Does Weekend Hospital Admission Affect Upper Gastrointestinal Hemorrhage Outcomes?: A Systematic Review and Network Meta-Analysis

Environmental and Clinical Factors Concerning Gastrointestinal Bleeding: An Umbrella Review of Meta-Analyses

OBJECTIVES

Gastrointestinal bleeding, an emergency and critical disease, is affected by multiple factors. This study aims to systematically summarize and appraise various factors associated with gastrointestinal bleeding.

DESIGN

Umbrella review.

SETTING AND PARTICIPANTS

Meta-analyses that evaluated environmental and clinical factors concerning gastrointestinal bleeding.

METHODS

We conducted a systematic search to identify eligible meta-analyses. For each included study, the risk estimates, heterogeneity estimates, small-study effects, excess significance tests, and publication biases were recalculated and appraised. Furthermore, we considered the methodologic quality and classified the evidence.

RESULTS

In this study, 51 beneficial and 44 harmful associations were found. This study found that preemptive transjugular intrahepatic portosystemic shunt was the most reliable treatment to reduce gastroesophageal variceal bleeding and mortality risk, followed by antibiotics. For gastroduodenal ulcer bleeding, Yunnan Baiyao and proton pump inhibitors (PPIs) were relatively dependable treatment drugs, and the comparatively reliable prophylactic drugs comprised PPIs and H2-receptor antagonists. Patients with hemodynamic instability and larger ulcers had a higher risk of rebleeding. Both weekend admissions and the combination of selective serotonin reuptake inhibitors and nonsteroidal anti-inflammatory drugs were high-risk factors for upper gastrointestinal bleeding and mortality. We also found that tranexamic acid was a credible drug for overall gastrointestinal bleeding. Meanwhile, aspirin, warfarin, diabetes, and renal failure were all high-risk factors.

CONCLUSIONS AND IMPLICATIONS

Altogether, many factors can substantially influence gastrointestinal bleeding. Therefore, in daily life and clinical practice, we should not only remain cautious in prescribing and taking some drugs but also pay attention to the management of lifestyle and underlying diseases. If necessary, protective drugs should be properly supplemented.

Trends for Admission, Mortality and Emergency Surgery in Upper Gastrointestinal Bleeding: A Study of Eight Years of Admissions in a Tertiary Care Hospital

Introduction

Most studies have shown a declining incidence of upper gastrointestinal bleeding (UGIB) in recent years. Data regarding mortality were controversial; in non-variceal bleeding, the increasing age of the population, increased use of anti-thrombotic and anticoagulant therapy in patients with cardiovascular diseases, and the use of non-steroidal anti-inflammatory drugs are counterbalanced by the progress in endoscopic therapy with stable mortality.

Material and Method

We performed a retrospective, cross-sectional study that included patients admitted with UGIB in Clinical Emergency Hospital Craiova during 2013-2020.

Results

3571 patients with UGIB were selected; a trend toward increased admission for UGIB from 2013 to 2019 was noted, with a significant decrease in 2020. Non-variceal bleeding remains the most frequent form, with a slight increase in variceal bleeding, of Mallory-Weiss syndrome and angiodysplasia, and a 3-fold decrease for unknown etiology bleeding (with no endoscopy performed) during the 2017-2020 period as compared to 2013-2016. There was a trend toward decreased mortality, with lower mortality in 2017-2020 (12.83%) compared to 2013-2016 (17.41%). The mortality for variceal bleeding and peptic ulcer bleeding has declined, but mortality for non-variceal bleeding has slightly increased during 2013-2020. Mortality has decreased in admissions during regular hours/after hours and weekdays/weekends, but the difference (off-hours and weekend effects) had increased. The percentage of endoscopies performed in the first 24 hours after admission and the rate of therapeutic endoscopy increased during 2017-2020; the median time between admission and endoscopy was 17.0 hours during 2017-2020 and 59.1 hours during 2013-2016. The proportion of patients who needed emergency surgery for uncontrolled bleeding has significantly declined since 2013-2015, with an average value of 1% in the last 5 years of the study.

Conclusion

Increased admissions for UGIB, with lower mortality, especially for peptic ulcer bleeding and variceal bleeding were noted; higher percentages of therapeutic endoscopies and endoscopies performed during the first 24 hours after admission were also recorded.

The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

Admission on weekends does not increase mortality after hip fracture: a meta-analysis of 1.4 million patients

BACKGROUND

The "weekend" effect resulting in increased complication rates in patients admitted on weekends has been noted in many diseases.

OBJECTIVE

This systematic review and meta-analysis aimed to collate adjusted data from published studies to assess if admission on weekends as compared to weekdays increases mortality rates in hip fracture patients.

METHODS

Databases of PubMed, CENTRAL, Scopus, Web of Science, and Embase were searched up to 31st December 2022 for studies comparing mortality between weekend versus weekday admission of hip fracture patients. Adjusted hazard ratios (HR) were pooled.

RESULTS

Fourteen studies including 1,487,986 patients were analyzed. Most studies were from Europe and North America. Results showed no difference in mortality rates of hip fracture patients admitted on weekends versus weekdays (HR: 1.00 95% 0.96, 1.04 I2 = 75%). There was no publication bias and results did not change on the leave-one-out analysis. Subgroup analysis based on sample size and treatment did not change outcomes.

CONCLUSION

This meta-analysis has shown no apparent weekend effect in cases of hip fractures. Patients admitted on weekends had similar mortality rates as compared to those admitted on weekdays. Current data has high heterogeneity and is mostly from developed countries.

The Reduction of After-Hours and Weekend Effects in Upper Gastro-intestinal Bleeding Mortality During the COVID-19 Pandemic Compared to the Pre-Pandemic Period

Background

In upper gastrointestinal bleeding (UGIB), admissions after normal working hours and during weekends may be associated with increased mortality.

Aim

To assess the evolution of the after-hours and weekend effects during the COVID-19 pandemic as a result of progressive improved management despite management challenges during the pandemic.

Methods

We performed an observational study of patients admitted for UGIB at a tertiary academic center between March 2020 and December 2021, compared to the corresponding timeframe before the pandemic. Admissions were assessed based on regular hours versus after-hours and weekdays versus weekends. We stratified patients based on demographic data, etiology, prognostic scores, the time between symptom onset and admission, as and between admission and endoscopy. The outcomes included mortality, rebleeding rate, the requirement for surgery and transfusion, and hospitalization days.

Results

802 cases were recorded during the pandemic, and 1006 cases before the pandemic. The overall mortality rate was 12.33%. Patients admitted after hours and during weekends had a higher mortality rate compared to those admitted during regular hours and weekdays (15.18% versus 10.22%, and 15.25% versus 11.16%), especially in cases of non-variceal bleeding. However, the difference in mortality rates was reduced by 2/3 during the pandemic, despite the challenges posed by COVID-19 infection. This suggests that there was an equalization effect of care in UGIB, regardless of the admission time. The differences observed in mortality rates for after-hours and weekend admissions seem to be primarily related to a higher proportion of patients who did not undergo endoscopy, while the proportion of severe cases remained similar. Blood requirements, hospital days, and rebleeding rate were similar between the two groups.

Conclusion

Admissions during weekends and after-hours have been associated with increased mortality, particularly in cases of non-variceal bleeding. However, the impact of this association was significantly reduced during the pandemic.

The Impact of Night-time Emergency Department Presentation on Upper Gastrointestinal Hemorrhage Outcomes

GOALS

The aim was to investigate the impact of night-time emergency department (ED) presentation on outcomes of patients admitted for acute upper gastrointestinal hemorrhage (UGIH).

BACKGROUND

The relationship between time of ED presentation and outcomes of gastrointestinal hemorrhage is unclear.

STUDY

Using the 2016 and 2017 Florida State Inpatient Databases which provide times of ED arrival, we identified and categorized adults hospitalized for UGIH to daytime (07:00 to 18:59 h) and night-time (19:00 to 06:59 h) based on the time of ED presentation. We matched both groups with propensity scores, and assessed their clinical outcomes including all-cause in-hospital mortality, in-hospital endoscopy utilization, length of stay (LOS), total hospitalization costs, and 30-day all-cause readmission rates.

RESULTS

Of the identified 38,114 patients with UGIH, 89.4% (n=34,068) had acute nonvariceal hemorrhage (ANVH), while 10.6% (n=4046) had acute variceal hemorrhage (AVH). Compared with daytime patients, ANVH patients admitted at night-time had higher odds of in-hospital mortality (odds ratio: 1.32; 95% confidence interval: 1.06-1.60), lower odds of in-patient endoscopy (odds ratio: 0.83; 95% confidence interval: 0.77-0.90), higher total hospital costs ($9911 vs. $9545, P <0.016), but similar LOS and readmission rates. Night-time AVH patients had a shorter LOS (5.4 vs. 5.8 d, P =0.045) but similar mortality rates, endoscopic utilization, total hospitalization costs, and readmission rates as daytime patients.

CONCLUSIONS

Patients arriving in the ED at night-time with ANVH had worse outcomes (mortality, hospitalization costs, and endoscopy utilization) compared with daytime patients. However, those with AVH had comparable outcomes irrespective of ED arrival time.

No evidence of "weekend effect" in upper gastrointestinal bleeding in Italy: data from a nationwide prospective registry

OBJECTIVES

The literature offers conflicting information about 'weekend effect' in acute upper gastrointestinal bleeding (AUGIB). Aim of our study was to compare clinical outcomes of patients admitted for AUGIB during the weekend or on weekdays in Italy.

METHODS

We analyzed data from a prospective registry of AUGIB (either nonvariceal, NV-AUGIB or variceal, V-AUGIB) from 50 Italian hospitals from January 2014 to December 2015. Mortality, rebleeding, need for salvage procedures and length of hospitalization were compared among patients admitted during the weekend or on weekdays.

RESULTS

In total 2599 patients (mean age 67.4 ± 15.0 years, 69.2% males) were included, 2119 (81.5%) with NV-AUGIB and 480 (18.5%) with V-AUGIB. Totally 494 patients with NV-AUGIB (23.3%) and 129 patients with V-AUGIB (20.7%) were admitted during the weekend. The two study groups were similar in terms of physical status (American Society of Anesthesiologists score, comorbidities) and bleeding-specific prognostic scores. We did not find differences in terms of mortality (5.6 vs. 4.9%; P = 0.48), rebleeding (5.9 vs. 5.1%; P = 0.39), need for salvage procedures (4.0 vs. 3.6%; P = 0.67) or duration of hospitalization (8.5 ± 6.9 vs. 8.3 ± 7.2 days; P = 0.58) between patients admitted during weekend or weekdays. Considering separately NV-AUGIB and V-AUGIB, the only difference found in clinical outcomes was a higher rebleeding risk in patients with V-AUGIB admitted during the weekend (13.2 vs. 7.4%; P = 0.05).

CONCLUSIONS

Data from our large, prospective multicenter registry shows that in Italy there is no significant 'weekend effect' for either NV- or V-AUGIB. Our results show that the Italian hospital network is efficient and able to provide adequate care and an effective therapeutic endoscopy even during the weekend.

Trends in the Epidemiology and Outcomes of Pneumocystis Pneumonia among Human Immunodeficiency Virus (HIV) Hospitalizations

Introduction: Pneumocystis Pneumonia (PCP) is a common opportunistic infection among people living with the human immunodeficiency virus (HIV). This study’s objective was to assess temporal trends in PCP epidemiology among hospitalized patients with HIV/AIDS in the US and to compare data for hospitalizations with HIV with PCP to those without PCP. Methods: The national inpatient sample (NIS) data were analyzed from 2002−2014. The discharge coding identified hospitalized patients with HIV or AIDS and with or without PCP. Results: We identified 3,011,725 hospitalizations with HIV/AIDS during the study period; PCP was present in 5% of the patients with a diagnosis of HIV. The rates of PCP progressively declined from 6.7% in 2002 to 3.5 % in 2014 (p < 0.001). Overall mortality in patients with HIV was 3.3% and was significantly higher in those with PCP than without PCP (9.9% vs. 2.9%; p < 0.001). After adjusting for demographics and other comorbidities, PCP had higher odds of hospital mortality 3.082 (OR 3.082; 95% CI, 3.007 to 3.159; p < 0.001). Conclusion: From 2002 to 2014, the rate of PCP in HIV patients has decreased significantly in the United States but is associated with substantially higher mortality.

Does off-hours endoscopic hemostasis affect outcomes of nonvariceal upper gastrointestinal bleeding?

Aim: Different researches showed controversial results about the 'off-hours effect' in nonvariceal upper gastrointestinal bleeding (NVUGIB). Materials & methods: A total of 301 patients with NVUGIB were divided into regular-hours group and off-hours group based on when they received endoscopic hemostasis, and the relationship of the clinical outcomes with off-hours endoscopic hemostasis was evaluated. Results: Patients who received off-hours endoscopy were sicker and more likely to experience worse clinical outcomes. Off-hours endoscopic hemostasis was a significant predictor of the composite outcome in higher-risk patients (adjusted OR: 4.63; 95% CI: 1.35-15.90). However, it did not associate with the outcomes in lower-risk patients. Conclusion: Off-hours effect may affect outcomes of higher-risk NVUGIB patients receiving endoscopic hemostasis (GBS ≥12).

Outcomes in lower GI bleeding comparing weekend with weekday admission

BACKGROUND AND AIMS

Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospitalization potentially requiring urgent intervention, which may not be readily available at weekends and off-hours. The aim of this study was to examine the association between weekend admission for LGIB and mortality, time to colonoscopy, length of stay, and hospital charges.

METHODS

The 2016 U.S. National Inpatient Sample (NIS) dataset was queried for admissions with a primary diagnosis of LGIB. Outcomes for weekend versus weekday admissions were compared using survey-adjusted chi-squared or bivariate correlation. Multivariable regression was then used to compare primary outcomes adjusting for the Elixhauser mortality score (a validated measure of comorbidities), colonoscopy, transfusion, shock, and hospital type.

RESULTS

An estimated 124,620 patients were admitted for LGIB in 2016. Comparing weekend with weekday admissions, there was no difference in unadjusted mortality (0.9% vs 1.0%, P = .636). Colonoscopy within the first day (28.6% vs 23.0%, P < .001) and transfusion (34.0% vs 31.5%, P < .001) were more common with weekday admissions; no differences in colonoscopy rate (60.7% vs 60.9%, P = .818), angiography rate (2.7% vs 2.7%, P = .976), mean days to colonoscopy (2.0 vs 2.0, P = .233), or length of stay (4.2 vs 4.1 days, P = .068) were seen. There was no difference in multivariable adjusted mortality rates (odds ratio, 1.11; 95% confidence interval, 0.81-1.54; P = .495) based on the above factors.

CONCLUSIONS

Early colonoscopy (within the first day) is more common for weekday admissions, but overall outcomes are not affected by weekend admission for LGIB compared with weekday admissions.