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2007-9-2 9:59:50

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Stroke patients admitted to hospitals on weekends were more likely to die than those admitted during the week, according to a journal report by Canadian researchers who also found that those who survived would have to stay longer in hospital or less likely to be discharged.

The study published in Stroke: Journal of the American Heart Association showed that patients admitted to hospitals for ischemic stroke on weekends had a 14 percent higher risk of dying than patients admitted during the week.

The researchers suggested that one of the reasons for the higher risk of death from stroke on weekends is because the attending physician is not a specialist, indicating that he is less competent to provide care needed in case of emergency like stroke.

Early studies have report the "weekend effect" in patients who sought care for other conditions such as cancer and pulmonary embolism. The current research was meant to examine whether the weekend effect affects death risk of patients with stroke.

"What is really novel in our work beyond the discovery of the 'weekend effect' on ischemic stroke is the subgroup analysis in other settings/characteristics and the identification of variables associated with the 'weekend effect,'" said Gustavo Saposnik, M.D., M.Sc., lead author of the study.

"This is a large, population-based study across Canada including different facilities-rural/urban, teaching/non-teaching facilities, and small/large community."

The researchers suggest that weekend effect is likely greater in other areas or countries where health care is not universal and provided by the government, assuming that the Canadian health system is less likely to provide different services between weekend and the week days.

In their study, the researchers evaluated the impact of weekend admission on in-hospital stroke deaths in different settings based on data from all ischemic stroke hospital admissions in Canada from April 2003 to March 2004.

An ischemic stroke is caused by a blood clot that blocks blood flow in an artery in or leading to the brain. Another type of stroke is caused by the bleeding of the arteries. The former is more common and considered in the study.

The analysis included 26,676 patients admitted to 606 hospitals. Among the patients, 24.8 percent were admitted on Saturdays and Sundays. Patients admitted on the weekend and on week days were at similar age, 75 versus 74, on average.

Considering all possible factors including age, gender and other medical complications, researchers found that those who were admitted on the weekend were 14 percent more likely to die within seven days of admission compared to those admitted on the week days.

The "weekend effect" on deaths from ischemic stroke in the seven-day period was even greater in a rural hospital than an urban hospital.

The weekend effect was also more evident when the physician in charge was a general practitioner rather than a specialist.  But the analysis did not define specialist.

"Although the 'weekend effect' affected patients admitted to both rural and urban hospitals and those treated by general practitioners and specialists, the effect may be larger in patients admitted to rural hospitals and when the most responsible physician is a general practitioner," said Saposnik, an assistant professor of medicine and director of the Stroke Research Unit Division of Neurology at the University of Toronto and a staff neurologist at St. Michael's Hospital in Toronto.

The weekend effect is also influenced by other factors.   The hospital setting, teaching or non-teaching may make a difference in the death risk.  The availability of care in the intensive care unit is another factor that influenced the risk.

"This appears be an 'unmodifiable' risk from the patient's side," Saposnik said. "This seems to be a 'natural' phenomenon in health care, even in Canada with universal, government-funded health insurance with no co-payments. If the 'weekend effect' occurs in a socialized health care system, it is likely that the effect may be larger in other settings."

The researchers attributed the weekend effect to disparities in resources, expertise and health care providers working during the weekend.

But Saposnik emphasized that patients, relatives, health care professionals and policy makers should not hesitate to seek care during the weekend should the emergency occur during the weekend as “time is brain” and “the sooner the patient seeks medical attention, the higher the chance of better outcome, no matter the day, time or living area."

Larry B. Goldstein, M.D., chair of the Stroke Council of the American Heart Association, agreed and he also emphasized the importance of seeking immediate treatment whenever a person experiences stroke symptoms.

"Although the differences in weekend admission found in this study may be real, the potential benefits of obtaining early treatment would well outweigh the risk of waiting," Goldstein said.

"Patients developing symptoms of stroke such as abrupt difficulty speaking or understanding, weakness or numbness affecting an arm or leg, and unexplained difficulty walking or with coordination need to get to a hospital organized to provide stroke care as soon as possible, regardless of the day of the week."


Title: "Weekends: A Dangerous Time for Having a Stroke?"
Authors: Gustavo Saposnik, Akerke Baibergenova, Neville Bayer, and Vladimir Hachinski
Published online before print March 8, 2007 Stroke 2007, doi:10.1161/01.STR.0000259622.78616.ea

Common Questions and Answers about stroke cited from NIH

What is a stroke?
A stroke occurs when blood flow to the brain is interrupted. When a stroke occurs, brain cells in the immediate area begin to die because they no longer receive the oxygen and nutrients they need to function.

What are the types of strokes?
A stroke can occur in two ways. In an ischemic stroke, a blood clot blocks or plugs a blood vessel or artery in the brain. About 80 percent of all strokes are ischemic. In an hemorrhagic stroke, a blood vessel in the brain breaks and bleeds into the brain. About 20 percent of strokes are hemorrhagic.

What are the symptoms of stroke?
What makes stroke symptoms distinct is their sudden onset:

Sudden numbness or weakness of face, arm or leg — especially on one side of the body
Sudden confusion or trouble speaking or understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination.
Sudden severe headache with no known cause
Why can't some victims identify stroke symptoms?
Because stroke injures the brain, one is not able to perceive one's own problems correctly. To a bystander, the stroke patient may seem unaware or confused. A stroke victim's best chance is if someone around her recognizes the stroke and acts quickly.

What should a bystander do?
Bystanders should know the signs and act in time. If you believe someone is having a stroke — if they lose the ability to speak, or move an arm or leg on one side, or experience facial paralysis on one side — call 911 immediately. Stroke is a medical emergency. Immediate treatment may save someone's life and enhance his or her chances for successful rehabilitation and recovery.

Why is there a need to act fast?
Ischemic strokes, the most common strokes, can be treated with a drug called t-PA which dissolves artery-obstructing clots. The window of opportunity to use t-PA to treat stroke patients is three hours, but to be evaluated and receive treatment, patients need to get to the hospital within 60 minutes. A five-year clinical trial conducted by NINDS found that selected stroke patients who received t-PA within three hours of the onset of stroke symptoms were at least 30 percent more likely than placebo patients to recover from their stroke with little or no disability after three months.

What are the risk factors for stroke?
There are things you can do to prevent stroke. High blood pressure increases your risk of stroke four to six times. Heart disease, especially a condition known as atrial fibrillation or AF, can double your risk of stroke. Your risk also increases if you smoke, have diabetes, sickle cell disease, high cholesterol, or a family history of stroke.

What can you do to reduce your risk of stroke?
To reduce your risk of stroke monitor your blood pressure, track your cholesterol level, stop smoking, exercise regularly and find out if you should be taking a drug to reduce blood clotting.

What is the toll on Americans?
Stroke is a leading cause of serious, long-term adult disability. Four million Americans are living with the effects of stroke. The length of time to recover from a stroke depends on its severity. Fifty to 70 percent of stroke survivors regain functional independence, but 15 to 30 percent are permanently disabled.