Off-hours admission and acute stroke care quality: a nationwide study of performance measures and case-fatality

Studies have reported higher risks of death and other adverse outcomes in acute stroke patients admitted off-hours; however, little is known about the underlying mechanisms. According to time of admission, our aim was to examine compliance with performance measures for acute stroke care processes, including the effect of a systematic quality improvement program, and to examine 30 days case-fatality.

A population-based historical cohort study, including patients admitted to Danish hospitals with a first ever acute stroke (January 1, 2003, to December 31, 2011; N=64 975). Off-hours were weekends and evening and nighttime shifts on weekdays. Compliance with performance measures was compared using general linear modeling, and odds ratios for 30 days case-fatality were obtained using multivariable logistic regression.

Patients admitted off-hours had a lower chance of compliance with 8 out of 10 performance measures; however, these differences diminished over time. Unadjusted odds ratio for 30 days case-fatality, for patients admitted off-hours compared with patients admitted on-hours, was 1.15 (95% confidence interval, 1.09-1.21). Adjusting for patient characteristics (in particular, stroke severity) decreased the odds ratio to 1.03 (95% confidence interval, 0.97-1.10). Additional adjustment for hospital characteristics and compliance with performance measures had no effect on the odds ratio.

Patients admitted off-hours received a poorer quality of care. However, the admission time-related differences in care were substantially reduced over time, and the differences in 30 days case-fatality appeared primarily to be explained by differences in stroke severity.