Weekend Stroke Patients More Likely to Receive tPA
By Susan Jeffrey
Medscape Medical News
January 14, 2010 — Patients who have acute ischemic stroke on the weekend are more likely to receive aggressive treatment, including thrombolysis, than those patients who have an event during the week, a new study shows.
Mortality rates, however, were similar whether strokes were treated during the week or on the weekend, the researchers, led by Abby S. Kazley, MD, from the Department of Health Professions at the Medical University of South Carolina, Charleston, report.
Their findings are counter to some previous studies that have suggested that stroke and cardiac care might be less aggressive during evenings and weekends.
"Perhaps the most important thing is that stroke can happen at any time, so regardless of the day or time patients seek care, hospitals have to have a protocol in place to ensure they can have quick access to expertise so they can be triaged," Dr. Kazley told Medscape Neurology.
"There is such a brief window of time that they can be treated with tPA [tissue plasminogen activator] that they need to get into the CT [computed tomographic] scanner almost immediately when they arrive at the hospital," she added, "so making sure that patients have ease of access to necessary equipment and expertise will help ensure they're treated appropriately."
The study is published in the January issue of Archives of Neurology.
Weekend Care Inferior?
Previous studies have suggested variability and disparities in hospital care in relation to a number of factors, among them time of hospital admission, the study authors write. Although hospitals operate around the clock every day of the year, "there are inevitable staffing differences during shifts, and there may be differences in the availability of diagnostic modalities or treatment options for care," they write. Staffing levels may be lower at weekends, for example, and these shifts may fall to less experienced staff.
Higher mortality rates and less aggressive care on weekends have been reported in the cardiac literature among patients with myocardial infarction (Kostis WJ, et al. N Engl J Med. 2007;356:1099-1109). Studies presented at the International Stroke Conference in 2008, and reported by Medscape Neurology at that time, also showed a similar effect in stroke patients, with increased mortality seen for off-hour admissions compared with on-hour admissions.
In this study, Dr. Kazley and colleagues looked both at mortality and whether care was aggressive — that is, appropriate and cutting edge, representing the desired standard of care — for patients admitted with an acute ischemic stroke in Virginia between 1998 and 2006. They analyzed data on 78,657 patients with ischemic stroke.
"What we found was that those who were admitted on weekends were more likely to get aggressive care defined as receipt of tPA, and there was no statistically significant difference in mortality based on whether patients were admitted on the weekends vs the weekdays," Dr. Kazley said. "We were a bit surprised by the findings that tPA was more likely to be given at the weekend," she added.
In all, tPA was used in 229 stroke patients admitted on the weekend and 543 admitted on weekdays, 1% of the total group. According to their model, stroke patients admitted on the weekend were 20% more likely to be treated with tPA than on weekdays (P < .05).
Mortality was similar based on day of hospital admission; significant predictors of mortality included patient age, hospital size and stroke case volume, patient proximity to a stroke center, treatment with tPA, and treatment for atrial fibrillation.
They looked further into their data and came up with some hypotheses that may explain their findings, Dr. Kazley said.
"First of all, we thought perhaps it's that patients are presenting to the hospital earlier on the weekends because they weren't having to deal with job obligations and traffic — so it could be something as simple as that," she speculated.
In addition, there are few scheduled elective procedures on weekends, so when patients arrive, they may have more expeditious access to CT scanners and to clinicians and neurology experts who are free of scheduled patient appointments during that time, she added.
Finally, many hospitals that treat with tPA maintain stroke center certification, which requires strict standards, with protocols that ensure 24-hour access to neurology expertise and CT scanners. "It may be that the required resources that need to be in place in order to maintain that certification make it more likely that the care is standardized regardless of when the patients seek care," Dr. Kazley concluded.
Reassuring Results
Asked for comment on these findings, Philip B. Gorelick, MD, MPH, John S. Garvin professor and head of the Department of Neurology and Rehabilitation at the University of Illinois College of Medicine at Chicago, pointed out that treatment of acute coronary heart disease has been shown to be less aggressive on weekends and associated with worse outcome in some cases.
The current findings that patients with acute ischemic stroke are more likely to receive tPA on weekends and that mortality rate is not higher during this period, if confirmed by additional studies, he said, "will help to reassure patients that rtPA [recombinant tPA] administration is not only possible all days of the week but is not more dangerous on weekends as some forms of cardiovascular care may be."
The precise explanation for the differences between weekend and weekday care in the setting of stroke is uncertain, Dr. Gorelick added.
"I suspect that a well-organized and dedicated stroke care delivery system may function more optimally on weekends when emergency departments may be less crowded and delivery of patients to the hospital may be facilitated by a less busy traffic pattern. Furthermore, there may be more home supervision during weekends to facilitate transfer to hospital."
The authors have disclosed no relevant financial relationships.
