Does the "Weekend Effect" for Postoperative Mortality Stand Up to Scrutiny? Association for Cardiothoracic Anesthesia and Critical Care Cohort Study of 110,728 Cardiac Surgical Patients

Outcomes of non-elective coronary artery bypass grafting performed on weekends

OBJECTIVES

A weekend effect with increased mortality has previously been reported in surgical patients and those with acute myocardial infarction (MI). We hypothesized that a similar phenomenon may exist in coronary artery bypass grafting (CABG).

METHODS

Patients undergoing non-elective isolated CABG (2011-2017) were included from a multicentre regional Society of Thoracic Surgeons database. Patients were stratified by weekend versus weekday operations and further analysed by specific day of the week.

RESULTS

A total of 14 374 patients underwent urgent or emergency isolated CABG with 410 (2.9%) operated on over the weekend. Weekend operations were more often emergency (36.1% vs 5.0%, P < 0.001) and more likely to be in the setting of MI (70.0% vs 51.2%, P < 0.001). Cardiopulmonary bypass times were similar [91 min (71-114) vs 94 min (74-117), P = 0.0749] and the frequency of complete revascularization equivalent (83.4% vs 85.3%, P = 0.284) between weekend and weekday operations. In risk-adjusted analyses, there was no increased odds for mortality in patients operated on over the weekend [odds ratio (OR) 1.07, P = 0.811]; however, there was an increased odds of major morbidity (OR 1.37, P = 0.034). Furthermore, compared with Monday, morbidity increased as the operative day approached the weekend (Tuesday 0.98, P = 0.828; Wednesday 1.07, P = 0.469; Thursday 1.12, P = 0.229; Friday 1.19, P = 0.041; weekend 1.47, P = 0.014).

CONCLUSIONS

While patients requiring surgery on the weekend are higher risk, there is no independent effect of weekend surgery on mortality. However, these patients are at increased risk for major morbidity, the causes of which require further investigation.

Association of day of the week with mortality after elective right hemicolectomy for colon cancer: Case analysis from the National Clinical Database

AIM

We aimed to investigate whether later weekdays are related to worse short-term outcomes after elective right hemicolectomy for colon cancer.

METHODS

We retrospectively analyzed adult patients who underwent elective right hemicolectomy for colon cancer between 2012 and 2017. Records lacking details about surgical mortality were excluded, and multiple imputation was performed for other missing data (variables). The primary endpoint was surgical mortality, defined as the sum of 30-day mortality and in-hospital deaths within 90 days postoperatively. Using 22 clinical variables, hierarchal logistic regression modeling with clustering of patients from the same institutes was performed.

RESULTS

Of the 112 658 patients undergoing elective right hemicolectomy for colon cancer, the 30-day mortality and surgical mortality were 0.6% and 1.1%, respectively. Surgery on Friday was less frequent, accounting for 17.1% of all cases. The occurrence of severe postoperative complications, anastomotic leakage, or unadjusted odds ratio for surgical mortality did not show significant differences between weekdays. A hierarchal logistic regression model identified 19 independent factors for surgical mortality. Adjusted odds ratios for surgical mortality were 1.01 (95% confidence interval: 0.83-1.22, P = .915), 0.86 (95% confidence interval: 0.71-1.05, P = .144), 0.86 (95% confidence interval: 0.71-1.05, P = .408), and 0.83 (95% confidence interval: 0.68-1.03, P = .176) for Tuesday, Wednesday, Thursday, and Friday, respectively, showing no significant differences.

CONCLUSION

This study did not identify an evident difference in surgical mortality between weekdays; a safe elective right hemicolectomy for colon cancer is being offered throughout the week in Japan.

Association between the weekday on which coronary artery bypass graft surgery is performed and the 30-day mortality: A nationwide cohort study in South Korea

BACKGROUND

Postoperative mortality associated with elective coronary artery bypass graft (CABG) surgery may reportedly increase as the weekday of surgery approaches the weekend. We aimed to investigate the potential effect of the weekday of CABG surgery on the 30-day mortality.

METHODS

This population-based cohort study analyzed data obtained from the South Korea national health insurance service database. The cohort included all adult patients diagnosed with ischemic heart disease (International Classification of Diseases-10 codes I20*-I25*) who underwent isolated and elective CABG surgery from January 2012 to December 2017.

RESULTS

Of the 13,556 patients included in the analysis, 595 (4.4%) died within 30 days after CABG surgery. In a multivariable Cox model, the 30-day mortality of patients who underwent CABG surgery later in the week (Wednesday-Friday) was not significantly associated with the weekday of surgery as similar to those who underwent surgery early in the week (Monday-Tuesday) (hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 0.97-1.34; p = .109). Multivariable sensitivity analysis revealed that CABG surgery on Friday was associated with a 1.40-fold higher hazard of 30-day mortality (HR: 1.40; 95% CI: 1.09-1.80; p = .008) than CABG surgery on Monday.

CONCLUSIONS

This South Korean population-based cohort study revealed that relative to surgery early in the week (Monday-Tuesday), CABG surgery later in the week (Wednesday-Friday) was not associated with higher 30-day mortality. However, using surgery on Monday as a reference, CABG surgery on Friday was associated with higher 30-day mortality. Future studies must confirm these findings.

Perioperative care in cardiac surgery

As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.