“At the moment we have an NHS where if you have a stroke at the weekends, you're 20% more likely to die.”
Jeremy Hunt, 12 January 2016
Responding to the junior doctors’ strike on Tuesday, Jeremy Hunt pointed to what he said was an increased risk of death for those who have a stroke at weekends. Two of our readers asked us to investigate.
Studies have found that stroke patients admitted to hospitals at weekends are at a greater risk of death.
People hospitalised on a Sunday after a stroke had an 11% risk of death within a week, compared to 9% for weekday patients. That’s according to one study which looked at admissions to English hospitals in 2009/10. It works out to a little above the 20% rise in risk the Health Secretary is talking about.
What isn’t clear is why the risk was higher. As with other conditions it might partly be because of differences in the types of patients who go to hospital at the weekends, rather than differences in the standard of healthcare at the weekends.
And experts and practitioners have questioned how much data from that far back tells us about the current standard of care in the NHS, saying that stroke care has improved greatly in the past few years.
The study found higher mortality at weekends, but we don’t know why
In the 2009/10 financial year, 94,000 patients were admitted to English hospitals following a stroke, academics found. Those who were hospitalised on a Sunday had an 11% chance of death within seven days, significantly higher than the 8.9% chance of death for patients admitted on the average weekday.
Those risk levels take into account information the researchers had on the patients and their circumstances, including their age, sex, level of deprivation, previous hospital admissions, and the type of stroke they’d had.
There were also significant differences in the way patients were treated. Weekend patients were less likely to receive a brain scan on the same day they came to hospital, for instance. They were also less likely to receivethrombolysis, a way of treating blood clots.
The researchers said these differences suggested that “care for patients admitted on weekends was inferior.”
But it’s not clear how much of the extra risk for weekend patients, if any, was caused by differences in care.
The researchers said that in particular, if patients who suffer less severe strokes tend not to come into hospital at the weekend, this might affect the result.
That’s because it would make for a more challenging ‘case mix’ at the weekend—in other words it would make the risk of death look higher at the weekend because the average patient would have been more seriously ill when they arrived:
“One explanation could be unmeasured differences in the case mix and severity of strokes… the underlying data have only limited information on the severity of stroke (such as patients’ level of consciousness), which has been suggested to be conceivably worse on weekends and, therefore, to affect treatment decisions and outcomes.”
A different case mix could also explain some of those differences in the treatments that patients received.
These findings were echoed in more recent research which looked at patients in Wales. It also found a 20% higher risk of death, and also said there wasn’t enough information to say exactly why. Again, the severity of cases coming in at the weekend is something the research wasn’t able to account for, as critics of the government have pointed out.
The figures don’t take account of recent changes to stroke care, according to some doctors
A group of doctors and other experts have written a letter to the Sunday Timesto challenge Jeremy Hunt’s use of this research, saying that the figures used are out of date.
They focus on the Welsh data, which looked at care from 2004-12.
“When Jeremy Hunt criticises the junior doctors’ strike by stating that “you are 20% more likely to die from a stroke at the weekend” he uses data from 2004-12 that is out of date as it precedes rapid improvements in stroke care. These include new acute stroke units that reduce mortality and disability by 25%. Only 5.1% of patients he refers to were cared for on these acute stroke units, compared with 82% in the 2015 national data.
“Recent audits of stroke outcomes in London show that there is no longer any excess of hospital deaths in patients with stroke admitted at the weekend.”
Last updated 18 January 2015
We updated this article to include the doctors’ letter to the Sunday Times, as well as more detail on the Welsh research and criticisms of it.