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Patients with stroke fare better when treated during regular hospital hours
Economic, practical restrictions in hospital staffing may affect clinical outcomes and mortality rates.
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Patients who have stroke may have better outcomes depending on what day of the week and what time of day they enter the hospital, according to results from two studies presented at the International Stroke Conference in New Orleans.
The results suggested that patients who enter the hospital during regular business hours and during the business week have better clinical outcomes than those who are admitted during evening and overnight hours or on weekends.
Admission disparities found
In the first study, researchers from Michigan State University, Massachusetts General Hospital and the Duke Clinical Research Institute analyzed data from 222,514 acute stroke admissions (187,669 ischemic and 34,845 hemorrhagic) from 857 hospitals between 2001 and 2007. On-hour presentation was defined as admission between 7 a.m. and 6 p.m. from Monday through Friday, with off-hour presentation defined as any other time.
“We found an elevated risk of in-hospital mortality for all stroke patients who presented after hours, but it was particularly striking for hemorrhagic stroke,” Matthew J. Reeves, MD, PhD, associate professor of epidemiology at Michigan State University, said in a press release.
During off-hours, 27.2% of patients presented with hemorrhagic stroke compared with the 24.1% of patients presenting during on-hours (OR=1.17; 95% CI, 1.11-1.23). The same dynamic occurred with the ischemic stroke population who presented in off-hours vs. on-hours, although the difference was less pronounced (OR=1.13; 95% CI, 1.08-1.18).
“For hemorrhagic stroke patients presenting during off-hours, there was a greater than 3% absolute increased risk in mortality,” said Reeves. “That is clinically important; it translates to one excess death for every 32 patients with hemorrhagic stroke present during off-hours compared with those who arrive during regular hours.”
Different study, same results
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Results from another study, which was the largest in the world to compare outcomes for weekend with weekday stroke admissions, suggested a similar dynamic. Researchers from the University of California in Los Angeles examined data taken from 1988 to 2004 from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, which included a sample of 2,409,043 stroke admissions (1,397,883 of whom had an ischemic stroke). The researchers found that the mortality rate was higher when stroke patients were admitted on the weekends compared with weekday admissions (10.1% vs. 7.9%; P<.001), with a similar but smaller difference observed in patients presenting with ischemic stroke (8.2% vs. 7.3%; P<.001).
“It is often easy to speculate about systems issues,” David S. Liebeskind, MD, associate professor of neurology at the University of California Los Angeles Stroke Center, told Cardiology Today. “Yet, if you look at the results of our study, which analyzed admissions on particular days of the week, there is an issue that arises and raises questions about staffing or availability and the process of care that exists on the weekends for stroke patients that is not an issue during the week.”
Liebeskind said that some of the logistical problems that hospitals and emergency departments may encounter with patients being admitted during off-hours or weekends may perhaps be alleviated by the proliferation of stroke centers equipped to deal exclusively with stroke patients in an emergency setting.
“Some of the things that are required for stroke care may include specialty or subspecialty expertise and other services that require organization and planning that has not been in place until recently with the development of stroke centers,” Liebeskind said. “Perhaps with the development of more primary stroke centers, establishment of comprehensive stroke centers or the recognition of tertiary stroke centers, these disparities will begin to disappear.” – by Eric Raible
The most logical explanation for this is that off-hour patients are coming in at a time when the hospitals are not as well equipped to deal with emergencies at night and on weekends. At night and on weekends, you have doctors and specialists on call, but they are not always in the hospital. So it is a delay in treatment primarily due to economic and practical considerations; there is just not the same amount of staff at night or on the weekends. This relates to just about any specialty. We may see an improvement with this, but if you look at it from a cost standpoint, we cannot afford to have fully-staffed hospitals all night or all weekend long. We can barely afford it now.
— David S. Sheps, MD
Associate Director,
Division of Cardiovascular Medicine,
University of Florida College of Medicine
For more information:
- Reeves MJ, Schwamm LH, Yu Y. Off-hour admission and in-hospital mortality in hospitals participating in the Get With the Guidelines-Stroke program. #P540.
- Lee DJ, Liebeskind DS. Weekends are worse for stroke care in the United States. #P174.
- Both posters presented at: the International Stroke Conference; Feb. 20-22, 2008; New Orleans.