Effects of weekend admission on the outcomes and management of ruptured aortic aneurysms

Groves, Elliott M.; Khoshchehreh, Mahdi; Le, Christine; Malik, Shaista

doi:10.1016/j.jvs.2014.02.052

Cited by 64 publications

(60 citation statements)

References 23 publications

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“…myocardial infarctions, strokes, and pulmonary embolism (1-5). Similar analyses for diagnoses requiring urgent surgery, such as ruptured aortic aneurysms, have also demonstrated inferior outcomes (6). Previous analyses have suggested that outcomes following kidney and liver transplants performed over the weekend are similar to transplants performed during the week (7-10).…”

Section: Introductionmentioning

confidence: 90%

The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States

Mohan

Foley

Chiles

et al. 2016

Kidney International

111

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Factors contributing to the high rate of discard among deceased donor kidneys remain poorly understood and the influence of resource limitations of weekends on kidney transplantation is unknown. To quantify this we used data from the Scientific Registry of Transplant Recipients and assembled a retrospective cohort of 181,799 deceased donor kidneys recovered for transplantation from 2000-2013. We identified the impact of the day of the week on the procurement and subsequent utilization or discard of deceased donor kidneys in the United States, as well as report the geographic variation on the impact of weekends on transplantation. Compared to weekday kidneys, organs procured on weekends were significantly more likely to be discarded than transplanted (odds ratio: 1.16; 95% confidence interval 1.13 – 1.19), even after adjusting for organ quality (adjusted odds ratio: 1.13; 95% confidence interval 1.10 – 1.17). Weekend discards were of a significantly higher quality than weekday discards (kidney donor profile index: 76.5 vs 77.3%). Considerable geographic variation was noted in the proportion of transplants that occurred over the weekend. Kidneys available for transplant over the weekend were significantly more likely to be used at larger transplant centers, be shared without payback, and experienced shorter cold ischemia times. Thus, factors other than kidney quality are contributing to the discard of deceased donor kidneys, particularly during weekends. Policy prescriptions, administrative or organizational solutions within transplant programs may potentially mitigate against the recent increase in kidney discards.

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Section: Introductionmentioning

confidence: 90%

The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States

Mohan

Foley

Chiles

et al. 2016

Kidney International

111

View full text Add to dashboard Cite

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“…There is weak evidence showing that time to treatment influences survival adversely. 52,53 This might be have been a contributor to mortality in the EVAR groups of the AJAX and ECAR trials but, for the IMPROVE trial, the time difference was much shorter. Misdiagnosis might also contribute to the mortality rate in the EVAR group because diagnosis, even after CT, can be in doubt.…”

Section: Mortality and Other 30-day Outcomes In The Improve Trial Andmentioning

confidence: 99%

“…Among 5800 ruptured AAA participants, the in-hospital mortality was significantly higher among those participants admitted at weekends than among those admitted during the week (OR 1.32, 95% CI 1.13 to 1.55; p = 0.0004), and only 77% of those admitted at weekends underwent same-day repair, compared with 80% admitted during the week (p = 0.004). 52 Given the large sample size, Groves et al 52 tried to identify factors contributing to the increased (32% higher) mortality at the weekend. It was not related to differential use of EVAR but, at weekends, participants received blood transfusion more often than during the week.…”

Section: Time Of Presentationmentioning

confidence: 99%

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

Ulug

Hinchliffe

Sweeting

et al. 2018

Health Technol Assess

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Background Ruptured abdominal aortic aneurysm (AAA) is a common vascular emergency. The mortality from emergency endovascular repair may be much lower than the 40–50% reported for open surgery. Objective To assess whether or not a strategy of endovascular repair compared with open repair reduces 30-day and mid-term mortality (including costs and cost-effectiveness) among patients with a suspected ruptured AAA. Design Randomised controlled trial, with computer-generated telephone randomisation of participants in a 1 : 1 ratio, using variable block size, stratified by centre and without blinding. Setting Vascular centres in the UK (n = 29) and Canada (n = 1) between 2009 and 2013. Participants A total of 613 eligible participants (480 men) with a ruptured aneurysm, clinically diagnosed at the trial centre. Interventions A total of 316 participants were randomised to the endovascular strategy group (immediate computerised tomography followed by endovascular repair if anatomically suitable or, if not suitable, open repair) and 297 were randomised to the open repair group (computerised tomography optional). Main outcome measures The primary outcome measure was 30-day mortality, with 30-day reinterventions, costs and disposal as early secondary outcome measures. Later outcome measures included 1- and 3-year mortality, reinterventions, quality of life (QoL) and cost-effectiveness. Results The 30-day mortality was 35.4% in the endovascular strategy group and 37.4% in the open repair group [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.66 to 1.28; p = 0.62, and, after adjustment for age, sex and Hardman index, OR 0.94, 95% CI 0.67 to 1.33]. The endovascular strategy appeared to be more effective in women than in men (interaction test p = 0.02). More discharges in the endovascular strategy group (94%) than in the open repair group (77%) were directly to home (p < 0.001). Average 30-day costs were similar between groups, with the mean difference in costs being –£1186 (95% CI –£2997 to £625), favouring the endovascular strategy group. After 1 year, survival and reintervention rates were similar in the two groups, QoL (at both 3 and 12 months) was higher in the endovascular strategy group and the mean cost difference was –£2329 (95% CI –£5489 to £922). At 3 years, mortality was 48% and 56% in the endovascular strategy group and open repair group, respectively (OR 0.73, 95% CI 0.53 to 1.00; p = 0.053), with a stronger benefit for the endovascular strategy in the subgroup of 502 participants in whom repair was started for a proven rupture (OR 0.62, 95% CI 0.43 to 0.89; p = 0.009), whereas aneurysm-related reintervention rates were non-significantly higher in this group. At 3 years, considering all participants, there was a mean difference of 0.174 quality-adjusted life-years (QALYs) (95% CI 0.002 to 0.353 QALYs) and, among the endovascular strategy group, a cost difference of –£2605 (95% CI –£5966 to £702), leading to 88% of estimates in the cost-effectiveness plane being in the quadrant showing the endovascular strategy to be ‘dominant’. Limitations Because of the pragmatic design of this trial, 33 participants in the endovascular strategy group and 26 in the open repair group breached randomisation allocation. Conclusions The endovascular strategy was not associated with a significant reduction in either 30-day mortality or cost but was associated with faster participant recovery. By 3 years, the endovascular strategy showed a survival and QALY gain and was highly likely to be cost-effective. Future research could include improving resuscitation for older persons with circulatory collapse, the impact of local anaesthesia and emergency consent procedures. Trial registration Current Controlled Trials ISRCTN48334791 and NCT00746122. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 31. See the NIHR Journals Library website for further project information.

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“…These results highlight the pitfalls associated with studies of the weekend effect in large databases, and call into question the results of previous studies1 13 showing an apparent weekend effect in the treatment of ruptured AAA. They suggest that two significant effects contribute to, or perhaps even account for, the weekend effect.…”

Section: Discussionmentioning

confidence: 67%

“…The weekend effect was originally highlighted for patients undergoing acute AAA repair in Canada1, and has more recently been explored using the American National Inpatient Sample13. Both studies found a significant effect for patients admitted at the weekend, but used large administrative coding databases, similar to the one found to suffer from inaccuracies in the context of acute stroke7, with no attempt to check diagnostic codes with treating clinicians.…”

Section: Introductionmentioning

confidence: 99%

Weekend effect in non-elective abdominal aortic aneurysm repair

et al. 2017

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BackgroundThe ‘weekend effect’ describes the phenomenon where patient outcomes appear worse for those admitted at the weekend. It has been used recently to justify significant changes in UK health policy. Recent evidence has suggested that the effect may be due to a combination of inadequate correction for confounding factors and inaccurate coding. The effects of these factors were investigated in patients with acute abdominal aortic aneurysm (AAA).MethodsPatients undergoing non‐elective AAA repair entered into the UK National Vascular Registry from January 2013 until December 2015 were included in a case–control study. The patients were divided according to whether they were treated during the week (Monday 08.00 hours to Friday 17.00 hours) or at the weekend. Data extracted included demographics, co‐morbidities, preoperative medications and baseline blood test results, as well as outcomes. Coding issues were investigated by looking at patients treated for ruptured, symptomatic or asymptomatic AAA within the non‐elective cohort. The primary outcome was in‐hospital mortality. Secondary outcomes included length of inpatient stay, and cardiac, respiratory and renal complications.ResultsThe mortality rate appeared to be higher at the weekend (odds ratio (OR) 1·69, 95 per cent c.i. 1·47 to 1·94; P < 0·001), but this effect disappeared when confounding factors and coding issues were corrected for (corrected OR for ruptured AAA 1·09, 0·92 to 1·29; P = 0·330). Differences in outcomes were similar for prolonged length of hospital stay (uncorrected OR 1·21, 95 per cent c.i. 1·06 to 1·37, P = 0·005; corrected OR for ruptured AAA 1·06, 0·91 to 1·10, P = 0·478), and morbidity outcomes.ConclusionAfter appropriate correction for confounding factors and coding effects, there was no evidence of a significant weekend effect in the treatment of non‐elective AAA in the UK.

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Effects of weekend admission on the outcomes and management of ruptured aortic aneurysms

Cited by 64 publications

References 23 publications

The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States

The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States

Strategy of endovascular versus open repair for patients with clinical diagnosis of ruptured abdominal aortic aneurysm: the IMPROVE RCT

Weekend effect in non-elective abdominal aortic aneurysm repair

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