for items to address to make sure that these inequalities are not persisting."

Dr. Reeves pointed out that roughly half of stroke patients in his study were treated during off-hours. Based on this, they calculated the population-attributable risk of this differential between on- and off-hours. "It’s about 5%, so theoretically, if you could get rid of the difference between on-hours and off-hours, you could lower the mortality rate by 5%," Dr. Reeves said. "Probably there are not many things you’ll see at this conference this week that could do that."

Previous studies in Canada and Europe have suggested that patients admitted for stroke on the weekends have poorer care and higher risk-adjusted mortality, Dr. Liebeskind said. In the study presented here, the researchers looked at stroke outcomes in the United States, comparing weekend and weekday admissions.

They used data on more than 2.4 million stroke admissions from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project between 1988 and 2004 based on ICD-9-CM codes 430 to 438. Annual percentages and trends analyses were conducted for demographic variables, admission characteristics, procedures, and outcomes. Of 2,409,043 total admissions, 1,397,883 were ischemic strokes.

Patients admitted on weekends vs weekdays did not differ in age, race, sex, or socioeconomic status, they note. Weekend patients were more often admitted emergently (70.2% vs 53.5%), but length of stay was similar between cohorts.

The researchers found that the mortality rate for all stroke patients admitted on weekdays was "remarkably lower," they write, than weekend admissions, a pattern that was also seen in the ischemic stroke subgroup.

Patients were also more likely to be routinely discharged if they were admitted on weekdays compared with weekends (53.2% vs 43.8%; P < .001). Again, this was also true of the ischemic stroke subgroup.

Dr. Liebeskind noted that the cohorts had a similar number of procedures done, but those in the weekend cohort underwent their first procedure almost 1 day later than the weekday group, with the first procedure at 2.65 days after the event, vs 1.76 days for the weekday group.

He added that although stroke mortality did go down over the 15-year period, the differential in mortality between those admitted on the weekend vs weekdays persisted.

Their analysis ended in 2004, during a time when primary stroke centers were still being developed and mobilized throughout the country, he added. "We don’t know how things will sit in coming years with stroke centers that have been developed and tailored, so that remains to be seen, but the hope is that we standardize care irrespective of the day of the week."

International Stroke Conference: Abstracts P174, P540. Presented February 20, 2008 and February 21, 2008.

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