Re-evaluating the Weekend Effect on SAH: A Nationwide Analysis of the Association Between Mortality and Weekend Admission

Weekend Admission and Mortality in Patients With Traumatic Brain Injury: A Meta-analysis

Objective

Previous studies have reported the presence of a "weekend effect" with respect to mortality in serious emergency admissions, including cases of traumatic brain injury (TBI). However, the relationship between weekend hospitalization and TBI mortality has not been fully established. This study aimed to conduct a systematic review of available evidence and investigate differences in mortality among TBI patients between weekday and weekend admissions.

Methods

Electronic databases including PubMed, Cochrane Library, and Embase were used to obtain relevant articles. Mortality, as the primary outcome of interest, encompassed in-hospital or 30-day mortality. Mortality rates were compared between the 2 groups, weekend and weekday admissions. Additionally, meta-regression analysis was performed on potential confounders to verify and provide comparative results.

Results

A total of 7 studies involving 522,942 TBI patients were eligible for inclusion in the synthesis of the systematic review. Of these patients, 71.6% were admitted during weekdays, whereas 28.4% were hospitalized on weekends. The overall integrated mortality was 11.0% (57,286/522,942), with a mortality rate of 10.8% in the weekday group and 11.3% in the weekend group. Pooled analysis revealed no significant difference in mortality between the weekday and weekend groups (risk ratio, 0.99; 95% confidence interval, 0.90-1.09; p=0.78). Furthermore, the meta-regression analysis for sensitivity assessment showed no modifying effect on mortality (p=0.79).

Conclusion

This study found no difference in mortality rates between weekday and weekend admissions among TBI patients. Additional sensitivity analyses also demonstrated no significant increase in the risk of mortality in the weekend group.

The weekend effect in aneurysmal subarachnoid haemorrhage: a single centre experience and review

Clinical outcomes for patients admitted to hospital during weekend hours have been reported to be poorer than for those admitted during the week. Aneurysmal subarachnoid haemorrhage (aSAH) is a devastating form of haemorrhagic stroke, with a mortality rate greater than 30%. A number of studies have reported higher mortality for patients with aSAH who are admitted during weekend hours. This study evaluates the effect of weekend admission on patients in our unit with aSAH in terms of time to treatment, treatment type, rebleeding rates, functional outcome, and mortality. We analysed a retrospective database of all patients admitted to our tertiary referral centre with aneurysmal subarachnoid haemorrhage between February 2016 and February 2020. Chi-square tests and t-tests were used to compare weekday and weekend demographic and clinical variables. Univariate and multivariate logistic regression analyses were performed to assess for any association between admission during weekend hours and increased neurological morbidity (assessed via Glasgow Outcome Scale at 3 months) and mortality. Of the 571 patients included in this study, 191 were admitted during on-call weekend hours. There were no significant differences found in time to treatment, type of treatment, rebleeding rates, neurological morbidity, or mortality rates between patients admitted during the week and those admitted during weekend hours. Weekend admission was not associated with worsened functional outcome or increased mortality in this cohort. These results suggest that provision of 7-day cover by vascular neurosurgeons and interventional neuroradiologists in high-volume centres could mitigate the weekend effect sometimes reported in the aSAH cohort.

Impact of Off-Hour Admission with Subarachnoid Hemorrhage: A Meta-Analysis

OBJECTIVE

This meta-analysis assessed the impact of off-hour hospitalization (weekends, and evenings or nighttime on weekdays) on mortality and morbidity in patients with nontraumatic subarachnoid hemorrhage (SAH).

METHODS

Electronic databases were systematically searched for studies comparing outcomes between patients with nontraumatic SAH hospitalized during off-hour and on-hour periods (daytime on weekdays). The primary outcome was mortality (in-hospital and at different follow-up periods after hospitalization). Secondary outcomes included delays in treatment, and complications. Sensitivity analysis including only studies in which adjusted multivariate analyses were performed for any of the outcomes, and meta-regression controlling for clinically important patient factors, were also performed.

RESULTS

Sixteen studies were included. There was no significant difference in in-hospital mortality (adjusted odds ratio, 1.03; 95% confidence interval [CI], 0.97-1.09; P = 0.30) and at all follow-up periods (7/14 days and 1/3/6 months) after hospitalization between SAH patients who were admitted during off-hour compared with on-hour periods, despite adjusted multivariate meta-analysis being performed. However, patients who were admitted during off-hour periods experienced greater delays from their initial scan to treatment (mean difference, 42.7, 25.2-60.1 hours; P < 0.0001) and had higher rates of pneumonia (odds ratio, 1.65, 1.12-2.44; P = 0.011).

CONCLUSIONS

This meta-analysis has not shown an increased risk of mortality in the short-term and long-term among patients with nontraumatic SAH who were hospitalized during off-hour compared with on-hour periods, despite adjusting for potentially confounding patient factors. The delays to treatment and higher observed rates of pneumonia highlight areas in which hospital services and resources should be targeted during these off-hour periods in patients presenting with nontraumatic SAH.

Microsurgical treatment of ruptured aneurysms beyond 72 hours after rupture: implications for advanced management

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to primary stroke centers are often transferred to neurosurgical and endovascular services at tertiary centers. The effect on microsurgical outcomes of the resultant delay in treatment is unknown. We evaluated microsurgical aSAH treatment > 72 h after the ictus.

METHODS

All aSAH patients treated at a single tertiary center between August 1, 2007, and July 31, 2019, were retrospectively reviewed. The additional inclusion criterion was the availability of treatment data relative to time of bleed. Patients were grouped based on bleed-to-treatment time as having acute treatment (on or before postbleed day [PBD] 3) or delayed treatment (on or after PBD 4). Propensity adjustments were used to correct for statistically significant confounding covariables.

RESULTS

Among 956 aSAH patients, 92 (10%) received delayed surgical treatment (delayed group), and 864 (90%) received acute endovascular or surgical treatment (acute group). Reruptures occurred in 3% (26/864) of the acute group and 1% (1/92) of the delayed group (p = 0.51). After propensity adjustments, the odds of residual aneurysm (OR = 0.09; 95% CI = 0.04-0.17; p < 0.001) or retreatment (OR = 0.14; 95% CI = 0.06-0.29; p < 0.001) was significantly lower among the delayed group. The OR was 0.50 for rerupture, after propensity adjustments, in the delayed setting (p = 0.03). Mean Glasgow Coma Scale scores at admission in the acute and delayed groups were 11.5 and 13.2, respectively (p < 0.001).

CONCLUSIONS

Delayed microsurgical management of aSAH, if required for definitive treatment, appeared to be noninferior with respect to retreatment, residual, and rerupture events in our cohort after adjusting for initial disease severity and significant confounding variables.

Early prophylactic anticoagulation after subarachnoid hemorrhage decreases systemic ischemia and improves outcome

BACKGROUND

In neurosurgical perioperative treatment, especially in connection with subarachnoid hemorrhage (SAH), the prophylactic anticoagulation (AC) regimen is still considered controversial. The goal of this retrospective study was to assess how the time point of low-molecular-weight heparin (LMWH) initiation (ToH) affects ischemic and hemorrhagic events after SAH.

METHODS

370 patients who received acute treatment for non-traumatic SAH between 2011 and 2018 were included, and 208 patients were followed up after 12 months. We assessed how the ToH affects ischemic and hemorrhagic events as well as outcome scores. Statistical analysis was performed using the Mann-Whitney U-Test, the chi-squared test, Fisher's exact test, and univariate binomial logistic regression. P-values below 0.05 were considered statistically significant.

RESULTS

The incidence of systemic ischemia was 4.6%, cerebral ischemia 33.5%, and intracranial rebleeding 14.6%. Delaying ToH (measured in hours) increases systemic ischemia (p = 0.009). The odds ratio for the impact of delayed anticoagulation on systemic ischemia is 1.013 per hour (95%CI of OR 1.001-1.024). ToH has no influence on cerebral ischemia or intracranial rebleeding. Early anticoagulation was associated with a more favorable Glasgow Outcome Score 12 months after discharge (ToH within 48 h: p = 0.006). ToH did not affect mortality or readmission rates.

CONCLUSIONS

Initiating prophylactic AC with LMWH later than 48 h after aneurysm repair or admission impairs outcomes 12 months after discharge. It might be safe for patients with non-traumatic SAH to be anticoagulated with prophylactic doses of heparin within 24 h after admission or the treatment of source of bleeding (SoB). Early AC with prophylactic LMWH does not promote rebleeding.

Impact of the weekend effect on outcome after microsurgical clipping of ruptured intracranial aneurysms

BACKGROUND

The "weekend effect" describes the assumption that weekend and/or on-call duty admission of emergency patients is associated with increased morbidity and mortality rates. For aneurysmal subarachnoid hemorrhage, we investigated, whether presentation out of regular working hours and microsurgical clipping at nighttime correlates with worse patient outcome.

METHODS

This is a retrospective review of consecutive patients that underwent microsurgical clipping of an acutely ruptured aneurysm at our institution between 2010 and 2019. Patients admitted during (1) regular working hours (Monday-Friday, 08:00-17:59) and (2) on-call duty and microsurgical clipping performed during (a) daytime (Monday-Sunday, 08:00-17:59) and (b) nighttime were compared regarding the following outcome parameters: operation time, treatment-related complications, vasospasm, functional outcome, and angiographic results.

RESULTS

Among 157 enrolled patients, 104 patients (66.2%) were admitted during on-call duty and 48 operations (30.6%) were performed at nighttime. Admission out of regular hours did not affect cerebral infarction (p = 0.545), mortality (p = 0.343), functional outcome (p = 0.178), and aneurysm occlusion (p = 0.689). Microsurgical clipping at nighttime carried higher odds of unfavorable outcome at discharge (OR: 2.3, 95%CI: 1.0-5.1, p = 0.039); however, there were no significant differences regarding the remaining outcome parameters. After multivariable adjustment, clipping at nighttime did not remain as independent prognosticator of short-term outcome (OR: 2.1, 95%CI: 0.7-6.2, p = 0.169).

CONCLUSIONS

Admission out of regular working hours and clipping at nighttime were not independently associated with poor outcome. The adherence to standardized treatment protocols might mitigate the "weekend effect."

Time and predictors of time to treatment for aneurysmal subarachnoid haemorrhage (aSAH): a systematic review

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appear to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and was registered in PROSPERO (Reg. No. CRD42019132748). We searched four electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment.

RESULTS

A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories-individual (n = 9 factors, e.g. age, sex and clinical characteristics) and health system (n = 8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up and type of treatment) were less associated with treatment delay.

CONCLUSIONS

The pathway from onset to definitive treatment of patients with aSAH consists of multiple stages with multiple influencing factors. This review provides the first comprehensive understanding of extent and factors associated with time to treatment of aSAH. There is an opportunity to target modifiable factors to reduce time to treatment, but further research considering more factors are needed.

The weekend effect in neurosurgery: the Leeds general infirmary experience

OBJECTIVE

In this article, we have studied what the impact of the 2016 contract has been on the weekend mortality rate in a single UK Neurosurgery centre for emergency admissions.

METHODS

All adult neurosurgery admissions and mortality data from Leeds General Infirmary in 2016 and 2018 was included. Weekday was defined as between 00:01 am Monday and 23:59 Friday. Weekend was defined as anything outside this timeframe. In the first part of the analysis, we excluded all public holiday admissions and compared mortality risks between weekday and weekend admissions. A Cox proportional hazard model was used to examine the time to in-hospital death or censorship. From the model, we compared the hazard ratio of weekend-vs.-weekday admissions for 7-day, 30-day and overall mortalities as well as compared the hazard of mortality on each day of the week to Wednesday admission. In the second part of the analysis, we compared mortality risks of weekday admissions versus public holiday admissions. Finally, to further evaluate whether there was any change in service standard from 2016 to 2018, we assessed the odds ratio of mortality between admission in 2018 and 2016 on weekends and weekdays excluding public holidays.

RESULTS

At 95% confidence interval, no significant difference in hazard ratio was found between admissions on different days in the week when compared to Wednesday in 2016 and 2018. There is a higher weekday admission 7-day mortality hazard ratio in 2018 compared to 2016 but overall there is no statistically significant difference in mortality hazard ratio between the two years. There is, however, a statistically significant difference in hazard ratio when comparing public holiday mortality in 2018 to weekday mortality.

CONCLUSIONS

There was no weekend effect in our unit in 2016 or in 2018, however there is a public holiday effect in 2018.

Impact of Off-Hour Hospital Presentation on Mortality in Different Subtypes of Acute Stroke in Korea : National Emergency Department Information System Data

Objective

Several studies have reported inconsistent findings among countries on whether off-hour hospital presentation is associated with worse outcome in patients with acute stroke. However, its association is yet not clear and has not been thoroughly studied in Korea. We assessed nationwide administrative data to verify off-hour effect in different subtypes of acute stroke in Korea.

Methods

We respectively analyzed the nationwide administrative data of National Emergency Department Information System in Korea; 7144 of ischemic stroke (IS), 2424 of intracerebral hemorrhage (ICH), and 1482 of subarachnoid hemorrhage (SAH), respectively. “Off-hour hospital presentation” was defined as weekends, holidays, and any times except 8:00 AM to 6:00 PM on weekdays. The primary outcome measure was in-hospital mortality in different subtypes of acute stroke. We adjusted for covariates to influence the primary outcome using binary logistic regression model and Cox's proportional hazard model.

Results

In subjects with IS, off-hour hospital presentation was associated with unfavorable outcome (24.6% off hours vs. 20.9% working hours, p<0.001) and in-hospital mortality (5.3% off hours vs. 3.9% working hours, p=0.004), even after adjustment for compounding variables (hazard ratio [HR], 1.244; 95% confidence interval [CI], 1.106–1.400; HR, 1.402; 95% CI, 1.124–1.747, respectively). Off-hours had significantly more elderly ≥65 years (35.4% off hours vs. 32.1% working hours, p=0.029) and significantly more frequent intensive care unit admission (32.5% off hours vs. 29.9% working hours, p=0.017) than working hours. However, off-hour hospital presentation was not related to poor short-term outcome in subjects with ICH and SAH.

Conclusion

This study indicates that off-hour hospital presentation may lead to poor short-term morbidity and mortality in patients with IS, but not in patients with ICH and SAH in Korea. Excessive death seems to be ascribed to old age or the higher severity of medical conditions apart from that of stroke during off hours.

Weekend effect among patients undergoing elective vascular surgery

OBJECTIVE

Several studies have described a higher mortality among patients admitted or operated during the weekend for various diseases. However, pooled data on patients undergoing elective vascular surgery procedures are sparse.

METHODS

The PubMed, Embase, Scopus, and Cochrane Library databases were systematically searched to identify eligible studies. Studies comparing short-term mortality (≤30 days) between patients undergoing elective vascular surgery during the weekend and working days were included. When studies included patients undergoing mixed types of surgery, only the vascular surgery subgroups were evaluated. Urgent/emergency vascular procedures were excluded according to certain definitions provided by each study. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd, Cambridge, UK).

RESULTS

Overall, four retrospective studies including 131,201 patients undergoing elective vascular surgery (on working days, n = 130,163; on the weekend, n = 1038) were evaluated. The pooled short-term mortality risk was higher among patients operated during the weekend compared with working days (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.58-3.67; P = .0004). This weekend effect was more evident among patients undergoing abdominal aortic aneurysm repair and carotid surgery (OR, 3.62 [95% CI, 1.49-8.82; P = .0046] and OR, 3.48 [95% CI, 1.15-10.54; P = .027], respectively). In the United States, the weekend effect was more evident among patients undergoing aortic aneurysm repair (OR, 3.61; 95% CI, 1.99-6.53; P < .0001). However, data from Canada originated from one study on patients undergoing carotid and peripheral arterial surgery only.

CONCLUSIONS

Elective vascular surgery is associated with a higher short-term mortality risk when conducted over the weekend. Improvement of perioperative management during these days may be necessary to improve outcomes.

Predictors of hospital readmission in US children and adults with atopic dermatitis

BACKGROUND

Decreasing readmissions is a health care priority in the United States. However, little is kanown about the determinants of hospital readmissions for atopic dermatitis (AD).

OBJECTIVE

To determine readmission rates among inpatients hospitalized for AD in the United States.

METHODS

We analyzed the 2012-2014 Nationwide Readmission Database, including a representative, cross-sectional sample of hospital readmissions in the United States.

RESULTS

Overall, 17.0% of inpatients with AD were readmitted within 1 year for all causes, including 12.5% with only a single readmission and 4.6% for AD. In multivariable Cox proportional hazards regression models, hospital readmission for AD was associated with below-median household income, being uninsured, having a prolonged initial hospitalization, but inversely associated with older age and a diagnosis of infection. Inpatients admitted for AD on a weekend, in the summer, or in autumn were more likely to be readmitted for AD. Hospital characteristics associated with readmission for AD included nonmetropolitan hospital location and hospital teaching status.

CONCLUSION

One in 5 inpatients with AD are readmitted within 1 year for all causes. There are socioeconomic and health care disparities in readmission rates for AD.