Off-Hour Admission and In-Hospital Stroke Case Fatality in the Get With The Guidelines-Stroke Program

Abstract

Previous reports have shown higher in-hospital mortality for patients with acute stroke who arrived on weekends compared with regular workdays. We analyzed the effect of presenting during off-hours, defined as weekends and weeknights (versus weekdays), on in-hospital mortality and on quality of care in the Get With The Guidelines (GWTG)-Stroke program. We analyzed data from 187 669 acute ischemic stroke and 34 845 acute hemorrhagic stroke admissions who presented to the emergency departments of 857 hospitals that participated in the GWTG-Stroke program during the 4-year period 2003 to 2007. Off-hour presentation was defined as presentation anytime outside of 7:00 am to 6:00 pm on weekdays. Quality of care was measured using standard GWTG quality indicators covering acute, subacute, and discharge measures. The relationship between off-hour presentation and in-hospital case fatality was examined using generalized estimating equation logistic regression adjusting for demographics, risk factors, arrival mode, and hospital characteristics. Half of ischemic stroke admissions and 57% of hemorrhagic stroke admissions presented during off-hours. Among ischemic stroke admissions, the in-hospital case fatality rate was 5.8% for off-hour presentation compared with 5.2% for on-hour presentation (P<0.001). For hemorrhagic stroke admissions, in-hospital case fatality was 27.2% for off-hour presentation compared with 24.1% for on-hour presentation (P<0.001). After adjusting for patient-level and hospital-level factors, presentation during off-hours was significantly associated with higher in-hospital mortality for both ischemic stroke (adjusted OR, 1.09; 95% CI, 1.03 to 1.14) and hemorrhagic stroke admissions (adjusted OR, 1.19; 95% CI, 1.12 to 1.27). No differences were observed between off-hour presentation and any of the quality of care measures. Off-hour presentation was associated with an increased risk of dying in-hospital, although the absolute effect was small for ischemic stroke admissions (0.6% difference; number needed to harm=166) and moderate for hemorrhagic stroke (3.1% difference; number needed to harm=32). Reducing the disparity in hospital-based outcomes for admissions that present during off-hours represents a potential target for quality improvement efforts, although evidence of differences in the quality of care by time of presentation was lacking.