Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis

Zha, Mingming; Yang, Qian; Liu, Shuo; Wu, Min; Huang, Kangmo; Cai, Haodi; Zhang, Xiaohao; Lv, Qiushi; Li, Rui; Yang, Dong; Liu, Xinfeng

doi:10.1177/17474930211012545

Cited by 5 publications

(6 citation statements)

References 42 publications

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“… 17 A recent meta-analysis also indicates that off-hour is associated with prevalent delays before EVT. 19 But some studies indicate that pre-EVT time metrics are not influenced by the off-hour effect. 14 15 Disparities in time metrics might result from the differences in EVT workflows in various stroke centres and heterogeneous definitions of off-hour.…”

Section: Discussionmentioning

confidence: 99%

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Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry

et al. 2021

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Background and purposeWhether the off-hour effect has an impact on workflow and outcomes of endovascular treatment (EVT) for anterior circulation large vessel occlusion (AC-LVO) remains uncertain. This study aimed to compare the characteristics and outcomes of patients who presented or were treated during off-hour versus on-hour in a multi-center registry.MethodsAC-LVO patients from 21 centres were categorised into the off-hour group and the on-hour group. Off-hour (weekends, holidays, and 18:00–7:59 on weekdays) and on-hour (8:00–17:59 on weekdays except for holidays) were defined according to arrival and groin-puncture time points, respectively. Subgroup comparisons between patients both arrived and treated during off-hour (true off-hour) and on-hour (true on-hour) were performed. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Secondary outcomes included favourable outcome (mRS 0–2 at 90 days), EVT-related time metrics, and other clinical outcomes. Ordinary and binary logistic regression and linear regression were taken to adjust for confounding factors.ResultsOf all 698 patients enrolled, 435 (62.3%) and 456 (65.3%) patients were categorised into the off-hour arrival and off-hour puncture group, respectively. Shorter onset to door time (adjusted ß coefficient: −21.56; 95% CI −39.96 to −3.16; p=0.022) was noted in the off-hour arrival group. Ordinal and dichotomous mRS scores at 90 days were comparable between the off-hour group and the on-hour group regardless of off-hour definitions. Other time metrics and outcomes were comparable between the two groups. Of 595 patients both presented and were treated during off-hour or on-hour, 394 patients were categorised into the true off-hour group and 201 into the true on-hour group. Time metrics and clinical outcomes were similar between the true off-hour and the true on-hour group.ConclusionsThe off-hour effect was not significant regarding clinical outcomes and in-hospital workflow in AC-LVO patients receiving EVT in this Chinese multicentre registry.

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Section: Discussionmentioning

confidence: 99%

“… 1 13–18 The definition of off-hour varies in different studies. 19 Some studies define the off-hour group according to arrival time, 2 13–15 17 20–23 and some according to groin-puncture time. 1 3 16 18 24–26 Whether the effect will change or not when grouped by different reference time point remains uncertain.…”

Section: Introductionmentioning

confidence: 99%

Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry

et al. 2021

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“…Many healthcare systems have since established or improved 24/7/365 coverage of EVT, while others are still struggling with this endeavor 2–4. However, even when complete coverage has been achieved, the quality of EVT may differ across regions or in different time windows 5 6…”

Section: Introductionmentioning

confidence: 99%

“…Previous studies have investigated the influence of treatment time of day on patient outcome in stroke with large vessel occlusion, but most of these studies were either small,9 focused on single specialized tertiary care centers10 11 and/or investigated cohorts before publication of large randomized controlled trials on EVT 12. Such variations likely explain the different results of these individual studies, although a meta-analysis found treatment delays and lower rates of successful recanalization in stroke patients treated with EVT outside core working hours 6. A recent study from the German Stroke Registry found worse outcomes in patients treated with EVT who had longer time intervals to recanalization, reporting longer door-to-groin time at night-time and weekends 13…”

Section: Introductionmentioning

confidence: 99%

Endovascular stroke therapy outside core working hours in a nationwide stroke system

Fandler‐Höfler

Mikšová

Deutschmann

et al. 2023

J NeuroIntervent Surg

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BackgroundEndovascular therapy (EVT) has been established as a major component in the acute treatment of large vessel occlusion stroke. However, it is unclear whether outcome and other treatment-related factors differ if patients are treated within or outside core working hours.MethodsWe analyzed data from the prospective nationwide Austrian Stroke Unit Registry capturing all consecutive stroke patients treated with EVT between 2016 and 2020. Patients were trichotomized according to the time of groin puncture into treatment within regular working hours (08:00–13:59), afternoon/evening (14:00–21:59) and night-time (22:00–07:59). Additionally, we analyzed 12 EVT treatment windows with equal patient numbers. Main outcome variables included favorable outcome (modified Rankin Scale scores of 0–2) 3 months post-stroke as well as procedural time metrics, recanalization status and complications.ResultsWe analyzed 2916 patients (median age 74 years, 50.7% female) who underwent EVT. Patients treated within core working hours more frequently had a favorable outcome (42.6% vs 36.1% treated in the afternoon/evening vs 35.8% treated at night-time; p=0.007). Similar results were found when analyzing 12 treatment windows. All these differences remained significant in multivariable analysis adjusting for outcome-relevant co-factors. Onset-to-recanalization time was considerably longer outside core working hours, which was mainly explained by longer door-to-groin time (p<0.001). There was no difference in the number of passes, recanalization status, groin-to-recanalization time and EVT-related complications.ConclusionsThe findings of delayed intrahospital EVT workflows and worse functional outcomes outside core working hours in this nationwide registry are relevant for optimization of stroke care, and might be applicable to other countries with similar settings.

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“…5 Time of day and day of week have been demonstrated to influence performance metrics and clinical outcomes on different medical conditions. [6][7][8] Arrival during nonregular working hours or nighttime has been associated with time delays in workflow times in patients with an acute ischemic stroke, [9][10][11] although contradictory results have been reported about its influence on clinical outcome. 12,13 Nighttime might increase time delays during acute stroke workflow stages and influence differently the 2 transport modalities, given that the management of patients initially evaluated at a local stroke center requires greater coordination and may be more susceptible to delays during interhospital transfers and understaffed healthcare services.…”

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confidence: 99%

Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia

García‐Tornel

Flores

Terceño

et al. 2023

Stroke

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Background: We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020. Methods: We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am –8:59 pm ) and nighttime (9:00 pm –7:59 am ). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated. Results: We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020–2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680–1.163]; P interaction =0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548–1.072]; nighttime, acOR, 1.785 [95% CI, 1.024–3.112] ; P interaction <0.01); no heterogeneity was observed for other stroke subtypes ( P interaction >0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers. Conclusions: Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02795962.

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Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis

Cited by 5 publications

References 42 publications

Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry

Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry

Endovascular stroke therapy outside core working hours in a nationwide stroke system

Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia

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