Off-hour presentation and outcomes in patients with acute ischemic stroke: a systematic review and meta-analysis.
BACKGROUND
Studies have suggested that patients with acute ischemic stroke who present to the hospital during off-hours (weekends and nights) may or may not have worse clinical outcomes compared to patients who present during regular hours.


METHODS
We searched Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus through August 2013, and included any study that evaluated the association between time of patient presentation to a healthcare facility and mortality or modified Rankin Scale in acute ischemic stroke. Quality of studies was assessed with the Newcastle-Ottawa Scale. A random-effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I(2). A priori subgroup analyses were used to explain observed heterogeneity.


RESULTS
A total of 21 cohort studies (23 cohorts) with fair quality enrolling 1,421,914 patients were included. Off-hour presentation for patients with acute ischemic stroke was associated with significantly higher short-term mortality (OR, 1.11, 95% CI 1.06-1.17). Presenting at accredited stroke centers (OR 1.04, 95% CI 0.98-1.11) and countries in North America (OR 1.05, 95% CI 1.01-1.09) were associated with smaller increase in mortality during off-hours. The results were not significantly different between adjusted (OR, 1.11, 95% CI 1.05-1.16) and unadjusted (OR, 1.13, 95% CI 0.95-1.35) outcomes. The proportion of patients with modified Rankin Scale at discharge ≥ 2-3 was higher in patients presenting during off-hours (OR, 1.14, 95% CI 1.06-1.22).


CONCLUSIONS
The evidence suggests that patients with acute ischemic stroke presenting during off-hours have higher short-term mortality and greater disability at discharge.
Division of Preventive Medicine, Mayo Clinic, Rochester, MN, United States.
Atsushi
A
Sorita
Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, United States.
Adil
A
Ahmed
Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States.
Stephanie R
SR
Starr
Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States.
Kristine M
KM
Thompson
Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, United States.
Darcy A
DA
Reed
Division of Preventive Medicine, Mayo Clinic, Rochester, MN, United States.
Abd Moain Abu
AM
Dabrh
Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, United States.
Larry
L
Prokop
Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States.
David M
DM
Kent
Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States.
Nilay D
ND
Shah
Division of Preventive Medicine, Mayo Clinic, Rochester, MN, United States.
Mohammad Hassan
MH
Murad
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States. Electronic address: ting.henry@mayo.edu.
Henry H
HH
Ting
D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D006801:Humans; D020521:Stroke / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D013997:Time Factors; D016896:Treatment Outcome
Acute ischemic stroke; Meta-analysis; Modified Rankin Scale; Mortality; Off-hours; Systematic review