NSTEMI Patients Admitted on the Weekend Less Likely to Receive Early Invasive Care

Patients who present to the hospital with NSTEMI on the weekend are less likely to receive an early invasive strategy than those who are admitted during the week, according to a new study. These findings may have implications for mortality, hospital length of stay, and other acute outcomes, according to the researchers.

Prior studies of the so-called weekend effect have shown higher in-hospital mortality and longer delays to catheterization in patients initially presenting on Saturdays and Sundays—when hospitals typically staff fewer people and resources can be scarce—versus the rest of the week. Guidelines for STEMI patients exist so that they are treated quickly and efficiently no matter the day, but no such strict parameters currently exist for NSTEMI.

“Our observation of higher rates of initial medical therapy and longer wait times to angiography among patients admitted for NSTEMI on weekends versus weekdays is in contradiction to current practice guidelines, reflects inferior care, and may have resulted from poorer staffing,” write lead investigator Sahil Agrawal, MD (St. Luke’s University Health Network, Bethlehem, PA), and colleagues in the September 1, 2016, issue of the American Journal of Cardiology. “Changes in health care policy are thereby warranted to ensure similar availability of guideline-directed therapy for patients with NSTEMI uniformly through the week.”

The latest findings emerged from an analysis of 3.6 million NSTEMI admissions between 2003 and 2011 in the Nationwide Inpatient Sample database. Rates of coronary angiography and an early invasive strategy—defined as coronary angiography with or without PCI performed on days 0 or 1 of admission—increased throughout the study period. However, the researchers found lower odds of both the former (OR 0.88; 95% CI 0.89-0.90) and the latter (OR 0.48; 95% CI 0.47-0.48) in the 25.1% of patients who presented on a Saturday or Sunday versus on a weekday.

Among patients who did receive angiography, there was more likely to be a procedural delay for those admitted on the weekend compared with a weekday (mean 1.31 vs 0.89 days; P < 0.001). Hospital length of stay was also longer for those who presented on the weekend (mean 5.24 vs 5.28 days; P < 0.001).

In-hospital mortality decreased over the study period for both weekend (5.9% to 4.0%) and weekday (5.3% to 3.7%) admissions. Risk of in-hospital mortality was higher for the weekend versus weekday cohort (adjusted OR 1.02; 95% CI 1.01-1.04), although this disparity disappeared after adjustment for use of an early invasive strategy.

Physicians, Hospitals Both Have Responsibility

“The relative risk increase in mortality in weekends is particularly small in this study, but the fact that it disappears with the early intervention included as an explanatory variable just shows how important early inventions are, and particularly in time-sensitive conditions like this,” said Cassie Aldridge, PhD (University of Birmingham, England), commenting on the study for TCTMD.

This study combined with the rest of the “weekend effect” literature precludes the argument over whether the phenomenon exists and should encourage researchers to investigate its causes and determine “what interventions would have the most bang for your buck,” she said.

The causes “behind it are not going to be simple,” Aldridge added. “You can’t just say, ‘You need more doctors. You need more nurses.’ I think it’s going to be complex interplays between different factors.” Ideally, hospitals should be fully operational 7 days a week, she said, “but obviously that’s not going to be possible with hospital budgets, especially here with [the National Health Service].”

While Agarwal acknowledged adding staff might pose a fiscal challenge for many hospitals, he suggested that “if we could get patients out of the hospital sooner, then that might kind of compensate for any increase in costs.” For now, he told TCTMD, hospitals should at least “make sure that patients coming in with NSTEMI or any other acute illness get the same quality of care as they would if they had presented on any other day of the week.”

The onus is on clinicians as much as administrators, he continued. “As physicians, we also need to realize that we may be subconsciously delivering inferior care to patients who come in on the weekend,” Agrawal said. Also, “physicians should probably take home the point that we should try and get them to the cath lab sooner rather than later.”

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• Dying on the Weekend? Not So Fast, Say Two Studies Examining Hospital Care on Saturdays, Sundays
• Women, Elderly, and Weekend Admissions Less Likely to Get Same-Day PCI
• Weekend vs. Weekday Admission Carries No Added Risk for NSTE ACS Patients