Diurnal variations in the quality of stroke care in Sweden

Abstract

Time of admission affects the quality of care across a wide range of clinical presentations including acute stroke. [1][2][3][4][5][6][7][8][9][10][11] In particular, a recently published meta-analysis revealed increased short-term mortality and disability at discharge in stroke patients who had presented off-hours. 12 However, less is known about the underlying causes of these effects. 13,14 A recent study on general emergency admissions found that the magnitude of the weekend effect was significantly reduced when adjusting for patient comorbidity and common blood tests, suggesting that differences in patient characteristics contribute. 15Objectives: A recent study of acute stroke patients in England and Wales revealed several patterns of temporal variation in quality of care. We hypothesized that similar patterns would be present in Sweden and aimed to describe these patterns.Additionally, we aimed to investigate whether hospital type conferred resilience against temporal variation. Materials and Methods:We conducted this nationwide registry-based study using data from the Swedish Stroke Register (Riksstroke) including all adult patients registered with acute stroke between 2011 and 2015. Outcomes included process measures and survival. We modeled time of presentation as on/off-hours, shifts, day of week, 4-hour, and 12-hour time blocks. We studied hospital resilience by comparing outcomes across hospital types. Results:A total of 113 862 stroke events in 72 hospitals were included. The process indicators and survival all showed significant temporal variation. Door-to-needle (DTN) time within 30 minutes was less likely during nighttime than daytime (OR 0.50; 95% CI 0.41-0.60). Patients admitted during off-hours had lower odds of direct stroke unit (SU) admission (OR 0.72; 95% CI 0.70-0.75). 30-day survival was lower in nighttime vs daytime presentations (OR 0.90, 95% CI 0.84-0.96). The effects of temporal variation differed significantly between hospital types for DTN time within 30 minutes and direct SU admission where university hospitals were more resilient than specialized non-university hospitals. Conclusions:Our study shows that variation in quality of care and survival is present throughout the whole week. We also found that university hospitals were more resilient to temporal variation than specialized non-university hospitals. K E Y W O R D S off-hours, quality of care, stroke, temporal variation, weekend effect, weekly variation S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section at the end of the article. How to cite this article: Darehed D, Blom M, Glader E-L, et al. Diurnal variations in the quality of stroke care in Sweden. Acta

Factors related to time of stroke onset versus time of hospital arrival: A SITS registry-based study in an Egyptian stroke center

“…The study of the Swedish Stroke Registry noted that patients admitted in night time had a lower 30 and 90 day survival than those in daytime. That finding was explained by that door-to-needle time within 30 minutes was less likely during nighttime than daytime [ 26 ]. Interestingly, they found that university hospitals were more resilient to temporal variation- this could be applied to our study- than specialized non-university hospitals.…”

Lifetime risk of stroke in the general male population

“…Despite improvements in treatment, stroke is still the third leading cause of death, following cancer and heart disease . Worldwide, 78% of all stroke events are caused by cerebral infarctions and 22% by a haemorrhage, while, in Western Europe, approximately 85% of all stroke events have an ischaemic origin . Today, stroke is also the leading cause of neurological long‐term disability and almost 30% of stroke survivors are dependent in activities of daily life one year after a stroke .…”

Performance of the RACE Prehospital Triage Score During Working and Nonworking Hours

“…Previous studies have evaluated the impact on door to needle, door to groin puncture, short‐term hospital mortality, and long‐term clinical outcomes in patients presenting to the hospital during working and nonworking hours. A negative “off‐hours effect” in many of these studies has been attributed to less experienced physicians at night, fewer available staff, and lack of advanced imaging availability 4,5 . However, this effect was not detected in patients presenting to CSCs, likely attributable to higher quality of care and efficient stroke protocols 5 .…”

“…A negative "off-hours effect" in many of these studies has been attributed to less experienced physicians at night, fewer available staff, and lack of advanced imaging availability. 4,5 However, this effect was not detected in patients presenting to CSCs, likely attributable to higher quality of care and efficient stroke protocols. 5 As treatment of LVOs advances, attempts to improve efficiency and reduce costs have been made across the stroke systems of care.…”

“…Additionally, less experienced emergency medical personnel often comprise a large portion of night time shifts. Previous studies have demonstrated the feasibility and accuracy of the Rapid Arterial occlusion Evaluation (RACE) scale in a real‐world setting; however, there are limited data on “on versus off” hours variations of prehospital stroke triage when a stroke severity score is used 4 . We sought to compare the positive predictive value (PPV) and clinical outcomes of the prehospital RACE score for the detection of LVO during working hours and nonworking hours.…”