Outcomes of weekend versus weekday admission for acute aortic dissection or rupture: A retrospective study on the Italian National Hospital Database

Gallerani, Massimo; Volpato, Stefano; Boari, Benedetta; Pala, Marco; Giorgi, Alfredo De; Fabbian, Fabio; Gasbarro, Vincenzo; Bossone, Eduardo; Eagle, Kim A.; Carle, Flavia; Manfredini, Roberto

doi:10.1016/j.ijcard.2013.04.065

Cited by 24 publications

(28 citation statements)

References 12 publications

(28 reference statements)

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“…It was not related to differential use of EVAR but, at weekends, participants received blood transfusion more often than during the week. Higher mortality among patients admitted at weekends may be a widespread phenomenon -it also has been reported in Italy 64 and in Canada, 65 where in-hospital mortality was 42% at weekends compared with 36% during the week -and might be attributable to the lower availability of specialised teams for treating patients or to staffing levels more generally.…”

Section: Time Of Presentationmentioning

confidence: 80%

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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Section: Time Of Presentationmentioning

confidence: 80%

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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“…Many studies have discussed the potential mechanisms of offhour effect. Researchers highlighted problems regarding the accessibility and quality of medical services on off-hours, such as lower levels of medical staff, 21 inadequate access to specialized services, 1,22 discontinuity of care, 23 and reduced availability of certain procedures. 2,24 Based on findings from the current systematic review of multiple diseases, we found that the off-hour effect may be exacerbated particularly when optimal patient care requires an increase in medical resources.…”

Section: Comparison With Other Studiesmentioning

confidence: 99%

Off‐Hour Admission and Mortality Risk for 28 Specific Diseases: A Systematic Review and Meta‐Analysis of 251 Cohorts

Zhou

Herath

et al. 2016

JAHA

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“…4,13,14,[20][21][22] Only a study by Dueck et al 22 included patients undergoing 'after-hours' RAAA repairs, which were defined as operations performed on week nights between 18:00 and 07:00, weekends, and holidays, and was determined with a supplemental fee code (E409 and E410) in the OHIP (Ontario Health Insurance Plan) database. In-hospital mortality was reported in nine studies, 4,[9][10][11][12][13][19][20][21] 30-day mortality in one, 22 and 90-day mortality in one, 14 and we combined these as 'early' mortality. Because Glance et al 13 reported four ORs (for subgroups of emergency open, urgent open, emergency endovascular, and urgent endovascular AAA repair) and Karthikesalingam et al 14 provided two ORs (for patients in England and those in Sweden), 15 relative-risk estimates from 11 studies were available.…”

Section: Search Resultsmentioning

confidence: 99%

“…Four studies [9][10][11]19 enrolled both patients undergoing aortic repair and those not doing (Supplemental Table S1). In a study by Kumar et al 19 enrolling exclusively patients with AAD, the overall utilization of surgical or endovascular aortic repair for all hospitalizations was 47.2%, and weekend hospitalization was associated with a significantly lower utilization of aortic repair compared with weekday hospitalization (adjusted OR, 0.76; 95% CI, 0.71 to 0.82; p < 0.001).…”

Section: Sensitivity Analysesmentioning

confidence: 99%

A meta-analysis of weekend admission and surgery for aortic rupture and dissection

2017

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We performed a meta-analysis to determine whether weekend admission and surgery for ruptured abdominal/thoracic aortic aneurysm (RAAA/RTAA) and acute aortic dissection (AAD) is associated with increased mortality. MEDLINE and EMBASE were searched from January 1946 to December 2016 using PubMed and OVID. Eligible studies were prospective or retrospective, comparative or cohort studies enrolling patients admitting or undergoing surgery for RAAA/RTAA/AAD and reporting mortality after weekend (including holiday) versus weekday admission/surgery. Our search identified 11 studies including a total of 166,195 patients. A pooled analysis of 13 adjusted odds ratios (ORs), one adjusted hazard ratio, and one unadjusted OR from all 11 studies demonstrated a statistically significant 32% increase in mortality with weekend admission/surgery (OR, 1.32; 95% confidence interval (CI), 1.20 to 1.45; p < 0.00001). Despite possible publication bias disadvantageous to weekend admission/surgery based on funnel plot asymmetry, adjustment for the asymmetry using the trim-and-fill method did not alter the significant association of weekend admission/surgery with increased mortality (OR, 1.21; 95% CI, 1.09 to 1.34; p = 0.0006). In conclusion, weekend admission/surgery for ruptured abdominal/thoracic aortic aneurysm and acute aortic dissection (AAD) may be associated with increased mortality.

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Outcomes of weekend versus weekday admission for acute aortic dissection or rupture: A retrospective study on the Italian National Hospital Database

Cited by 24 publications

References 12 publications

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

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

Off‐Hour Admission and Mortality Risk for 28 Specific Diseases: A Systematic Review and Meta‐Analysis of 251 Cohorts

A meta-analysis of weekend admission and surgery for aortic rupture and dissection

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