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Florissi I, Radomski SN, Shou B, Cloyd JM, Kim A, Grotz T, Fournier K, Baumgartner JM, Lambert L, Abbott DE, Schwartz P, Staley CA, Clarke C, Dineen S, Patel SH, Wilson GC, Raoof M, Johnston FM, Greer JB. Weekend Discharge Is Not Associated With Increased Readmission After Hyperthermic Intraperitoneal Chemotherapy. J Surg Res 2024; 293:403-412. [PMID: 37806228 DOI: 10.1016/j.jss.2023.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/18/2023] [Accepted: 08/26/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION We explored the association between weekend discharge and 30- and 90-d readmission rates in patients undergoing hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal carcinomatosis. METHODS The US HIPEC Collaborative database, comprised of a longitudinal cohort of patients undergoing CRS/HIPEC for peritoneal carcinomatosis at twelve academic institutions between 2000 and 2017, was queried for date of discharge information. Patients were retrospectively divided into weekday and weekend/holiday discharge groups. Patients <18 y old, lacking day of discharge information, or who experienced intraoperative/in-hospital mortality were excluded. Comparisons were made between patients discharged on a weekday versus those discharged on a weekend or major holiday. RESULTS 1415 patients met inclusion criteria for the study: 1108 (78%) patients with a weekday discharge and 308 (22%) with a weekend/holiday discharge. Median age at time of surgery was 55 y (Interquartile Range: 46-63); 59% (n = 841) patients were female, 25% (n = 328) of patients had high volume disease (defined as a peritoneal cancer index >20 intraoperatively), and 92% (n = 1210) of patients had a complete cytoreduction (defined as a completeness of cytoreduction score of 0 or 1). Overall, 15% (n = 218) of patients were readmitted within 30 d and 19% (n = 265) within 90 d. In a linear mixed effects model, weekend discharge was not associated with higher 30- or 90-d readmissions (P = 0.291, P = 0.743). CONCLUSIONS Weekend discharges are safe following CRS/HIPEC. Length of stay initiatives should focus on discharging the patient when medically ready, rather than avoiding weekend discharge out of an abundance of caution.
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Affiliation(s)
- Isabella Florissi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Benjamin Shou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alex Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Travis Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, La Jolla, California
| | - Laura Lambert
- Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Patrick Schwartz
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sean Dineen
- Moffitt Cancer Center, Department of Gastrointestinal Oncology, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, Florida
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mustafa Raoof
- City of Hope National Medical Center, Department of Surgery, Duarte, California
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Chiou LJ, Chen HM, Pan LF, Lee CC. Holiday ratio of hospitalization and 30-day readmission rates among cancer patients after major surgery. Cancer Med 2021; 11:743-752. [PMID: 34904394 PMCID: PMC8817097 DOI: 10.1002/cam4.4482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 10/16/2021] [Accepted: 11/15/2021] [Indexed: 11/24/2022] Open
Abstract
Background To determine the association of 30‐day readmission with weekend discharge and the number of holiday days during a hospital stay (holiday ratio). Methods This retrospective cohort study used the clinical research database and cancer registry data of our hospital from January 1, 2011 to December 31, 2017. Patient characteristics, tumor factors, clinical laboratory data, and proxies of continuity of care, such as weekend discharge or holiday ratio (holiday days/total hospitalization days), received statistical analysis. Multivariate logistic regression identified the independent factors for 30‐day potentially avoidable readmission rate (PAR). Results Of 1433 patients receiving tumor resection, 520 (36.29%) had colon cancer; 440 (30.70%) had head and neck cancer (HNC), and 473 (33.01%) had other cancers (lung, liver, and prostate). The rate of 30‐day PAR was 6.3% for those with colon cancer, 8.6% for HNC, and 3.6% for other cancers. The 30‐day PAR did not significantly differ by discharge on a weekend versus weekday for those with colon cancer (8.33% vs. 5.90%; p = 0.379), HNC (7.06% vs. 9.01%; p = 0.566), or other cancers (0.00% vs. 4.28%; p = 0.960). Colon cancer patients with holiday ratio >0.3 had a higher readmission rate (9.58% vs. 4.82%, p = 0.041). In multivariate analysis, a holiday ratio >0.3 (adjusted odds ratio 2.16; 95% Confidence Interval, 1.05–4.39) in those with colon cancer was an independent predictor of 30‐day PAR. Conclusions Weekend discharge after major surgery did not affect 30‐day readmission rates in cancer patients, but the holiday ratio did affect 30‐day PAR for those with colon cancer.
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Affiliation(s)
- Ling-Jan Chiou
- Department of Health Business Administration, Department of Nursing, and Department of Oral Hygiene, Meiho University, Pingtung, Taiwan
| | - Hsiu-Min Chen
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Li-Fei Pan
- Department of Medical Affair Administration, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ching-Chih Lee
- Department of Otolaryngology, Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Institute of Hospital and Health Care Administration, National Yang Ming Chao Tung University, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan
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Son YJ, Lee HJ, Lim SH, Hong J, Seo EJ. Predictors of unplanned 30-day readmissions after coronary artery bypass graft: a systematic review and meta-analysis of cohort studies. Eur J Cardiovasc Nurs 2021; 20:717-725. [PMID: 33864067 DOI: 10.1093/eurjcn/zvab023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 11/14/2022]
Abstract
AIMS Coronary artery bypass graft (CABG) is one of the most performed cardiac surgery globally. CABG is known to have a high rate of short-term readmissions. The 30-day unplanned readmission rate as a quality measure is associated with adverse health outcomes. This study aimed to identify and synthesize the perioperative risk factors for 30-day unplanned readmission after CABG. METHODS AND RESULTS We systematically searched seven databases and reviewed studies to identify all eligible English articles published from 1 October 1999 to 30 September 2019. Random-effect models were employed to perform pooled analyses. Odds ratio and 95% confidence interval were used to estimate the risk factors for 30-day unplanned readmission. The 30-day hospital readmission rates after CABG ranged from 9.2% to 18.9% in 14 cohort studies. Among preoperative characteristics, older adults, female, weight loss, high serum creatinine, anticoagulant use or dialysis, and comorbidities were found to be statistically significant. Postoperative complications, prolonged length of hospital stay, and mechanical ventilation were revealed as the postoperative risk factors for 30-day unplanned readmission. However, intraoperative risk factors were not found to be significant in this review. CONCLUSION Our findings emphasize the importance of a comprehensive assessment during the perioperative period of CABG. Healthcare professionals can perform a readmission risk stratification and develop strategies to reduce readmission rates after CABG using the risk factors identified in this review. Future studies with prospective cohort samples are needed to identify the personal or psychosocial factors influencing readmission after CABG, including perioperative risk factors.
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Affiliation(s)
- Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, Seoul 06974, Republic of Korea
| | - Hyeon-Ju Lee
- Department of Nursing, Tongmyoung University, Busan 48520, Republic of Korea
| | - Sang-Hyun Lim
- Department of Thoracic and Cardiovascular Surgery, Ajou University, Suwon 16499, Republic of Korea
| | - Joonhwa Hong
- Department of Thoracic and Cardiovascular Surgery, Chung-Ang University, Seoul 06974, Republic of Korea
| | - Eun Ji Seo
- Ajou University College of Nursing and Research Institute of Nursing Science, 164, Worldcup-Ro, Yeongtong-Gu, Suwon 16499, Republic of Korea
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Ahmadi N, Marshall MB. Commentary: TGIF? Not if You're Getting a Lobectomy. Semin Thorac Cardiovasc Surg 2021; 33:902-903. [PMID: 33600981 DOI: 10.1053/j.semtcvs.2021.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Negar Ahmadi
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - M Blair Marshall
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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Son AY, Karim AS, Fiehler M, Andrei AC, Vassallo P, Churyla A, Pham DT, McCarthy PM, Chris Malaisrie S. Outcomes of 3-day discharge after elective cardiac surgery. J Card Surg 2021; 36:1441-1447. [PMID: 33567130 DOI: 10.1111/jocs.15404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/06/2020] [Accepted: 12/14/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Shorter length of stay (LOS) is a welcome consequence of optimized perioperative care. However, accelerated hospital discharge may have unintended consequences. Before implementing an institutional enhanced recovery after surgery protocol, we evaluated the safety of shorter LOS and compared outcomes of patients with shorter LOS (LOS ≤ 3 days) to those with longer LOS (LOS > 3 days). METHODS We identified all patients undergoing elective cardiac surgery with cardiopulmonary bypass between July 2004 and June 2017. Transcatheter approaches, ventricular assist devices, transplants, and traumas were excluded. Patients were divided into two cohorts, one with shorter hospitalizations (LOS ≤ 3 days) and one with longer hospitalizations (LOS > 3 days). Propensity score matching (PSM) was performed and differences between the two groups were compared. RESULTS A total of 5,987 patients (63.0 ± 13.8 years old, 34% female) were identified and 131 (2.2%) patients were LOS ≤ 3 days; median STS Risk score was 1.2 (0.6-2.4). PSM resulted in a total of 478 patients (357 LOS > 3 and 121 LOS ≤ 3 days); median STS Risk score was 0.4 (0.3-0.9). LOS ≤ 3 days had lower rates of postoperative atrial fibrillation (2% vs. 19%; p < .001) and major in-hospital complications (0% vs. 9%; p = .001); however, 30-day readmissions (8% LOS ≤ 3 vs. 6% LOS > 3 days; p = .66) and mortality rates (0% vs. 0%) were comparable between the two groups. CONCLUSION LOS ≤ 3 days was associated with less postoperative atrial fibrillation and fewer major in-hospital complications. LOS ≤ 3 days was not associated with rehospitalization or mortality. Shorter LOS after elective cardiac surgery appears to be a safe practice with favorable outcomes, especially in low operative risk patients.
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Affiliation(s)
- Andre Y Son
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Azad S Karim
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Monica Fiehler
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Adin-Cristian Andrei
- Division of Biostatistics, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Patricia Vassallo
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Andrei Churyla
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Duc Thinh Pham
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Patrick M McCarthy
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
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Glans M, Kragh Ekstam A, Jakobsson U, Bondesson Å, Midlöv P. Risk factors for hospital readmission in older adults within 30 days of discharge - a comparative retrospective study. BMC Geriatr 2020; 20:467. [PMID: 33176721 PMCID: PMC7659222 DOI: 10.1186/s12877-020-01867-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The area of hospital readmission in older adults within 30 days of discharge is extensively researched but few studies look at the whole process. In this study we investigated risk factors related, not only to patient characteristics prior to and events during initial hospitalisation, but also to the processes of discharge, transition of care and follow-up. We aimed to identify patients at most risk of being readmitted as well as processes in greatest need of improvement, the goal being to find tools to help reduce early readmissions in this population. METHODS This comparative retrospective study included 720 patients in total. Medical records were reviewed and variables concerning patient characteristics prior to and events during initial hospital stay, as well as those related to the processes of discharge, transition of care and follow-up, were collected in a standardised manner. Either a Student's t-test, χ2-test or Fishers' exact test was used for comparisons between groups. A multiple logistic regression analysis was conducted to identify variables associated with readmission. RESULTS The final model showed increased odds of readmission in patients with a higher Charlson Co-morbidity Index (OR 1.12, p-value 0.002), excessive polypharmacy (OR 1.66, p-value 0.007) and living in the community with home care (OR 1.61, p-value 0.025). The odds of being readmitted within 30 days increased if the length of stay was 5 days or longer (OR 1.72, p-value 0.005) as well as if being discharged on a Friday (OR 1.88, p-value 0.003) or from a surgical unit (OR 2.09, p-value 0.001). CONCLUSION Patients of poor health, using 10 medications or more regularly and living in the community with home care, are at greater risk of being readmitted to hospital within 30 days of discharge. Readmissions occur more often after being discharged on a Friday or from a surgical unit. Our findings indicate patients at most risk of being readmitted as well as discharging routines in most need of improvement thus laying the ground for further studies as well as targeted actions to take in order to reduce hospital readmissions within 30 days in this population.
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Affiliation(s)
- Maria Glans
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Center, Box 50332, 20213, Malmö, Sweden. .,Department of Medications, Region Skåne Office for Hospitals in Northeastern Skåne, SE-291 85, Kristianstad, Sweden.
| | - Annika Kragh Ekstam
- Department of Orthopaedics, Region Skåne Office for Hospitals in Northeastern Skåne, SE-291 85, Kristianstad, Sweden
| | - Ulf Jakobsson
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Center, Box 50332, 20213, Malmö, Sweden
| | - Åsa Bondesson
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Center, Box 50332, 20213, Malmö, Sweden.,Department of Medicines Management and Informatics in Skåne County, SE-291 85, Kristianstad, Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Center, Box 50332, 20213, Malmö, Sweden
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Voeten DM, van der Werf LR, van Sandick JW, van Hillegersberg R, van Berge Henegouwen MI; Dutch Upper Gastrointestinal Cancer Audit Group. Length of hospital stay after uncomplicated esophagectomy. Hospital variation shows room for nationwide improvement. Surg Endosc 2020. [PMID: 33104919 DOI: 10.1007/s00464-020-08103-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/16/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Within the scope of value-based health care, this study aimed to analyze Dutch hospital performance in terms of length of hospital stay after esophageal cancer surgery and its association with 30-day readmission rates. Since both parameters are influenced by the occurrence of complications, this study only included patients with an uneventful recovery after esophagectomy. METHODS All patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) who underwent a potentially curative esophagectomy between 2015 and 2018 were considered for inclusion. Patients were excluded in case of an intraoperative/post-operative complication, readmission to the intensive care unit, or any re-intervention. Length of hospital stay was dichotomized around the national median into 'short admissions' and 'long admissions'. Hospital variation was evaluated using a case-mix-corrected funnel plot based on multivariable logistic regression analyses. Association of length of hospital stay with 30-day readmission rates was investigated using the χ2-statistic. RESULTS A total of 1007 patients was included. National median length of hospital stay was 9 days, ranging from 6.5 to 12.5 days among 17 hospitals. The percentage of 'short admissions' per hospital ranged from 7.7 to 93.5%. After correction for case-mix variables, 3 hospitals had significantly higher 'short admission' rates and 4 hospitals had significantly lower 'short admission' rates. Overall, 6.2% [hospital variation (0.0-13.2%)] of patients were readmitted. Hospital 30-day readmission rates were not significantly different between patients with a short length of hospital stay and those with a long length of hospital stay (5.5% versus 7.6%; p = 0.19). CONCLUSIONS Based on these nationwide audit data, median length of hospital stay after an uncomplicated esophagectomy was 9 days ranging from 6.5 to 12.5 days among Dutch hospitals. There was no association between length of hospital stay and readmission rates. Nationwide improvement might lead to a substantial reduction of hospital costs.
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Chiu CY, Oria D, Yangga P, Kang D. Quality assessment of weekend discharge: a systematic review and meta-analysis. Int J Qual Health Care 2020; 32:347-355. [PMID: 32453404 DOI: 10.1093/intqhc/mzaa060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/13/2020] [Accepted: 05/07/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Hospital bed utility and length of stay affect the healthcare budget and quality of patient care. Prior studies already show admission and operation on weekends have higher mortality rates compared with weekdays, which has been identified as the 'weekend effect.' However, discharges on weekends are also linked with quality of care, and have been evaluated in the recent decade with different dimensions. This meta-analysis aims to discuss weekend discharges associated with 30-day readmission, 30-day mortality, 30-day emergency department visits and 14-day follow-up visits compared with weekday discharges. DATA SOURCES PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov were searched from January 2000 to November 2019. STUDY SELECTION Preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Only studies published in English were reviewed. The random-effects model was applied to assess the effects of heterogeneity among the selected studies. DATA EXTRACTION Year of publication, country, sample size, number of weekday/weekend discharges, 30-day readmission, 30-day mortality, 30-day ED visits and 14-day appointment follow-up rate. RESULTS OF DATA SYNTHESIS There are 20 studies from seven countries, including 13 articles from America, in the present meta-analysis. There was no significant difference in odds ratio (OR) in 30-day readmission, 30-day mortality, 30-day ED visit, and 14-day follow-up between weekday and weekend. However, the OR for 30-day readmission was significantly higher among patients in the USA, including studies with high heterogeneity. CONCLUSION In the USA, the 30-day readmission rate was higher in patients who had been discharged on the weekend compared with the weekday. However, interpretation should be cautious because of data limitation and high heterogeneity. Further intervention should be conducted to eliminate any healthcare inequality within the healthcare system and to improve the quality of patient care.
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Affiliation(s)
- Chia-Yu Chiu
- Department of Internal Medicine, Lincoln Medical Center, Room 8-20, 234 E 149th St, New York, NY 10451, USA
| | - David Oria
- Department of Internal Medicine, Lincoln Medical Center, Room 8-20, 234 E 149th St, New York, NY 10451, USA
| | - Peter Yangga
- Department of Internal Medicine, Lincoln Medical Center, Room 8-20, 234 E 149th St, New York, NY 10451, USA
| | - Dasol Kang
- Department of Internal Medicine, Lincoln Medical Center, Room 8-20, 234 E 149th St, New York, NY 10451, USA
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