Published online before print August 23, 2007, doi: 10.1161/STROKEAHA.107.491076
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(Stroke. 2007;38:e114.)
© 2007 American Heart Association, Inc.
Letters to the Editor |
Response to Letters by Hamilton and Filardo, and Manfredini et al
Stroke Program, Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada, Stroke Program, Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
Stroke Program, Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
Stroke Program, Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
Response
We would like to thank Drs Hamilton and Filardo, and Dr Manfredini et al very much for their interest and positive comments regarding our article.1 Drs Hamilton and Filardo pointed to 3 questions/comments:
First, we agree that perhaps adding an interaction term reflecting the time of the day (night hours) may also increase the magnitude of the "weekend effect". Unfortunately, we have no time information in our dataset. They were also concerned regarding the classification of the "weekend period". Interestingly, most of the authors (including the articles cited by Drs Hamilton and Filardo) analyzed the weekend effect on other medical conditions using the same criteria/definition (Friday Midnight to Sunday Midnight).2–6
Second, our primary goal was to determine whether weekend admission was associated with poor outcome after stroke. We explored those interactions that may potentially confound the relationship between weekend admission and stroke outcome.
Our secondary goal was to explore potential variations of the weekend effect in different settings. We used a stratified analysis to evaluate the differences in the weekend effect for patients admitted to rural/urban, teaching/nonteaching, and when the most responsible physician was either a GP/specialist (Table 3). Because this was an exploratory analysis, no adjustment was made.
Finally, we agree that an adjusted Kaplan Meier curve would have been more representative for this analysis. However, within the limitations stated in the discussion, our results were consistent and revealed a strong association between weekend admission and stroke outcome after adjusting for other covariates.
Regarding the letter of Dr Manfredini et al, they nicely summarized the current evidence available on the influence of the circadian rhythm, day of the week and interventions on the incidence and mortality after acute coronary syndrome and stroke. They also comment on the potential influence of the weekend effect by stroke type and severity. Our article focuses only on ischemic stroke because this is a medical condition that generally does not require a surgical intervention. That decision was made a priori because outcome in intracerebral hemorrhage or subarachnoid hemorrhage may depend on the expertise of the neurosurgeon.7–9 Unfortunately, as mentioned in the limitations, we do not have information on stroke severity.
As mentioned, there are several examples in the literature reflecting poorer outcomes for patients admitted on weekends.2,4–6 In addition, a few days after the publication of our article on stroke, other investigators reported that admission on weekends was associated with higher mortality and lower use of invasive cardiac procedures for patients with myocardial infarction.10 In an accompanied editorial, it is mentioned the potential explanations for the "weekend effect" includes the shortage of staff and other allied health professionals, lack of attractive incentives, among others. The authors concluded mentioning that "the goal is to improve patient care yet avoid excessive demands on clinicians and unaffordable premiums for payers".11
In summary, we should all accept that the "weekend effect" is a real and common phenomenon in health care, and not an artifact of poor design, lack of adjustment, case-mix variations or other limitations of health services research. Our pending assignment is to elaborate quality improvement strategies to provide more uniform care translating in better outcomes.
Acknowledgments
Disclosures
None.
References
1. Saposnik G, Baibergenova A, Bayer N, Hachinski V. Weekend: a dangerous time for having a stroke? Stroke. 2007; 38: 1211–1215.
2. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med. 2001; 345: 663–668.
3. Hasegawa Y, Yoneda Y, Okuda S, Hamada R, Toyota A, Gotoh J, Watanabe M, Okada Y, Ikeda K, Ibayashi S. The effect of weekends and holidays on stroke outcome in acute stroke units. Cerebrovasc Dis. 2005; 20: 325–331.[CrossRef][Medline] [Order article via Infotrieve]
4. Haapaniemi H, Hillbom M, Juvela S. Weekend and holiday increase in the onset of ischemic stroke in young women. Stroke. 1996; 27: 1023–1027.
5. Barba R, Losa JE, Velasco M, Guijarro C, Garcia de Casasola G, Zapatero A. Mortality among adult patients admitted to the hospital on weekends. Eur J Intern Med. 2006; 17: 322–324.[CrossRef][Medline] [Order article via Infotrieve]
6. 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.[CrossRef][Medline] [Order article via Infotrieve]
7. Berman MF, Solomon RA, Mayer SA, Johnston SC, Yung PP. Impact of hospital-related factors on outcome after treatment of cerebral aneurysms. Stroke. 2003; 34: 2200–2207.
8. Solomon RA, Mayer SA, Tarmey JJ. Relationship between the volume of craniotomies for cerebral aneurysm performed at New York state hospitals and in-hospital mortality. Stroke. 1996; 27: 13–17.
9. Johnston SC. Effect of endovascular services and hospital volume on cerebral aneurysm treatment outcomes. Stroke. 2000; 31: 111–117.
10. 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.
11. Redelmeier DA, Bell CM. Weekend worriers. N Engl J Med. 2007; 356: 1164–1165.
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