Admission Time Is Associated With Outcome of UGIB
Admission Time Is Associated With Outcome of UGIB
Background It has been suggested that patients presenting with upper gastrointestinal bleeding (UGIB) during the weekend have a worse outcome compared with weekdays, with an increased risk of recurrent bleeding and mortality.
Aim To investigate the association between timing of admission and adverse outcome after UGIB.
Methods We prospectively collected data from patients presenting with symptoms suggestive of UGIB to the emergency room of eight participating hospitals. Using standard descriptive statistics and logistic regression analyses, differences in 30-day mortality, rebleeding rate, and need for angiography and surgical intervention were assessed for week- and weekend admissions and time of admission. Moreover, patient- and procedure-related factors were identified that could influence outcome.
Results In total, 571 patients were included with suspected UGIB. Patient admitted during the weekend had a higher mortality rate than patients admitted during the week [9% vs.3%; adjusted odds ratio 2.68 (95%CI 1.07–6.72)]. Weekend admissions were not associated with other adverse outcomes. Patients admitted during the weekend presented more often with bleeding and had a significantly lower systolic and diastolic blood pressure. No differences were found in procedure-related factors. Time of admission was not associated with an adverse outcome, although patients admitted during the evening had a significantly longer time to endoscopy (15, 22 and 16 h for day, evening and night admissions respectively, P < 0.01).
Conclusion Although quality of care did not appear to differ between week/weekend admissions, patients with suspected upper gastrointestinal bleeding admitted during the weekend were at higher risk of an adverse outcome. This might be due to the fact that these patients have more severe haemorrhage.
Upper gastrointestinal bleeding (UGIB) is a common indication for hospital admission. Although incidence rates for hospitalisation have decreased, still around 40/100 000 patients with UGIB are being admitted each year. More importantly, mortality rates remain high (6–8%) despite more advanced pharmacological and endoscopic treatment modalities available. Because of the acute and potential critical presentation of UGIB, early diagnosis and treatment through endoscopic risk stratification and intervention are needed.
Although at least as many patients are being hospitalised for UGIB during a weekend day as during a weekday, staffing levels are lower during weekends. It has been previously reported that hospital admission in the weekend was associated with a higher mortality rate and longer length of stay for several acute illnesses. Beside changes in hospital staffing, it may also be so that fewer urgent procedures are performed in emergently hospitalised patients in the weekend explaining this 'weekend effect'. For UGIB, only limited data exist for the 'weekend effect'. Although three large cohort studies were performed with increased weekend mortality ranging from 3.4% to 3.8%, the data used were derived from healthcare databases. This indicates limitations in available clinical, biochemical and endoscopic data of included patients, with consequent high residual confounding. In contrast with the results of these studies, a recent prospective cohort study showed that patients admitted during the weekend were more critically ill (presented more often with shock and received more often blood transfusion); however, this did not result in higher mortality rates compared with weekday admission.
It therefore remains to be established whether patients admitted during the weekend have higher risks of an adverse outcome and whether patient-related factors (e.g. more severe bleedings during the weekend) and/or procedure-related factors (e.g. delayed endoscopy) account for this possible higher risk of an adverse outcome. Early endoscopy (i.e. endoscopy within 24 h) is nowadays recommended by international guidelines. A systematic review on early vs. delayed endoscopy reported that early endoscopy is indeed safe and effective. However, whether early endoscopy also results in a better prognosis for the individual is still unknown. In addition, no distinction has been made between day and night-time admissions, while this could be equally important as week day vs. weekend effects.
We conducted a prospective cohort study to investigate whether (i) rebleeding and mortality rates differ between weekday or weekend admission; (ii) time of the day is associated with rebleeding or mortality outcomes; (iii) patient- or procedure-related factors could be identified that are responsible for a potential out-of-hours effect.
Abstract and Introduction
Abstract
Background It has been suggested that patients presenting with upper gastrointestinal bleeding (UGIB) during the weekend have a worse outcome compared with weekdays, with an increased risk of recurrent bleeding and mortality.
Aim To investigate the association between timing of admission and adverse outcome after UGIB.
Methods We prospectively collected data from patients presenting with symptoms suggestive of UGIB to the emergency room of eight participating hospitals. Using standard descriptive statistics and logistic regression analyses, differences in 30-day mortality, rebleeding rate, and need for angiography and surgical intervention were assessed for week- and weekend admissions and time of admission. Moreover, patient- and procedure-related factors were identified that could influence outcome.
Results In total, 571 patients were included with suspected UGIB. Patient admitted during the weekend had a higher mortality rate than patients admitted during the week [9% vs.3%; adjusted odds ratio 2.68 (95%CI 1.07–6.72)]. Weekend admissions were not associated with other adverse outcomes. Patients admitted during the weekend presented more often with bleeding and had a significantly lower systolic and diastolic blood pressure. No differences were found in procedure-related factors. Time of admission was not associated with an adverse outcome, although patients admitted during the evening had a significantly longer time to endoscopy (15, 22 and 16 h for day, evening and night admissions respectively, P < 0.01).
Conclusion Although quality of care did not appear to differ between week/weekend admissions, patients with suspected upper gastrointestinal bleeding admitted during the weekend were at higher risk of an adverse outcome. This might be due to the fact that these patients have more severe haemorrhage.
Introduction
Upper gastrointestinal bleeding (UGIB) is a common indication for hospital admission. Although incidence rates for hospitalisation have decreased, still around 40/100 000 patients with UGIB are being admitted each year. More importantly, mortality rates remain high (6–8%) despite more advanced pharmacological and endoscopic treatment modalities available. Because of the acute and potential critical presentation of UGIB, early diagnosis and treatment through endoscopic risk stratification and intervention are needed.
Although at least as many patients are being hospitalised for UGIB during a weekend day as during a weekday, staffing levels are lower during weekends. It has been previously reported that hospital admission in the weekend was associated with a higher mortality rate and longer length of stay for several acute illnesses. Beside changes in hospital staffing, it may also be so that fewer urgent procedures are performed in emergently hospitalised patients in the weekend explaining this 'weekend effect'. For UGIB, only limited data exist for the 'weekend effect'. Although three large cohort studies were performed with increased weekend mortality ranging from 3.4% to 3.8%, the data used were derived from healthcare databases. This indicates limitations in available clinical, biochemical and endoscopic data of included patients, with consequent high residual confounding. In contrast with the results of these studies, a recent prospective cohort study showed that patients admitted during the weekend were more critically ill (presented more often with shock and received more often blood transfusion); however, this did not result in higher mortality rates compared with weekday admission.
It therefore remains to be established whether patients admitted during the weekend have higher risks of an adverse outcome and whether patient-related factors (e.g. more severe bleedings during the weekend) and/or procedure-related factors (e.g. delayed endoscopy) account for this possible higher risk of an adverse outcome. Early endoscopy (i.e. endoscopy within 24 h) is nowadays recommended by international guidelines. A systematic review on early vs. delayed endoscopy reported that early endoscopy is indeed safe and effective. However, whether early endoscopy also results in a better prognosis for the individual is still unknown. In addition, no distinction has been made between day and night-time admissions, while this could be equally important as week day vs. weekend effects.
We conducted a prospective cohort study to investigate whether (i) rebleeding and mortality rates differ between weekday or weekend admission; (ii) time of the day is associated with rebleeding or mortality outcomes; (iii) patient- or procedure-related factors could be identified that are responsible for a potential out-of-hours effect.