Comprehensive stroke centers: eliminating an apparent disparity in stroke care on weekends versus weekdays?

See related article, pages 2403–2409. A growing body of literature has highlighted a significant discrepancy in outcomes for patients admitted on weekends versus weekdays for a number of diseases such as acute myocardial infarction,1 congestive heart failure,2 gastrointestinal hemorrhage,3 pulmonary embolism,4 and intracerebral hemorrhage.5 For acute ischemic stroke, the results have been variable with some studies demonstrating a significant difference in outcomes for patients admitted on weekends compared with weekdays6,7 whereas others,8 including a recent study using the Nationwide Inpatient Sample Database,9 failed to demonstrate a difference. Up to this point, much of this work has focused on early or in-hospital mortality and there is a paucity of data concerning longer-term outcomes examining a potential weekend effect. Additionally, previous work has noted that this weekend effect may have diminished over time10; this observation has been ascribed to a potential improvement in stroke care over time. Finally, there have been some data demonstrating that patients admitted to comprehensive stroke centers on the weekends have similar outcomes compared with weekday admissions.11 In the present study, McKinney and colleagues have provided an additional contribution attempting to examine disparities in stroke care dependent on the time of the week admitted. Furthermore, they sought to examine if this potential difference has been mitigated over time through modifications in the organization and delivery of stroke care. The authors have used a database that has several inherent advantages well suited to the aims of their study. They used the Myocardial Infarction Data Acquisition System (MIDAS) administrative database containing demographic and clinical data on patients discharged with a primary diagnosis of cerebral infarction from all nonfederal acute care hospitals in New Jersey. The authors obtained data on out-of-hospital deaths by matching MIDAS records with New Jersey death registration files using validated software in a blinded automated procedure. For the strategic purposes of this study, the state of New Jersey enacted the “Stroke Center Act” in 2004, which designated hospitals that meet certain standards as Primary Stroke Centers (PSC) or Comprehensive Stroke Centers (CSC). The state issued its first certification for both PSC and CSC in 2007. The MIDAS database included 134 441 patients admitted with a primary diagnosis of cerebral infarction during the study period of 1996 to 2007. Twenty-three point four percent, 51.5%, and 25.1% of patients were admitted to a CSC, PSC, and nonstroke center (NSC), respectively. Mortality 90 days after admission was significantly higher for patients admitted on weekends compared with weekdays (17.2% versus 16.5%, P 0.001; as were in-hospital and 30-day mortality rates) and this was found for all time periods assessed throughout the study. After adjusting for potential confounding variables, 90-day mortality remained significantly higher for patients admitted on weekends than for weekdays (hazard ratio, 1.05; 95% CI, 1.02 to 1.09). McKinney et al also examined use of intravenous thrombolysis as a function of weekend versus weekday admission and as a function of stroke center designation. They found that administration of intravenous thrombolysis was more frequent for patients admitted on weekends compared with weekdays (1.6% versus 1.3%, P 0.0001; higher adjusted OR for intravenous tissue plasminogen activator for patients admitted on weekends, OR, 1.19; 95% CI, 1.07 to 1.31). Moreover, the adjusted odds of intravenous tissue plasminogen activator administration was also higher at CSC (OR, 5.82; 95% CI, 4.88 to 6.94) or PSC (OR, 2.48; 95% CI, 2.07 to 2.96) compared with NSC. Compared with the period between 1998 and 1999, patients treated during the period of initial stroke center designation by The Joint Commission (2002 to 2003) and New Jersey state stroke center designation (2006 to 2007) were 4 and 10 times, respectively, more likely to receive intravenous tissue plasminogen activator. When examining trends for admission to stroke centers versus NSC, weekday versus weekend admissions remained similar in all time periods studied for all hospital types except during the period 2006 to 2007, when patients were more frequently admitted to a CSC on weekends versus weekdays (30.3% versus 26.8%, P 0.0001). There was no increase in adjusted 90-day mortality observed in patients admitted to CSC on weekends (hazard ratio, 1.01; 95% CI, 0.95 to 1.08); however, adjusted mortality was greater with weekend admissions to PSC (hazard ratio, 1.06; 95% CI, 1.02 to 1.10) and NSC (hazard ratio, 1.08; 95% CI, 1.02 to 1.15). This study lends further credence to an apparent discrepancy in stroke care observed on weekends compared with Received June 23, 2011; final revision received June 28, 2011; accepted June 30, 2011. The opinions in this editorial are not necessarily those of the editors or of the American Heart Association. From the Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA. Correspondence to Aaron S. Dumont, MD, 909 Walnut Street, 2nd Floor, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19147. E-mail [email protected] (Stroke. 2011;42:2380-2382.) © 2011 American Heart Association, Inc.