Off-hour admission and in-hospital stroke case fatality in the get with the guidelines-stroke program.
OBJECTIVE
Previous reports have shown higher in-hospital mortality for patients with acute stroke who arrived on weekends compared with regular workdays. We analyzed the effect of presenting during off-hours, defined as weekends and weeknights (versus weekdays), on in-hospital mortality and on quality of care in the Get With The Guidelines (GWTG)-Stroke program.


METHODS
We analyzed data from 187 669 acute ischemic stroke and 34 845 acute hemorrhagic stroke admissions who presented to the emergency departments of 857 hospitals that participated in the GWTG-Stroke program during the 4-year period 2003 to 2007. Off-hour presentation was defined as presentation anytime outside of 7:00 am to 6:00 pm on weekdays. Quality of care was measured using standard GWTG quality indicators covering acute, subacute, and discharge measures. The relationship between off-hour presentation and in-hospital case fatality was examined using generalized estimating equation logistic regression adjusting for demographics, risk factors, arrival mode, and hospital characteristics.


RESULTS
Half of ischemic stroke admissions and 57% of hemorrhagic stroke admissions presented during off-hours. Among ischemic stroke admissions, the in-hospital case fatality rate was 5.8% for off-hour presentation compared with 5.2% for on-hour presentation (P<0.001). For hemorrhagic stroke admissions, in-hospital case fatality was 27.2% for off-hour presentation compared with 24.1% for on-hour presentation (P<0.001). After adjusting for patient-level and hospital-level factors, presentation during off-hours was significantly associated with higher in-hospital mortality for both ischemic stroke (adjusted OR, 1.09; 95% CI, 1.03 to 1.14) and hemorrhagic stroke admissions (adjusted OR, 1.19; 95% CI, 1.12 to 1.27). No differences were observed between off-hour presentation and any of the quality of care measures.


CONCLUSIONS
Off-hour presentation was associated with an increased risk of dying in-hospital, although the absolute effect was small for ischemic stroke admissions (0.6% difference; number needed to harm=166) and moderate for hemorrhagic stroke (3.1% difference; number needed to harm=32). Reducing the disparity in hospital-based outcomes for admissions that present during off-hours represents a potential target for quality improvement efforts, although evidence of differences in the quality of care by time of presentation was lacking.
Reeves
Mathew J
MJ
Department of Epidemiology, Michigan State University, East Lansing, Mich 48824, USA. reevesm@msu.edu
Smith
Eric
E
Fonarow
Gregg
G
Hernandez
Adrian
A
Pan
Wenqin
W
Schwamm
Lee H
LH
D000367:Age Factors; D000368:Aged; D002545:Brain Ischemia / Q000150:complications; D002543:Cerebral Hemorrhage / Q000150:complications; D005006:Ethnicity; D005260:Female; D017408:Guidelines as Topic; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D010351:Patient Discharge; D010960:Plasminogen Activators / Q000627:therapeutic use; D011787:Quality of Health Care / Q000592:standards* / Q000706:statistics & numerical data; D012737:Sex Factors; D020521:Stroke / Q000209:etiology / Q000401:mortality* / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000009:adverse effects
D010960:Plasminogen Activators