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Trenner M, Kirchhoff F, Knappich C, Heuberger S, Eckstein HH, Kuehnl A. Editor's Choice - Temporal fluctuations of hospital incidence and mortality of ruptured abdominal aortic aneurysms in Germany: A secondary data analysis of German hospital episode statistics 2009 - 2018. Eur J Vasc Endovasc Surg 2023; 66:766-774. [PMID: 37573938 DOI: 10.1016/j.ejvs.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/09/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE Abdominal aortic aneurysm rupture (rAAA) is still associated with high mortality. Recent studies have shown higher incidences in autumn and winter, and worse outcomes after rAAA treatment on weekends in some countries. This study aimed to analyse seasonal, weekday, and daytime fluctuations of the hospital incidence, treatment modalities, and outcomes of rAAA, based on the most recent nationwide German real world data. METHODS A secondary data analysis of diagnosis related group statistics (2009 - 2018), obtained from the German Federal Statistical Office, was conducted. Cases encoded by a diagnosis of rAAA in conjunction with procedural codes for endovascular aortic repair (EVAR) or open aortic repair were included. Patient and procedural characteristics, comorbidities, and outcomes were analysed for seasonal (spring, summer, autumn, and winter), weekday (Monday - Sunday) and daytime (0:00 - 8:00, 8:00 -16:00, 16:00 -20:00, and 20:00 - 24:00) fluctuations by descriptive statistics and multivariable regression analyses. RESULTS Thirteen thousand and seventy patients (85% male, median age 75 years) were treated for rAAA. Endovascular aortic repair was associated with lower mortality (adjusted OR 0.40, 95% CI 0.37 - 0.44). While no significant seasonal fluctuations were found, on a weekday basis lower hospital incidences were found on Mondays (12%) and Sundays (11%) compared with other weekdays (15 - 16%). Similarly, EVAR rates were lower on Mondays and Sundays (25% and 24%, respectively) compared with other weekdays (30 - 33%). Multivariable analyses revealed higher mortality rates on Mondays and Sundays. On a daytime basis, lower EVAR rates and higher mortality rates were found during the 16:00 - 8:00 period. CONCLUSION In German hospitals, incidences and EVAR rates to treat rAAA were lowest on Mondays and Sundays. The associated overall mortality rates were highest on the respective days. Further restructuring and centralisation of AAA treatment in Germany could potentially mitigate this weekday effect.
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Affiliation(s)
- Matthias Trenner
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany; Division of vascular medicine, St.-Josefs Hospital, Wiesbaden, Germany. https://twitter.com/matthiastrenner
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Simon Heuberger
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany.
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Jessula S, Cote CL, Kim Y, Cooper M, McDougall G, Casey P, Lee MS, Smith M, Dua A, Herman C. Effect of after-hours presentation in ruptured abdominal aortic aneurysm. J Vasc Surg 2023; 77:1045-1053.e3. [PMID: 36343873 DOI: 10.1016/j.jvs.2022.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ruptured abdominal aortic aneurysms (RAAAs) are surgical emergencies that require immediate and expert treatment. It has been unclear whether presentation during evenings and weekends, when "on call" teams are primarily responsible for patient care, is associated with worse outcomes. Our objective was to evaluate the outcomes of patients presenting with RAAAs after-hours vs during the workday. METHODS A retrospective cohort study of all RAAAs in Nova Scotia between 2005 and 2015 was performed through linkage of administrative databases. Patients who had presented to the hospital with RAAAs during the workday (Monday through Friday, 6 am to 6 pm) were compared with those who had presented after-hours (6 pm to 6 am during the week and on weekends). The baseline and operative characteristics were identified for all patients through the available databases and a review of the medical records. Mortality before surgery, 30-day mortality, and operative mortality were compared between groups using multivariable logistic regression, adjusting for factors clinically significant on univariable analysis. RESULTS A total of 390 patients with RAAAs were identified from 2005 to 2015, of whom 205 (53%) had presented during the workday and 185 (47%) after-hours. The overall chance of survival (OCS) was 45% overall, 49% if admitted to hospital, and 64% if surgery had been performed. During the workday, the OCS was 43% overall, 48% if admitted to hospital, and 67% if surgery had been performed. After-hours, the OCS was 46% overall, 49% if admitted to hospital, and 61% if surgery had been performed. Mortality before surgery was increased for patients who had presented to the hospital during the workday compared with after-hours (36% vs 26%; P = .04). The 30-day mortality (57% vs 54%; P = .62), rates of operative management (63% vs 72%; P = .06), and operative mortality (33% vs 39%; P = .33) were similar between the workday and after-hours groups (57% vs 54%; P = .06). After adjusting for significant clinical variables, the patients who had presented with RAAAs after-hours had had a similar odds of dying before surgery (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.41-1.03), operative management (OR, 1.47; 95% CI, 0.93-2.31), 30-day mortality (OR, 0.98; 95% CI, 0.63-1.51), and operative mortality (OR, 1.33; 95% CI, 0.78-2.26). In the subgroup of patients presenting to a hospital with endovascular capabilities, patients presenting after-hours had had similar odds of 30-day mortality (OR, 1.07; 95% CI, 0.57-2.02), and operative mortality (OR, 1.14; 95% CI, 0.58-2.23). CONCLUSIONS We found that patients presenting to the hospital with RAAAs after-hours did not have increased adjusted odds of mortality before surgery, operative management, 30-day mortality, or operative mortality.
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Affiliation(s)
- Samuel Jessula
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA.
| | - Claudia L Cote
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC
| | - Matthew Cooper
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Garrett McDougall
- Department of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Patrick Casey
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Min S Lee
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Matthew Smith
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Christine Herman
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada; Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
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Birmpili P, Johal A, Li Q, Waton S, Chetter I, Boyle JR, Cromwell D. Factors associated with delays in revascularization in patients with chronic limb-threatening ischaemia: population-based cohort study. Br J Surg 2021; 108:951-959. [PMID: 33842943 DOI: 10.1093/bjs/znab039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/24/2020] [Accepted: 01/17/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prompt revascularization in patients with chronic limb-threatening ischaemia (CLTI) is important, and recent guidance has suggested that patients should undergo revascularization within 5 days of an emergency admission to hospital. The aim of this cohort study was to identify factors associated with the ability of UK vascular services to meet this standard of care. METHODS Data on all patients admitted non-electively with CLTI who underwent open or endovascular revascularization between 2016 and 2019 were extracted from the National Vascular Registry. The primary outcome was interval between admission and procedure, analysed as a binary variable (5 days or less, over 5 days). Multivariable Poisson regression was used to examine the relationship between time to revascularization and patient and admission characteristics. RESULTS The study analysed information on 11 398 patients (5973 open, 5425 endovascular), 50.6 per of whom underwent revascularization within 5 days. The median interval between admission and intervention was 5 (i.q.r. 2-9) days. Patient factors associated with increased risk of delayed revascularization were older age, greater burden of co-morbidity, non-smoking status, presentation with infection and tissue loss, and a Fontaine score of IV. Patients admitted later in the week were less likely undergo revascularization within 5 days than those admitted on Sundays and Mondays (P < 0.001). Delays were slightly worse among patients having open compared with endovascular procedures (P = 0.005) and in hospitals with lower procedure volumes (P < 0.001). CONCLUSION Several factors were associated with delays in time to revascularization for patients with CLTI in the UK, most notably the weekday of admission, which reflects how services are organized. The results support arguments for vascular units providing revascularization to have the resources for a 7-day service.
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Affiliation(s)
- P Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Hull York Medical School, Hull, UK
| | - A Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Q Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - I Chetter
- Hull York Medical School, Hull, UK.,Academic Vascular Surgical Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - J R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Leatherby RJ, Shan MR, Antoniou GA. Editor's Choice - Systematic Review and Meta-Analysis of the Effect of Weekend Admission on Outcomes for Ruptured Abdominal Aortic Aneurysms: A Call for an Equitable Seven Day Vascular Service. Eur J Vasc Endovasc Surg 2021; 61:767-778. [PMID: 33632610 DOI: 10.1016/j.ejvs.2020.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 12/01/2020] [Accepted: 12/31/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE "The weekend effect" of higher patient mortality when presenting at a weekend compared with a weekday has been established for several conditions. The aim of this study was to investigate whether a weekend effect exists for the emergency condition of ruptured abdominal aortic aneurysm. DATA SOURCES A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration number CRD42020157484). MEDLINE, EMBASE and CINAHL were searched using the Healthcare Databases Advanced Search interface developed by NICE. REVIEW METHODS The prognostic factor of interest was weekend admission. The primary outcome of interest was all cause peri-operative mortality, with a secondary outcome of hospital length of stay. A random effects meta-analysis was performed, and the results were reported as summary odds ratio (OR) and 95% confidence interval (CI). RESULTS Twelve observational cohort studies published between 2001 and 2019 comprising 14 patient cohorts with a total of 95 856 patients were eligible for quantitative synthesis. Patients presenting on a weekend had a significantly higher risk of unadjusted in hospital mortality (OR 1.20, 95% CI 1.10 - 1.31, p < .001). Both the unadjusted 30 day mortality risk (OR 1.16, 95% CI 0.98 - 1.39, p = .090) and unadjusted 90 day mortality risk (OR 1.12, 95% CI 0.90 - 1.40, p = .30) were higher for those presenting at a weekend, but neither reached statistical significance. There was a significantly greater risk of combined unadjusted in hospital, 30 and 90 day mortality for those presenting at a weekend (OR 1.17, 95% CI 1.09 - 1.27, p < .001). Hospital length of stay was not statistically different between groups. CONCLUSION There is an association between weekend admission and higher mortality in patients presenting with ruptured abdominal aortic aneurysm.
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Affiliation(s)
- Robert J Leatherby
- Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, UK
| | - Madison R Shan
- Department of Medicine, Tameside Hospital, Tameside and Glossop NHS Foundation Trust, Manchester, UK
| | - George A Antoniou
- Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK.
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Mikhail M, Ayling OGS, Eagles ME, Ibrahim GM, Macdonald RL. Association between weekend admissions and mortality after aneurysmal subarachnoid hemorrhage: the "weekend effect" revisited. J Neurosurg 2019; 132:1167-1173. [PMID: 30925472 DOI: 10.3171/2019.1.jns183185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 01/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Higher mortality has been reported with weekend or after-hours patient admission across a wide range of surgical and medical specialties, a phenomenon termed the "weekend effect." The authors evaluated whether weekend admission contributed to death and long-term neurological outcome in patients following aneurysmal subarachnoid hemorrhage. METHODS A post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) study was conducted. Univariable and stepwise multivariable logistic regression analyses were performed to assess the associations between weekend admission and mortality and long-term neurological outcome. RESULTS Of 413 subjects included in the CONSCIOUS-1 study, 140 patients had been admitted during the weekend. A significant interaction was identified between weekend admission and neurological grade on presentation, suggesting that the outcomes of patients who had initially presented with a poor grade were disproportionately influenced by the weekend admission. On stepwise multivariable logistic regression in the subgroup of patients who had presented with a poor neurological grade (29 of 100 patients), admission on the weekend was found to be independently associated with death (OR 6.59, 95% CI 1.62-26.88, p = 0.009). Weekend admission was not associated with long-term neurological outcome. CONCLUSIONS Weekend admission was an independent risk factor for death within 12 weeks following aneurysmal subarachnoid hemorrhage in patients presenting with a poor neurological grade. Further work is required to identify and mitigate any mediating factors.
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Affiliation(s)
| | - Oliver G S Ayling
- 2Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia
| | | | - George M Ibrahim
- 4Division of Neurosurgery, Department of Surgery, Hospital for Sick Children, University of Toronto, Ontario
| | - R Loch Macdonald
- 5Division of Neurosurgery, St. Michael's Hospital.,6Labatt Family Centre of Excellence in Brain Injury and Trauma Research.,7Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital; and.,8Departments of Physiology and Surgery, University of Toronto, Ontario, Canada
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Behrendt CA, Kölbel T, Debus ES, Rieß HC, Sedrakyan A. Reply. J Vasc Surg 2019; 69:1328. [PMID: 30905370 DOI: 10.1016/j.jvs.2018.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Christian-Alexander Behrendt
- Department of Vascular Medicine, Working Group GermanVasc, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, Working Group GermanVasc, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, Working Group GermanVasc, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Christian Rieß
- Department of Vascular Medicine, Working Group GermanVasc, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Art Sedrakyan
- Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
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Botes A, Ambler GK, Boyle JR. Regarding "Impact of weekend treatment on short-term and long-term survival after urgent repair of ruptured aortic aneurysms in Germany". J Vasc Surg 2019; 69:1327. [PMID: 30905369 DOI: 10.1016/j.jvs.2018.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Azel Botes
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, United Kingdom
| | - Graeme K Ambler
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, United Kingdom; Bristol Centre for Surgical Research, University of Bristol, Bristol, United Kingdom
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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