Skip to main content
AAN.com
Articles
November 1, 2010
Letter to the Editor

Association between weekend hospital presentation and stroke fatality

November 2, 2010 issue
75 (18) 1589-1596

Abstract

Background:

Previous studies have found higher stroke case fatality in patients admitted to the hospital on weekends compared to weekdays, but the reasons for this association are not known.

Methods:

This was a cohort study using data from the Registry of the Canadian Stroke Network. We included consecutive patients with acute stroke or TIA seen in the emergency department or admitted to the hospital at 11 stroke centers in Ontario, Canada, between July 1, 2003, and March 30, 2008 (n = 20,657). We compared in-hospital stroke care and 7-day all-cause stroke case fatality rates between patients seen on weekends and weekdays, with adjustment for stroke severity and other baseline factors.

Results:

Overall rates of hospital presentation were lower on weekends compared to weekdays, with lower rates of weekend presentation among individuals with minor stroke and TIA compared to those with more severe strokes. Stroke care, including admission to a stroke unit, neuroimaging, and dysphagia screening, was similar in those treated on weekends and weekdays. All-cause 7-day fatality rates were higher in patients seen on weekends compared to weekdays (8.1% vs 7.0%), even after adjustment for age, sex, stroke severity, and comorbid conditions (adjusted hazard ratio 1.12, 95% confidence interval 1.00 to 1.25).

Conclusions:

Stroke fatality is higher with weekend compared to weekday admission, even after adjustment for case mix.

Get full access to this article

View all available purchase options and get full access to this article.

COINVESTIGATORS

The Investigators of the Registry of the Canadian Stroke Network (Phase 3) are as follows: Frank Silver, MD, FRCPC (Coordinating Centre at the Institute for Clinical Evaluative Sciences [ICES], Toronto); Moira Kapral, MD, MSc, FRCPC (ICES); Jack Tu, MD, MSc, PhD, FRCPC (ICES); Ruth Hall, BASc, MSc, PhD (ICES); Janice Richards, RN (ICES); Annette Robertson, RN, RDCS (ICES); Neville Bayer, MD (St. Michael's Hospital, Site Principal Investigator); Sandra Black, MD (Sunnybrook & Women's College Health Sciences Centre, Site Principal Investigator); Donald Brunet, MD (Kingston General Hospital, Site Principal Investigator); Vladimir Hachinski, MD (London Health Sciences Centre, Site Principal Investigator); David Howse, MD (Thunder Bay Regional Health Sciences Centre, Site Principal Investigator); John Maher, MD (Royal Victoria Hospital, Site Principal Investigator); Wieslaw Oczkowski, MD (Hamilton Health Science Centre, Site Principal Investigator); Stephen Phillips, MD (Queen Elizabeth II Health Sciences Centre, Site Principal Investigator); Dan Selchen, MD (Trillium Health Centre, Site Principal Investigator); Mukul Sharma, BSc, MD, FRCPC, MSc (The Ottawa Hospital, Site Principal Investigator); Peter Zalan, MD (Hôpital Régional de Sudbury Regional Hospital, Site Principal Investigator).

REFERENCES

1.
Saposnik G, Baibergenova A, Bayer N, Hachinski V. Weekends: a dangerous time for having a stroke? Stroke 2007;38:1211–1215.
2.
Reeves MJ, Smith E, Fanarow G, Hernandez A, Pan W, Schwamm LH. Off-hour admission and in-hospital stroke case fatality in the Get With The Guidelines: Stroke Program. Stroke 2009;40:569–576.
3.
Hasegawa Y, Yoneda Y, Hamada R, et al. The effect of weekends and holidays on stroke outcome in acute stroke units. Cerebrovasc Dis 2005;20:325–331.
4.
Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared to weekdays. N Engl J Med 2001;345:663–668.
5.
Redelmeier DA, Bell CM. Weekend worriers. N Engl J Med 2007;356:1164–1165.
6.
Shulkin DJ. Like night and day: shedding light on off-hours care. N Engl J Med 2008;358:2091–2093.
7.
Kapral M, Silver F, Richards J, Lindsay M, Fang J, Shi S. Registry of the Canadian Stroke Network: Progress Report 2001–2005. Toronto: Institute for Clinical Evaluative Sciences; 2005.
8.
Cote R, Battista RN, Wolfson C, Boucher J, Adam J, Hachinski V. The Canadian Neurological Scale: validation and reliability assessment. Neurology 1989;39:638–643.
9.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.
10.
Jauss M, Oertel W, Allendoerfer J, Misselwitz B, Hamer H. Bias in request for medical care and impact on outcome during office and non-office hours in stroke patients. Eur J Neurol 2009;16:1165–1167.
11.
Janszky I, Ahnve S, Ljung R. Weekend versus weekday admission and stroke outcome in Sweden from 1968 to 2005. Stroke 2007;38:e94.
12.
Cram P, Hillis SL, Barnett M, Rosenthal GE. Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med 2004;117:151–157.
13.
Albright KC, Raman R, Ernstrom K, et al. Can comprehensive stroke centers erase the ‘weekend effect’? Cerebrovasc Dis 2009;27:107–113.
14.
Kazley AS, Gartner Hillman D, Johnston KC, Simpson KN. Hospital care for patients experiencing weekend vs weekday stroke. Arch Neurol 2010;67:39–44.
15.
Weimar C, Kong IR, Kraywinkel K, Ziegler A, Diener HC. Age and National Institutes of Health Stroke Scale score within 6 hours after onset are accurate predictors of outcome after cerebral ischemia: development and external validation of prognostic models. Stroke 2004;35:158–162.
16.
Kelly-Hayes M, Wolf PA, Kase CS, Brand FN, McGuirk JM, D'Agostino RB. Temporal patterns of stroke onset. Stroke 1995;26:1343–1347.
17.
Jakovljevic D. FINSTROKE Register Group: day of the week and ischemic stroke: is it Monday high or Sunday low? Stroke 2004;35:2089–2093.
18.
Haapaniemi H, Hillbom M, Juvela S. Weekend and holiday increase in the onset of ischemic stroke in young women. Stroke 1996;27:1023–1027.
19.
Brackenridge CJ. Daily variation and other factors affecting the occurrence of cerebrovascular accidents. J Gerontol 1981;36:176–179.
20.
Maestroni A, Mandelli C, Manganaro D, et al. Factors influencing delay in presentation for acute stroke in an emergency department in Milan, Italy. Emerg Med J 2008;25:340–345.
21.
Giles MF, Flossman E, Rothwell PM. Patient behavior immediately after transient ischemic attack according to clinical characteristics, perception of the event, and predicted risk of stroke. Stroke 2006;37:1254–1260.
22.
Chang K-C, Tseng M-C, Tan T-Y. Prehospital delay after acute stroke in Kaohsiung, Taiwan. Stroke 2004;35:700–704.
23.
Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke. Stroke 2006;37:1248–1253.
24.
Fogelholm R, Murros K, Rissanen A, Ilmavira M. Factors delaying hospital admission after acute stroke. Stroke 1996;27:398–400.
25.
Lasserson DS, Chandratheva A, Giles MF, Mant D, Rothwell PM. Influence of general practice opening hours on delay in seeking medical attention after transient ischaemic attack (TIA) and minor stroke: prospective population based study. BMJ 2008;337:a1569.
26.
Gladstone DJ, Kapral MK, Fang J, Laupacis AL, Tu JV. Management and outcomes of transient ischemic attacks in Ontario. Can Med Assoc J 2004;170:1099–1104.
27.
Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901–2906.
28.
Lindsay P, Bayley M, McDonald A, Graham ID, Warner G, Phillips S. Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care. Can Med Assoc J 2008;178:1418–1425.
29.
Adams HP, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38:1655–1711.
30.
National Stroke Foundation. Clinical guidelines for acute stroke management: Melbourne (AU): The Foundation; 2007. Available at: www.strokefoundation.com.au/acute-clinical-guidelines-for-Acute-stroke-management. Accessed April 26, 2009.
31.
European Stroke Organization (ESO) Executive Committee, ESO Writing Committee. Guidelines for the management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:457–507.
32.
National Collaborating Centre for Chronic Conditions. Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA): London (UK): National Institute for Health and Clinical Excellence; 2008. Available at: www.nice.org.uk/nicemedia/pdf/CG68NICEGuideline.pdf. Accessed April 26, 2009.
33.
Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007;6:953–960.
34.
Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007;370:1432–1442.
35.
Hodgson C, Lindsay P, Rubini F. Can mass media influence emergency department visits for stroke? Stroke 2007;38:2115–2122.
36.
Harraf F, Sharma AK, Brown MM, Lees KR, Vass RI, Kalra L. A multicentre observational study of presentation and early assessment of acute stroke. BMJ 2002;325:17–21.
37.
Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE. Weekend versus weekday admission and mortality from myocardial infarction. N Engl J Med 2007;356:1099–1109.
38.
Magid DJ, Wang YF, Herrin J, et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction. JAMA 2005;294:803–812.
39.
Rudd AG, Hoffman A, Down C, Pearson M, Lowe D. Access to stroke care in England, Wales and Northern Ireland: the effect of age, gender and weekend admission. Age Ageing 2007;36:247–255.
40.
Jauss M, Schutz HJ, Tanislav C, Misselwitz B, Rosenow F. Effect of daytime, weekday and year of admission on outcome in acute ischemic stroke patients treated with thrombolytic therapy. Eur J Neurol 2010;17:555–561.
Letters to the Editor
9 March 2011
Association between weekend hospital presentation and stroke fatality
Christina Campbell, Acute Care Nurse Practioner
Heidi Woessner, William D Freeman

Fang et al. described a 12% increase in patient mortality for patients admitted on the weekend versus the weekday for stroke. [1] These findings prompt the question: Why do stroke patients experience different outcomes on weekends versus weekdays?

The authors did not report the cause of death or whether do not resuscitate orders existed on such patients. We reviewed whether a similar increased mortality difference existed for stroke patients admitted on the weekend compared to the weekday at our own institution.

We reviewed all stroke admissions between September 2009 and September 2010. Of 388 stroke patients admitted during that time, thirty-three (8%) died during hospitalization. Of those that died, twenty-four (73%) were admitted during the weekdays defined as Monday through Friday. Nine (24.7%) were admitted on a Saturday or Sunday. When accounting for the distribution of time for weekdays -- 5 out of 7 days out of the week (71% of the week) and weekends being 2/7 or 28% of the week-- our one-year data suggest similar distribution among weekdays and weekend mortality after stroke similar to Kazley et al. [2]

Our study was not as large as Fang et al's, but these data are important for stroke centers providing the same level of care on a continuous basis (e.g., "24/7/365"). The reasons for these differences are unclear. The authors theorize that the sicker stroke patients might present for admission on weekends rather than waiting until Monday. Another theory provided by Bell and Redelmeier [3] suggests that hospitals function less effectively on weekends. In addition, many hospitals do not have the same resources on nights and weekends, which has also been suggested for differences in outcomes in cardiac arrest. [4]

Futures studies should investigate factors causing death in stroke patients on nights and weekends compared to the teams that care for them during weekdays.

References

1.Fang J, Saposnik G, Silver, FL Kapra MK. Association between weekend hospital presentation and stroke fatality. Neurology 2010;75:1589-1596.

2.Kazley A, et al Hospital care for patients experiencing weekend versus weekday stroke: a comparison of quality and aggressiveness of care Arch Neurol 2010; 67: 39-44.

3.Bell C, Redelmeier DA. Mortality Among Patients Admitted to Hospitals to Hospitals on Weekends as Compared with Weekdays. N Engl J Med. 2001;345:663-668

4.Peberdy MA, Ornato JP, Larkin GL et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299:785-792.

Disclosure: The authors report no disclosures.

9 March 2011
Reply from the authors
Moira Kapral, Toronto General Hospital
Jiming Fang, Gustavo Saposnik

We appreciate the comments by Campbell et al. and read the results of their study with interest. We agree that future work should focus on identifying the reasons behind the higher mortality rates seen with weekend admissions. In addition, it should be determined whether institutional initiatives to increase staffing and resources on weekends would lead to improved outcomes.

For disclosures, please see original article.

Information & Authors

Information

Published In

Neurology®
Volume 75Number 18November 2, 2010
Pages: 1589-1596
PubMed: 21041782

Publication History

Received: March 11, 2010
Accepted: July 13, 2010
Published online: November 1, 2010
Published in print: November 2, 2010

Permissions

Request permissions for this article.

Disclosure

Dr. Fang reports no disclosures. Dr. Saposnik served on the editorial board of Stroke; has served on a scientific advisory board for Sanofi-Aventis; and receives research support from the Heart and Stroke Foundation of Ontario. Dr. Silver has served on scientific advisory boards for Boehringer Ingelheim and Victhom Human Bionics Inc.; has received funding for travel from Boehringer Ingelheim; and has served on speakers' bureaus for and received speaker honoraria from Boehringer Ingelheim, Merck & Co., Inc., and Servier. Dr. Kapral serves on the editorial board of Stroke and receives research support from the Canadian Institutes for Health Research and the University Health Network Women's Health Program.

Authors

Affiliations & Disclosures

Jiming Fang, PhD
From the Departments of Medicine (G.S., F.L.S., M.K.K.) and Health Policy, Management and Evaluation (G.S., M.K.K.), University of Toronto, Toronto; Institute for Clinical Evaluative Sciences (J.F., G.S., M.K.K.), Toronto; Divisions of General Internal Medicine and Clinical Epidemiology and Women's Health Program (M.K.K.) and Neurology (F.L.S.), University Health Network, Toronto; Stroke Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, Toronto; and Canadian Stroke Network (F.L.S., M.K.K.), Toronto, Canada.
Gustavo Saposnik, MD
From the Departments of Medicine (G.S., F.L.S., M.K.K.) and Health Policy, Management and Evaluation (G.S., M.K.K.), University of Toronto, Toronto; Institute for Clinical Evaluative Sciences (J.F., G.S., M.K.K.), Toronto; Divisions of General Internal Medicine and Clinical Epidemiology and Women's Health Program (M.K.K.) and Neurology (F.L.S.), University Health Network, Toronto; Stroke Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, Toronto; and Canadian Stroke Network (F.L.S., M.K.K.), Toronto, Canada.
Frank L. Silver, MD
From the Departments of Medicine (G.S., F.L.S., M.K.K.) and Health Policy, Management and Evaluation (G.S., M.K.K.), University of Toronto, Toronto; Institute for Clinical Evaluative Sciences (J.F., G.S., M.K.K.), Toronto; Divisions of General Internal Medicine and Clinical Epidemiology and Women's Health Program (M.K.K.) and Neurology (F.L.S.), University Health Network, Toronto; Stroke Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, Toronto; and Canadian Stroke Network (F.L.S., M.K.K.), Toronto, Canada.
Moira K. Kapral, MD
From the Departments of Medicine (G.S., F.L.S., M.K.K.) and Health Policy, Management and Evaluation (G.S., M.K.K.), University of Toronto, Toronto; Institute for Clinical Evaluative Sciences (J.F., G.S., M.K.K.), Toronto; Divisions of General Internal Medicine and Clinical Epidemiology and Women's Health Program (M.K.K.) and Neurology (F.L.S.), University Health Network, Toronto; Stroke Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, Toronto; and Canadian Stroke Network (F.L.S., M.K.K.), Toronto, Canada.
For the Investigators of the Registry of the Canadian Stroke Network
From the Departments of Medicine (G.S., F.L.S., M.K.K.) and Health Policy, Management and Evaluation (G.S., M.K.K.), University of Toronto, Toronto; Institute for Clinical Evaluative Sciences (J.F., G.S., M.K.K.), Toronto; Divisions of General Internal Medicine and Clinical Epidemiology and Women's Health Program (M.K.K.) and Neurology (F.L.S.), University Health Network, Toronto; Stroke Research Unit (G.S.), Division of Neurology, Department of Medicine, St. Michael's Hospital, Toronto; and Canadian Stroke Network (F.L.S., M.K.K.), Toronto, Canada.

Notes

Address correspondence and reprint requests to Dr. Moira K. Kapral, Toronto General Hospital, 200 Elizabeth St., 14 Eaton North, Room 215, Toronto, Ontario, Canada M5G 2C4 [email protected]
Study funding: Supported by the Canadian Stroke Network. The Registry of the Canadian Stroke Network is funded by the Canadian Stroke Network and by the Ontario Ministry of Health and Long-Term Care. The Institute for Clinical Evaluative Sciences is supported by an operating grant from the Ontario Ministry of Health and Long-Term Care. The funding agencies had no role in the design or conduct of the study or the collection, management, analysis, or interpretation of the data. The manuscript was reviewed and approved by the publications committee of the Registry of the Canadian Stroke Network.

Author Contributions

J.F., F.L.S., and M.K.K. conceived and designed the project. Statistical analysis was conducted by J.F. All authors participated in the interpretation of data and critical revision of the manuscript. All authors have read and approved submission of the manuscript. The corresponding author had full access to all of the data in the study and had final responsibility for the decision to submit for publication.

Metrics & Citations

Metrics

Citations

Download Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.

Cited By
  1. Weekend effect on 30-day mortality for ischemic and hemorrhagic stroke analyzed using severity index and staffing level, PLOS ONE, 18, 6, (e0283491), (2023).https://doi.org/10.1371/journal.pone.0283491
    Crossref
  2. Association Between Stroke Presentation During Off‐Hours and Mechanical Thrombectomy, Stroke: Vascular and Interventional Neurology, 3, 1, (2023).https://doi.org/10.1161/SVIN.122.000415
    Crossref
  3. The weekend effect on mechanical thrombectomy: A nationwide analysis before and after the pivotal 2015 trials, Brain Circulation, 8, 3, (137), (2022).https://doi.org/10.4103/bc.bc_23_22
    Crossref
  4. Off-Hour Admission Is Associated with Poor Outcome in Patients with Intracerebral Hemorrhage, Journal of Clinical Medicine, 12, 1, (66), (2022).https://doi.org/10.3390/jcm12010066
    Crossref
  5. The Management and Outcome of Stroke Patients Admitted on Weekdays Compared to Weekends at the King Abdulaziz Medical City, Riyadh, Saudi Arabia, The Neurohospitalist, (194187442211085), (2022).https://doi.org/10.1177/19418744221108559
    Crossref
  6. Is there a ‘weekend effect’ on mortality among hospitalised patients in an internal medicine ward? A retrospective study, Internal Medicine Journal, 53, 7, (1240-1247), (2022).https://doi.org/10.1111/imj.15723
    Crossref
  7. Mortality of major cardiovascular emergencies among patients admitted to hospitals on weekends as compared with weekdays in Taiwan, BMC Health Services Research, 21, 1, (2021).https://doi.org/10.1186/s12913-021-06553-7
    Crossref
  8. Factors Associated With Prolonged Length of Stay in Patients Hospitalized With Generalized Convulsive Status Epilepticus in the United States, The Neurohospitalist, 11, 4, (310-316), (2021).https://doi.org/10.1177/19418744211000534
    Crossref
  9. Hospitalized with stroke at the weekend: Higher cost and risk of early death?, International Journal of Stroke, 17, 1, (67-76), (2021).https://doi.org/10.1177/1747493021992597
    Crossref
  10. Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke on Nights and Weekends Versus Weekdays at Comprehensive Stroke Centers, Journal of Stroke and Cerebrovascular Diseases, 30, 4, (105632), (2021).https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105632
    Crossref
  11. See more
Loading...

View Options

Get Access

Login options

Check if you have access through your login credentials or your institution to get full access on this article.

Personal login Institutional Login
Purchase Options

The neurology.org payment platform is currently offline. Our technical team is working as quickly as possible to restore service.

If you need immediate support or to place an order, please call or email customer service:

  • 1-800-638-3030 for U.S. customers - 8:30 - 7 pm ET (M-F)
  • 1-301-223-2300 for customers outside the U.S. - 8:30 - 7 pm ET (M-F)
  • [email protected]

We appreciate your patience during this time and apologize for any inconvenience.

View options

Full Text

View Full Text

Full Text HTML

View Full Text HTML

Media

Figures

Other

Tables

Share

Share

Share article link

Share