Meeting News

Upper GI hemorrhage more often deadly on weekends

Ashutosh Gupta, MD
Ashutosh Gupta

ORLANDO — Patients with nonvariceal upper GI hemorrhage showed a significantly higher mortality risk when admitted to hospitals in the U.S. on weekends, according to research presented at the World Congress of Gastroenterology at ACG 2017.

Investigators noted this “weekend effect” could be due to delay in endoscopy due to lack of endoscopic services on weekends.

“Overall there is increased mortality when the weekend rounder is not available,” Ashutosh Gupta, MD, a gastroenterologist at the Medical Center Hospital/ProCare Gastroenterology in Odessa, Texas, said during his presentation. “The weekend effect is definitely seen in patients with non-variceal bleeding — not much with variceal bleeding — timing of endoscopy seems to play a crucial role here, and I think we all should ensure we have consistent quality and access to care throughout the week.”

Studies on the weekend effect — which refers to the poorer outcomes seen among patients admitted to the hospital on weekends or holidays, possibly due to reduced staffing, procedural delay, and patients being in critical condition — are conflicting in upper GI hemorrhage, Gupta said. Therefore, he and colleagues, including Rajender Agarwal, MD, director of Center for Health Reform in Dallas, Texas, and Ashwin Ananthakrishnan, MD, of the division of gastroenterology at Massachusetts General Hospital, reviewed related medical literature published up to 2017, and included 20 studies in their meta-analysis (n = 592,293; 15 retrospective), which were performed across North America, Europe and Asia.

Ashwin Ananthakrishnan, MD
Ashwin Ananthakrishnan

Overall, they found no association between weekend admission and increased mortality in patients with upper GI hemorrhage (OR = 1.05; 95% CI, 0.98-1.14). However, the association became significant in a subgroup analysis of eight studies that did not mention a weekend rounder (OR = 1.12; 95% CI, 1.06-1.18). Further, a subgroup analysis of studies that did mention having a weekend rounder showed a reduction in mortality, but this did not reach significance (OR = 0.82; 95% CI, 0.62-1.1).

“There was no difference in mortality in a subgroup analysis done for variceal bleeding, which is the less common type seen in advanced liver patients/cirrhosis, and this appeared to be related to the timing of endoscopy,” Gupta told Healio Gastroenterology and Liver Disease. “Hospitals and physicians seem to act faster when it is a variceal bleeder, since the bleeding can be rapid and fatal. However, when data for nonvariceal bleeding (that includes peptic ulcers, esophagitis, gastritis, arterio-venous malformations, Dieulafoy’s lesion) was analyzed, there appeared to be a small but significant increase in mortality for weekend admissions [OR = 1.12; 95% CI, 1.07-1.16].”

Again, timing of endoscopy appeared important, with six of the studies revealing an association between mortality risk and weekend vs. weekday endoscopy (OR = 1.11; 95% CI, 1.07-1.15).

Finally, Gupta noted that the weekend effect was observed in the U.S. (OR = 1.1; 95% CI, 1.06-1.15) but not in studies performed in Europe of Asia.

“Possible explanation for this could be the nature of large databases included in the studies done in [the] U.S.,” he said in an email. “The authors had no way to look into the specifics about the availability of a weekend rounder, and the samples came from National Inpatient Sample (NIS), that includes the largest database for hospital discharges in the country.”

Gupta cautioned that the data were largely from retrospective, observational studies, and emphasized that not mentioning a weekend rounder does not necessarily mean the hospital did not have one available.

“I believe if we took only hospitals that had clearly mentioned no weekend rounder, the mortality rate would have been higher,” he said. “More studies need to be done to look into the availability of a weekend rounder rather than just weekend admissions as a priority. It would be hard for the hospitals to report data on mortality for a weekend admission when they do not have a weekend rounder available.” – by Adam Leitenberger

References:

Gupta A, et al. Abstract 29. Presented at: World Congress of Gastroenterology at American College of Gastroenterology Annual Scientific Meeting; Oct. 13-18, 2017; Orlando, FL.

Disclosures: The researchers report no relevant financial disclosures.

 

Ashutosh Gupta, MD
Ashutosh Gupta

ORLANDO — Patients with nonvariceal upper GI hemorrhage showed a significantly higher mortality risk when admitted to hospitals in the U.S. on weekends, according to research presented at the World Congress of Gastroenterology at ACG 2017.

Investigators noted this “weekend effect” could be due to delay in endoscopy due to lack of endoscopic services on weekends.

“Overall there is increased mortality when the weekend rounder is not available,” Ashutosh Gupta, MD, a gastroenterologist at the Medical Center Hospital/ProCare Gastroenterology in Odessa, Texas, said during his presentation. “The weekend effect is definitely seen in patients with non-variceal bleeding — not much with variceal bleeding — timing of endoscopy seems to play a crucial role here, and I think we all should ensure we have consistent quality and access to care throughout the week.”

Studies on the weekend effect — which refers to the poorer outcomes seen among patients admitted to the hospital on weekends or holidays, possibly due to reduced staffing, procedural delay, and patients being in critical condition — are conflicting in upper GI hemorrhage, Gupta said. Therefore, he and colleagues, including Rajender Agarwal, MD, director of Center for Health Reform in Dallas, Texas, and Ashwin Ananthakrishnan, MD, of the division of gastroenterology at Massachusetts General Hospital, reviewed related medical literature published up to 2017, and included 20 studies in their meta-analysis (n = 592,293; 15 retrospective), which were performed across North America, Europe and Asia.

Ashwin Ananthakrishnan, MD
Ashwin Ananthakrishnan

Overall, they found no association between weekend admission and increased mortality in patients with upper GI hemorrhage (OR = 1.05; 95% CI, 0.98-1.14). However, the association became significant in a subgroup analysis of eight studies that did not mention a weekend rounder (OR = 1.12; 95% CI, 1.06-1.18). Further, a subgroup analysis of studies that did mention having a weekend rounder showed a reduction in mortality, but this did not reach significance (OR = 0.82; 95% CI, 0.62-1.1).

“There was no difference in mortality in a subgroup analysis done for variceal bleeding, which is the less common type seen in advanced liver patients/cirrhosis, and this appeared to be related to the timing of endoscopy,” Gupta told Healio Gastroenterology and Liver Disease. “Hospitals and physicians seem to act faster when it is a variceal bleeder, since the bleeding can be rapid and fatal. However, when data for nonvariceal bleeding (that includes peptic ulcers, esophagitis, gastritis, arterio-venous malformations, Dieulafoy’s lesion) was analyzed, there appeared to be a small but significant increase in mortality for weekend admissions [OR = 1.12; 95% CI, 1.07-1.16].”

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Again, timing of endoscopy appeared important, with six of the studies revealing an association between mortality risk and weekend vs. weekday endoscopy (OR = 1.11; 95% CI, 1.07-1.15).

Finally, Gupta noted that the weekend effect was observed in the U.S. (OR = 1.1; 95% CI, 1.06-1.15) but not in studies performed in Europe of Asia.

“Possible explanation for this could be the nature of large databases included in the studies done in [the] U.S.,” he said in an email. “The authors had no way to look into the specifics about the availability of a weekend rounder, and the samples came from National Inpatient Sample (NIS), that includes the largest database for hospital discharges in the country.”

Gupta cautioned that the data were largely from retrospective, observational studies, and emphasized that not mentioning a weekend rounder does not necessarily mean the hospital did not have one available.

“I believe if we took only hospitals that had clearly mentioned no weekend rounder, the mortality rate would have been higher,” he said. “More studies need to be done to look into the availability of a weekend rounder rather than just weekend admissions as a priority. It would be hard for the hospitals to report data on mortality for a weekend admission when they do not have a weekend rounder available.” – by Adam Leitenberger

References:

Gupta A, et al. Abstract 29. Presented at: World Congress of Gastroenterology at American College of Gastroenterology Annual Scientific Meeting; Oct. 13-18, 2017; Orlando, FL.

Disclosures: The researchers report no relevant financial disclosures.

 

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