Weekend and nighttime effect on the prognosis of peptic ulcer bleeding

The Reduction of After-Hours and Weekend Effects in Upper Gastro-intestinal Bleeding Mortality During the COVID-19 Pandemic Compared to the Pre-Pandemic Period

Background

In upper gastrointestinal bleeding (UGIB), admissions after normal working hours and during weekends may be associated with increased mortality.

Aim

To assess the evolution of the after-hours and weekend effects during the COVID-19 pandemic as a result of progressive improved management despite management challenges during the pandemic.

Methods

We performed an observational study of patients admitted for UGIB at a tertiary academic center between March 2020 and December 2021, compared to the corresponding timeframe before the pandemic. Admissions were assessed based on regular hours versus after-hours and weekdays versus weekends. We stratified patients based on demographic data, etiology, prognostic scores, the time between symptom onset and admission, as and between admission and endoscopy. The outcomes included mortality, rebleeding rate, the requirement for surgery and transfusion, and hospitalization days.

Results

802 cases were recorded during the pandemic, and 1006 cases before the pandemic. The overall mortality rate was 12.33%. Patients admitted after hours and during weekends had a higher mortality rate compared to those admitted during regular hours and weekdays (15.18% versus 10.22%, and 15.25% versus 11.16%), especially in cases of non-variceal bleeding. However, the difference in mortality rates was reduced by 2/3 during the pandemic, despite the challenges posed by COVID-19 infection. This suggests that there was an equalization effect of care in UGIB, regardless of the admission time. The differences observed in mortality rates for after-hours and weekend admissions seem to be primarily related to a higher proportion of patients who did not undergo endoscopy, while the proportion of severe cases remained similar. Blood requirements, hospital days, and rebleeding rate were similar between the two groups.

Conclusion

Admissions during weekends and after-hours have been associated with increased mortality, particularly in cases of non-variceal bleeding. However, the impact of this association was significantly reduced during the pandemic.

The effect of platelet-albumin ratio on mortality and morbidity in peptic ulcer perforation

BACKGROUND

The aim of our study was to investigate the prognostic role of platelet/albumin ratio in patients treated under emergency conditions for peptic ulcer perforation (PUP).

METHODS

A retrospective study involving emergency patients who were operated for PUP was carried out. The patients were divided into 2 groups: PUP patients who died after surgical treatment (PUP-M) and PUP patients who survived after surgical treatment (PUP-S). The laboratory values of the patients were compared statistically. A P value of <.05 was considered statistically significant.

RESULTS

This cohort study consisted of 171 patients treated between June 2013 and December 2019. The mean age of the patients was 46.3 ± 20.5 years; and 33 (19.3%) patients were women. The age (P ≤ .001), platelet/lymphocyte ratio (P = .02), lactic dehydrogenase to albumin ratio (P ≤ .001), and platelet/albumin ratio (PAR; P ≤ .001) values were high and lymphocyte count was low (P = .006) in the PUP-M group. A positive correlation was determined between length of stay in hospital and age (P ≤ .001), lactic dehydrogenase/albumin ratio (P ≤ .001), platelet count (P = .044), and PAR (P ≤ .001). A substantial negative correlation was determined between length of stay in hospital and albumin count (P ≤ .001).

CONCLUSIONS

We determined a high preoperative PAR level in PUP patients who had undergone surgery as a negative prognostic parameter. PAR is a candidate biomarker for clinical practice.

The Impact of Night-time Emergency Department Presentation on Upper Gastrointestinal Hemorrhage Outcomes

GOALS

The aim was to investigate the impact of night-time emergency department (ED) presentation on outcomes of patients admitted for acute upper gastrointestinal hemorrhage (UGIH).

BACKGROUND

The relationship between time of ED presentation and outcomes of gastrointestinal hemorrhage is unclear.

STUDY

Using the 2016 and 2017 Florida State Inpatient Databases which provide times of ED arrival, we identified and categorized adults hospitalized for UGIH to daytime (07:00 to 18:59 h) and night-time (19:00 to 06:59 h) based on the time of ED presentation. We matched both groups with propensity scores, and assessed their clinical outcomes including all-cause in-hospital mortality, in-hospital endoscopy utilization, length of stay (LOS), total hospitalization costs, and 30-day all-cause readmission rates.

RESULTS

Of the identified 38,114 patients with UGIH, 89.4% (n=34,068) had acute nonvariceal hemorrhage (ANVH), while 10.6% (n=4046) had acute variceal hemorrhage (AVH). Compared with daytime patients, ANVH patients admitted at night-time had higher odds of in-hospital mortality (odds ratio: 1.32; 95% confidence interval: 1.06-1.60), lower odds of in-patient endoscopy (odds ratio: 0.83; 95% confidence interval: 0.77-0.90), higher total hospital costs ($9911 vs. $9545, P <0.016), but similar LOS and readmission rates. Night-time AVH patients had a shorter LOS (5.4 vs. 5.8 d, P =0.045) but similar mortality rates, endoscopic utilization, total hospitalization costs, and readmission rates as daytime patients.

CONCLUSIONS

Patients arriving in the ED at night-time with ANVH had worse outcomes (mortality, hospitalization costs, and endoscopy utilization) compared with daytime patients. However, those with AVH had comparable outcomes irrespective of ED arrival time.

Weekend effect in upper gastrointestinal bleeding: a systematic review and meta-analysis

Aim

To perform a systematic review and meta-analysis of the weekend effect on the mortality of patients with upper gastrointestinal bleeding(UGIB).

Methods

The review protocol has been registered in the PROSPERO International Prospective Register of Systematic Reviews (registration number: CRD42017073313) and was written according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We conducted a search of the PUBMED, COCHRANE, EMBASE and CINAHL databases from inception to August 2017. All observational studies comparing mortality between UGIB patients with weekend versus weekday admissions were included. Articles that were published only in abstract form or not published in a peer-reviewed journal were excluded. The quality of articles was assessed using the Newcastle-Ottawa Scale. We pooled results from the articles using random-effect models. Heterogeneity was evaluated by the chi-square-based Q-test and I²test. To address heterogeneity, we performed sensitivity and subgroup analyses. Potential publication bias was assessed via funnel plot.

Results

Eighteen observational cohort studies involving 1,232,083 study patients were included. Weekend admission was associated with significantly higher 30-day or in-hospital mortality in all studies (OR = 1.12, 95% CI [1.07–1.17], P < 0.00001). Increased in-hospital mortality was also associated with weekend admission (OR = 1.12, 95% CI [1.08–1.17], P < 0.00001). No significant difference in in-hospital mortality was observed between patients admitted with variceal bleeding during the weekend or on weekdays (OR = 0.99, 95% CI [0.91–1.08], P = 0.82); however, weekend admission was associated with a 15% increase in in-hospital mortality for patients with non-variceal bleeding (OR = 1.15, 95% CI [1.09–1.21], P < 0.00001). The time to endoscopy for weekday admission was significantly less than that obtained for weekend admission (MD = −2.50, 95% CI [−4.08–−0.92], P = 0.002).

Conclusions

The weekend effect is associated with increased mortality of UGIB patients, particularly in non-variceal bleeding. The timing of endoscopic intervention might be a factor that influences mortality of UGIB patients.

Effect of Admission Time on the Outcomes of Liver Cirrhosis with Acute Upper Gastrointestinal Bleeding: Regular Hours versus Off-Hours Admission

BACKGROUND AND AIMS

Acute upper gastrointestinal bleeding (AUGIB) is a lethal complication of liver cirrhosis. We aimed to compare the outcomes of patients with liver cirrhosis and AUGIB who were admitted to hospital on regular hours and off-hours.

METHODS

This retrospective study screened all cirrhotic patients with AUGIB who were admitted to our hospital from January 2010 to June 2014 for the test cohort and from December 2014 to March 2018 for the validation cohort. A 1:1 propensity score matching analysis was performed to adjust the Child-Pugh and MELD scores. In-hospital mortality, 5-day rebleeding rate, length of stay, and total payment were primary outcomes.

RESULTS

Overall, 826 and 173 patients with liver cirrhosis and AUGIB were included in the test and validation cohorts, respectively. After propensity score matching, 226 and 40 patients were included in the test and validation cohorts, respectively. The overall analysis of the test cohort found significantly higher Child-Pugh score (P=0.006), 5-day rebleeding rate (18.69% versus 10.72%, P=0.001), and total payment (¥25,906.83 versus ¥22,017.42, P<0.001) in patients admitted on off-hours. By contrast, the overall analysis of the validation cohort did not find any difference in Child-Pugh score, 5-day rebleeding, in-hospital mortality, length of stay, or hospital payment between patients admitted on regular hours and off-hours. Similarly, the propensity score matching analyses of both test and validation cohorts found no difference in these primary outcomes between the two groups.

CONCLUSIONS

Off-hours admission might not be negatively associated with the outcomes of patients with liver cirrhosis and AUGIB.

"Weekend Effect" in Patients With Upper Gastrointestinal Hemorrhage: A Systematic Review and Meta-analysis

OBJECTIVES

"Weekend effect" refers to worse outcomes among patients presenting to the hospital on weekends or holidays. We performed a systematic review and meta-analysis of observational studies assessing the impact of the "weekend effect" in patients with upper gastrointestinal hemorrhage (UGIH).

METHODS

We searched key bibliographic databases using keywords and MeSH terms related to gastrointestinal hemorrhage and "weekend effect". Our primary analysis evaluated mortality in patients with UGIH who were hospitalized on the weekend or after-hours compared with a weekday. Secondary outcomes included need for definitive therapy and length of hospital stay. Relevant data were extracted and meta-analyses were performed using random effects model. Subgroup sensitivity analyses were also performed to assess the effects of key variables.

RESULTS

A total of 21 of 224 identified studies met inclusion criteria. Overall, there was no association between weekend admission and mortality among patients with UGIH (Odds Ratio (OR): 1.06; 95% confidence interval (CI): 0.99-1.14). However, meta-analysis using only the nine studies that did not report having a weekend rounder showed a significant increase in mortality (OR: 1.12; 95% CI: 1.07-1.17). There was no effect of weekend admission on any of our secondary outcomes.

CONCLUSIONS

Current evidence suggests that weekend admission is associated with significant increase in mortality in patients with non-variceal UGIH but no difference in mortality was noted in patients with variceal UGIH. Our findings are relevant to policymakers, practitioners and providers who should ensure the creation of consistent quality and access to care throughout the week.

The effect of off-hours hospital admission on mortality and clinical outcomes for patients with upper gastrointestinal hemorrhage: A systematic review and meta-analysis of 20 cohorts

Objective

The objective of this article is to evaluate the relationship between off-hours hospital admission (weekends, public holidays or nighttime) and mortality for upper gastrointestinal hemorrhage (UGIH).

Methods

Medline, Embase, Scopus, and the Chinese Biomedical Literature were searched through December 2016 to identify eligible records for inclusion in this meta-analysis. A random-effects model was applied.

Results

Twenty cohort studies were included for analysis. Patients with UGIH who were admitted during off-hours had a significantly higher mortality and were less likely to receive endoscopy within 24 hours of admission. In comparison to variceal cases, patients with nonvariceal bleeding showed a higher mortality when admitted during off-hours. However, for studies conducted in hospitals that provided endoscopy outside normal hours, off-hours admission was not associated with an increased risk of mortality.

Conclusion

Our study showed a higher mortality for patients with nonvariceal UGIH who were admitted during off-hours, while this effect might be offset in hospitals with a formal out-of-hours endoscopy on-call rotation.

Interhospital transfer of pediatric neurosurgical patients

OBJECTIVE The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients. METHODS All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%-30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score. RESULTS Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1-269 days). Median length of hospital stay was 2 days (range 1-269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home. CONCLUSIONS This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.

The effect of weekend and after-hours surgery on morbidity and mortality rates in pediatric neurosurgery patients

OBJECT

Several studies have indicated that the 30-day morbidity and mortality risks are higher among pediatric and adult patients who are admitted on the weekends. This "weekend effect" has been observed among patients admitted with and for a variety of diagnoses and procedures, including myocardial infarction, pulmonary embolism, ruptured abdominal aortic aneurysm, stroke, peptic ulcer disease, and pediatric surgery. In this study, morbidity and mortality outcomes for emergency pediatric neurosurgical procedures carried out on the weekend or after hours are compared with emergency surgical procedures performed during regular weekday business hours.

METHODS

A retrospective analysis of operative data was conducted. Between December 1, 2011, and August 20, 2014, a total of 710 urgent or emergency neurosurgical procedures were performed at Texas Children's Hospital in children younger than than 18 years of age. These procedures were then stratified into 3 groups: weekday regular hours, weekday after hours, and weekend hours. By cross-referencing these events with a prospectively collected morbidity and mortality database, the impact of the day and time on complication incidence was examined. Outcome metrics were compared using logistic regression models.

RESULTS

The weekday regular hours and after-hours (weekday after hours and weekends) surgery groups consisted of 341 and 239 patients and 434 and 276 procedures, respectively. There were no significant differences in the types of cases performed (p = 0.629) or baseline preoperative health status as determined by American Society of Anesthesiologists classifications (p = 0.220) between the 2 cohorts. After multivariate adjustment and regression, children undergoing emergency neurosurgical procedures during weekday after hours or weekends were more likely to experience complications (p = 0.0227).

CONCLUSIONS

Weekday after-hours and weekend emergency pediatric neurosurgical procedures are associated with significantly increased 30-day morbidity and mortality risk compared with procedures performed during weekday regular hours.

Weekday vs weekend endoscopy: Is there a true difference in patient outcomes? A meta-analysis

AIM: To evaluate the “weekend effect” on outcomes in patient admitted on the weekend for upper gastrointestinal bleeding (UGIB).

METHODS: A comprehensive search was performed (March 2014). Studies comparing weekend and weekday endoscopy in patients with UGIB were included. All studies had at least 2 of 3 primary outcomes which included: mortality, need for surgery, time to endoscopy, endoscopy on admission day, and length of hospital stay. Three authors individually extracted data. Meta-analysis was performed using pooled estimates with odds ratio or mean difference by fixed and random effects models.

RESULTS: Eleven studies met the inclusion criteria. Patients admitted with UGIB on the weekend exhibited a statistically significant increase in mortality (OR = 1.13; 95%CI: 1.06-1.20; P < 0.01), need for surgery (OR = 2.46; 95%CI: 1.51-3.99; P < 0.01), and time to endoscopy (MD 2.68; 95%CI: 0.17-5.20; P = 0.04) as compared to patients admitted with UGIB on a weekday. Furthermore, patients with UGIB admitted on weekend experienced statistically significant less endoscopy on day of admission (OR = 0.72; 95%CI: 0.62-0.85; P < 0.01). No difference was noted between the two groups for length of hospital stay (MD -1.29; 95%CI: -3.03-0.45; P = 0.15).

CONCLUSION: A weekend effect seems to be apparent in patients with UGIB with significantly poorer outcomes.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer

BACKGROUND

Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed.

METHODS

PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred.

RESULTS

Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence.

CONCLUSION

Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.

Rockall score in predicting outcomes of elderly patients with acute upper gastrointestinal bleeding

AIM: To validate the clinical Rockall score in predicting outcomes (rebleeding, surgery and mortality) in elderly patients with acute upper gastrointestinal bleeding (AUGIB).

METHODS: A retrospective analysis was undertaken in 341 patients admitted to the emergency room and Intensive Care Unit of Xuanwu Hospital of Capital Medical University with non-variceal upper gastrointestinal bleeding. The Rockall scores were calculated, and the association between clinical Rockall scores and patient outcomes (rebleeding, surgery and mortality) was assessed. Based on the Rockall scores, patients were divided into three risk categories: low risk ≤ 3, moderate risk 3-4, high risk ≥ 4, and the percentages of rebleeding/death/surgery in each risk category were compared. The area under the receiver operating characteristic (ROC) curve was calculated to assess the validity of the Rockall system in predicting rebleeding, surgery and mortality of patients with AUGIB.

RESULTS: A positive linear correlation between clinical Rockall scores and patient outcomes in terms of rebleeding, surgery and mortality was observed (r = 0.962, 0.955 and 0.946, respectively, P = 0.001). High clinical Rockall scores > 3 were associated with adverse outcomes (rebleeding, surgery and death). There was a significant correlation between high Rockall scores and the occurrence of rebleeding, surgery and mortality in the entire patient population (χ² = 49.29, 23.10 and 27.64, respectively, P = 0.001). For rebleeding, the area under the ROC curve was 0.788 (95%CI: 0.726-0.849, P = 0.001); For surgery, the area under the ROC curve was 0.752 (95%CI: 0.679-0.825, P = 0.001) and for mortality, the area under the ROC curve was 0.787 (95%CI: 0.716-0.859, P = 0.001).

CONCLUSION: The Rockall score is clinically useful, rapid and accurate in predicting rebleeding, surgery and mortality outcomes in elderly patients with AUGIB.