Off-hours admission and acute stroke care quality: a nationwide study of performance measures and case-fatality.
OBJECTIVE
Studies have reported higher risks of death and other adverse outcomes in acute stroke patients admitted off-hours; however, little is known about the underlying mechanisms. According to time of admission, our aim was to examine compliance with performance measures for acute stroke care processes, including the effect of a systematic quality improvement program, and to examine 30 days case-fatality.


METHODS
A population-based historical cohort study, including patients admitted to Danish hospitals with a first ever acute stroke (January 1, 2003, to December 31, 2011; N=64 975). Off-hours were weekends and evening and nighttime shifts on weekdays. Compliance with performance measures was compared using general linear modeling, and odds ratios for 30 days case-fatality were obtained using multivariable logistic regression.


RESULTS
Patients admitted off-hours had a lower chance of compliance with 8 out of 10 performance measures; however, these differences diminished over time. Unadjusted odds ratio for 30 days case-fatality, for patients admitted off-hours compared with patients admitted on-hours, was 1.15 (95% confidence interval, 1.09-1.21). Adjusting for patient characteristics (in particular, stroke severity) decreased the odds ratio to 1.03 (95% confidence interval, 0.97-1.10). Additional adjustment for hospital characteristics and compliance with performance measures had no effect on the odds ratio.


CONCLUSIONS
Patients admitted off-hours received a poorer quality of care. However, the admission time-related differences in care were substantially reduced over time, and the differences in 30 days case-fatality appeared primarily to be explained by differences in stroke severity.
From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark. nskristiansen@health.sdu.dk.
Nina Sahlertz
NS
Kristiansen
From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark.
Jan
J
Mainz
From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark.
Bente Mertz
BM
Nørgård
From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark.
Paul D
PD
Bartels
From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark.
Grethe
G
Andersen
From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark.
Søren Paaske
SP
Johnsen
D000368:Aged; D015331:Cohort Studies; D003718:Denmark; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009462:Neurology / Q000592:standards* / Q000706:statistics & numerical data; D020521:Stroke / Q000453:epidemiology*; D013997:Time Factors
case-fatality; quality of care; stroke