title: Consciousness level and off-hour admission affect discharge outcome of acute stroke patients: a J-ASPECT study.
abstract: BACKGROUND
  Poor outcomes have been reported for stroke patients admitted outside of regular working hours. However, few studies have adjusted for case severity. In this nationwide assessment, we examined relationships between hospital admission time and disabilities at discharge while considering case severity.
  
  
  RESULTS
  We analyzed 35 685 acute stroke patients admitted to 262 hospitals between April 2010 and May 2011 for ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). The proportion of disabilities/death at discharge as measured by the modified Rankin Scale (mRS) was quantified. We constructed 2 hierarchical logistic regression models to estimate the effect of admission time, one adjusted for age, sex, comorbidities, and number of beds; and the second adjusted for the effect of consciousness levels and the above variables at admission. The percentage of severe disabilities/death at discharge increased for patients admitted outside of regular hours (22.8%, 27.2%, and 28.2% for working-hour, off-hour, and nighttime; P<0.001). These tendencies were significant in the bivariate and multivariable models without adjusting for consciousness level. However, the effects of off-hour or nighttime admissions were negated when adjusted for consciousness levels at admission (adjusted OR, 1.00 and 0.99; 95% CI, 1.00 to 1.13 and 0.89 to 1.10; P=0.067 and 0.851 for off-hour and nighttime, respectively, versus working-hour). The same trend was observed when each stroke subtype was stratified.
  
  
  CONCLUSIONS
  The well-known off-hour effect might be attributed to the severely ill patient population. Thus, sustained stroke care that is sufficient to treat severely ill patients during off-hours is important.
authors.affiliation: Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.).
authors.forename: Satoru
authors.initials: S
authors.lastname: Kamitani
authors.affiliation: Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Japan (K.N., Y.M.).
authors.forename: Kunihiro
authors.initials: K
authors.lastname: Nishimura
authors.affiliation: Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.).
authors.forename: Fumiaki
authors.initials: F
authors.lastname: Nakamura
authors.affiliation: Clinical Research Center, Nagoya Medical Center, Nagoya, Japan (A.K.).
authors.forename: Akiko
authors.initials: A
authors.lastname: Kada
authors.affiliation: Department of Integrative Stroke Imaging Center, National Cerebral and Cardiovascular Center, Suita, Japan (J.N.).
authors.forename: Jyoji
authors.initials: J
authors.lastname: Nakagawara
authors.affiliation: Department of Cerebrovascular Medicine and Neurology, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.).
authors.forename: Kazunori
authors.initials: K
authors.lastname: Toyoda
authors.affiliation: Department of neurosurgery, Iwate Medical University, Morioka, Japan (K.O.).
authors.forename: Kuniaki
authors.initials: K
authors.lastname: Ogasawara
authors.affiliation: Chiba Cardiovascular Center, Chiba, Japan (J.O.).
authors.forename: Junichi
authors.initials: J
authors.lastname: Ono
authors.affiliation: Department of Neurosurgery, Kyorin University, Mitaka, Japan (Y.S.).
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Shiokawa
authors.affiliation: Showa University Hospital, Shinagawa-ku, Japan (T.A.).
authors.forename: Toru
authors.initials: T
authors.lastname: Aruga
authors.affiliation: Department of Neurosurgery, Nagoya University, Nagoya, Japan (S.M.).
authors.forename: Shigeru
authors.initials: S
authors.lastname: Miyachi
authors.affiliation: Department of Neurosurgery, Nagasaki University.
authors.forename: Izumi
authors.initials: I
authors.lastname: Nagata
authors.affiliation: Department of Preventive Medicine and Community Health, School of Medicine, Universityof Occupational and Environmental Health, Kitakyushu, Japan (S.M.).
authors.forename: Shinya
authors.initials: S
authors.lastname: Matsuda
authors.affiliation: Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Japan (K.N., Y.M.).
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Miyamoto
authors.affiliation: Department of Intellectual Asset Management, National Cerebral and Cardiovascular Center, Suita, Japan (M.I.).
authors.forename: Michiaki
authors.initials: M
authors.lastname: Iwata
authors.affiliation: Research Institute for Brain and Blood Vessels, Akita, Japan (A.S.).
authors.forename: Akifumi
authors.initials: A
authors.lastname: Suzuki
authors.affiliation: Center for Cancer Controland Information Services, National Cancer Center, Chuo-ku, Japan (K.B.I.).
authors.forename: Koichi B
authors.initials: KB
authors.lastname: Ishikawa
authors.affiliation: Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan (H.K., K.M.).
authors.forename: Hiroharu
authors.initials: H
authors.lastname: Kataoka
authors.affiliation: Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan (H.K., K.M.).
authors.forename: Kenichi
authors.initials: K
authors.lastname: Morita
authors.affiliation: Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.).
authors.forename: Yasuki
authors.initials: Y
authors.lastname: Kobayashi
authors.affiliation: Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan (K.I.).
authors.forename: Koji
authors.initials: K
authors.lastname: Iihara
mesh_terms: D039602:After-Hours Care; D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D015331:Cohort Studies; D016001:Confidence Intervals; D003243:Consciousness / Q000502:physiology*; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D007564:Japan; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010343:Patient Admission / Q000706:statistics & numerical data*; D010351:Patient Discharge / Q000706:statistics & numerical data; D063868:Patient Outcome Assessment; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D016019:Survival Analysis
keywords: hemorrhagic stroke; ischemic stroke; mortality; stroke; weekend effect