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The relationship between off-hours admissions for primary percutaneous coronary intervention, door-to-balloon time and mortality for patients with ST-elevation myocardial infarction in England: a registry-based prospective national cohort study

Jayawardana, Sahan, Salas-Vega, Sebastian, Cornehl, Felix, Mossialos, Elias and Krumholz, Harlan M (2019) The relationship between off-hours admissions for primary percutaneous coronary intervention, door-to-balloon time and mortality for patients with ST-elevation myocardial infarction in England: a registry-based prospective national cohort study. BMJ Quality and Safety. ISSN 2044-5415

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Identification Number: 10.1136/bmjqs-2019-010067

Abstract

Background: The degree to which elevated mortality associated with weekend or night-time hospital admissions reflects poorer quality of care (â off-hours effect') is a contentious issue. We examined if off-hours admissions for primary percutaneous coronary intervention (PPCI) were associated with higher adjusted mortality and estimated the extent to which potential differences in door-to-balloon (DTB) times- A key indicator of care quality for ST elevation myocardial infarction (STEMI) patients-could explain this association. Methods: Nationwide registry-based prospective observational study using Myocardial Ischemia National Audit Project data in England. We examined how off-hours admissions and DTB times were associated with our primary outcome measure, 30-day mortality, using hierarchical logistic regression models that adjusted for STEMI patient risk factors. In-hospital mortality was assessed as a secondary outcome. Results: From 76 648 records of patients undergoing PPCI between January 2007 and December 2012, we included 42 677 admissions in our analysis. Fifty-six per cent of admissions for PPCI occurred during off-hours. PPCI admissions during off-hours were associated with a higher likelihood of adjusted 30-day mortality (OR 1.13; 95% CI 1.01 to 1.25). The median DTB time was longer for off-hours admissions (45 min; IQR 30-68) than regular hours (38 min; IQR 27-58; p<0.001). After adjusting for DTB time, the difference in adjusted 30-day mortality between regular and off-hours admissions for PPCI was attenuated and no longer statistically significant (OR 1.08; CI 0.97 to 1.20). Conclusion: Higher adjusted mortality associated with off-hours admissions for PPCI could be partly explained by differences in DTB times. Further investigations to understand the off-hours effect should focus on conditions likely to be sensitive to the rapid availability of services, where timeliness of care is a significant determinant of outcomes.

Item Type: Article
Official URL: https://qualitysafety.bmj.com/
Additional Information: © 2019 The Authors
Divisions: LSE Health
Health Policy
Subjects: R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
R Medicine > RC Internal medicine
Date Deposited: 30 Nov 2019 11:09
Last Modified: 20 Jun 2020 02:56
URI: http://eprints.lse.ac.uk/id/eprint/102713

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