Tuinman, M.P. (2013) Is de uitkomst van CVA-patiënten opgenomen buiten kantooruren minstens even goed vergeleken met CVA-patiënten opgenomen binnen kantooruren? thesis, Medicine.
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Abstract
Background: Previous studies report worse outcome of stroke patients admitted during off-hours (OH) compared to working hours (WH). This “off-hour effect” is attributed to reduced staff levels. Increasing staff levels is expensive and many studies have not taken stroke severity into account. The existence of the off-hour effect has never been questioned with a non-inferiority analysis. We therefore examined whether the outcome of stroke patients admitted during OH was non-inferior to patients admitted during WH, after adjustment for stroke severity. Methods: This retrospective cohort study is a non-inferiority analysis of patients included in the Enschedese Stroke Service. This is an ongoing patient-linked database of patients admitted to the stroke unit of a teaching hospital in Enschede, the Netherlands. Stroke patients were included in our study, categorized by time of admission: during WH (weekdays 08:30 – 16:59) or OH. Primarily, we have compared in-hospital mortality using a Cox-regression analysis. Secondly we analyzed the functional outcome (mRS-score at discharge) and location of discharge, using an ANCOVA-analysis and a logistic regression analysis. In all models, we have integrated a 5% non-inferiority margin. All outcomes were adjusted for clinical severity at admission (NIHSS-score and Glasgow Coma Scale) and characteristics of brain imaging (dense vessel sign and mass effect). Outcomes were also adjusted for possible confounders (mRS-score at admission and eleven cardiovascular risk factors). Analysis was performed on the whole group and separately on patients with ischemic or hemorrhagic stroke. Results: A total of 3667 patients were studied, admitted from January 2003 until November 2012. Overall, 51.2% were admitted during OH. The OH-group had a higher NIHSS-score (p=0.018) and more frequently the presence of a dense vessel sign on brain imaging (p=0.005). In-hospital mortality during OH was 6.5% compared to 7.0% during WH (p=0.470). The adjusted Hazard Ratio of in hospital mortality during OH was 0.740 (95%-CI: 0.576-0.952) for the whole group, 0.727 (95%-CI: 0.523-1.011) for ischemic stroke and 0.746 (95%-CI: 0.503-1.105) for hemorrhagic stroke. Admission during OH caused -0.013 (95%-CI: -0.089 – 0.063) points difference of the mRS-score at discharge. The Odd’s ratio of discharge to other housing was 0.978 (95%-CI: 0.821-1.165) in the OH-group. Results of the secondary outcome measurements of the subgroups were similar to the results of the total study population. Conclusion: Adjusted for stroke severity, we proved that mortality and functional outcome of the OH-group was non-inferior to the WH-group. Therefore we could not demonstrate an off-hour effect for stroke patients admitted in our hospital.
| Item Type: | Thesis (Thesis) |
|---|---|
| Supervisor name: | Brouwers, Dr. P.J.A.M and Stroke Unit and Medisch Spectrum Twente. |
| Faculty: | Medical Sciences |
| Date Deposited: | 25 Jun 2020 10:40 |
| Last Modified: | 25 Jun 2020 10:40 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/156 |
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