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Why stroke victims fare better at hospitals on weekdays remains a mystery

People who are hospitalized for a stroke are more likely to survive if they are admitted to a hospital on a weekday rather than on a weekend — no matter how severe the stroke, a new Canadian study has found.

And, interestingly, the poorer weekend outcomes appear to have nothing to do with weekend versus weekday medical care at the hospitals.

“We did not find any significant differences in stroke care on weekends compared to weekdays,” wrote the authors of the study, which was published Monday in the St. Paul-based medical journal Neurology. In fact, the study found that patients who arrived at hospitals on weekends received life-saving clot-busting medication more often and brain scans more quickly than those who entered the hospitals on weekdays.

The study’s authors did offer a caveat on this point, however. Their study wasn’t designed, they noted, to determine subtler differences in quality of care, such as the skill and expertise of the medical personnel. “[I]t is likely that the data available to us do not reflect the overall quality of care delivery on weekends vs weekdays, and our findings do not negate the need for initiatives aimed at improving staffing and access to resources on weekends and off hours,” they wrote.

Severity of symptoms not a factor
For the study, the researchers analyzed data on more than 20,000 patients with stroke who entered 11 different stroke centers in Ontario during a five-year period. They found that admissions for stroke were spread out evenly throughout all seven days of the week, but that people with mild strokes (known as transient ischemic attacks, or TIAs) were more likely to delay going to the hospital until after the weekend (usually Monday or Tuesday). People with moderate to severe stroke, on the other hand, were just as likely to enter the hospital on a weekend as on a weekday.

However, even after adjusting for the severity of the stroke (as well as for age, sex and other factors), the study found that stroke patients admitted to the hospital on the weekends were more likely to die within seven days than those admitted on weekdays. The difference wasn’t huge, but it was significant: Weekend-admitted patients had an 8.1 percent risk of dying compared to a 7.0 percent risk for weekday-admitted patients.

Why? That’s the mystery. “Most of the time,” Dr. Louise McCullough, a stroke expert at the University of Connecticut who was not involved in the study, told Medscape reporter Megan Brooks, “it isn’t going to be the stroke itself that’s causing the fatality in seven days. It could be infection, herniation, aspiration, or things like that. This study does not give us enough detail on what that mortality was from. Is it a direct stroke-related mortality, or is it a complication mortality? We really need a study to see what these patients are dying of. What is it over the weekend that predisposes patients to mortality that may be independent of their stroke? And it certainly is independent of their stroke care because they are dying yet getting better care.”

Another caveat — for Americans
As the study’s authors point out in their introduction, previous research conducted in several other countries, including the United States, has demonstrated a similar link between weekend hospital admissions for stroke and poorer outcomes. But these specific Canadian findings may not be applicable to the U.S. “[O]ur study sample included only patients seen at specialized stroke centers in a country [Canada] with universal access to medical services,” write the researchers, “and the results may not be generalizable to other type of institutions or to countries with different health care systems.”

Indeed, a 2007 study found that uninsured Americans who experience a stroke are up to 56 percent more likely to die as a result of the stroke than their privately insured peers — whether they were admitted to a hospital on the weekend or not.

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