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Research Article | DOI: https://doi.org/10.31579/2692-9392/125
1 Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto,Portugal.
2 Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar Universitário do Porto,Porto, Portugal.
*Corresponding Author: Daniela Falcão, Gastroenterology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal, and João Cruz, Instituto de Ciências Biomédicas Abel Salazar, Centro Hospitalar Universitário do Porto, Porto, Portugal.
Citation: Daniela Falcão, João Cruz, Joana Silva, Professora Doutora Isabel Pedroto, (2022) Weekend Hospitalization in Nonvariceal Upper Gastrointestinal Bleeding – an Additional Risk?. J. Archives of Medical Case Reports and Case Study, 6(2); DOI:10.31579/2692-9392/125
Copyright: © 2022 Daniela Falcão and João Cruz, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 02 May 2022 | Accepted: 06 June 2022 | Published: 10 June 2022
Keywords: weekend effect; upper gi bleeding; nonvariceal; rebleeding, mortality
Introduction: Weekend admission has been related to worse outcomes. The aim of this study is to assess the impact of the “weekend effect” in patients with nonvariceal uppergastrointestinal bleeding (NVUGIB).
Methods: Retrospective analysis of clinical and endoscopic data of patients admitted to Centro Hospitalar Universitário do Porto, from January/2016 to December/2018 for upper gastrointestinal bleeding (UGIB). The association between weekend admission and the timing of endoscopy; level of hospitalisation; surgery need; rebleeding and mortality was evaluated.
Results: Atotal of 545 patients were included. No significant association between weekday and weekend admissions was observed in any of the outcomes. The majority of patients underwent upper endoscopy up to 12 hours afteradmission (62.0% vs. 57.2%, weekday vs. weekend admission, respectively), with similar timings of endoscopy between both groups (p=0.607). Hospitalization in intensive and/or intermediate care units (41.6% vs. 42.8%, p=0.869) was not related to the day of admission. Also, no differences were assessed in the following outcomes: surgery need (5.8% vs. 6.3%, p=0.843), rebleeding (9.3% vs. 6.2%, p=0.289) and mortality rates (6.2% vs. 2.4%, p=0.103).
Discussion and Conclusion: In this sample of patients with NVUGIB, clinical management and results were independent of the day of admission. The absence of “weekend effect” seems to be related to the gastroenterology emergency model evaluated and its continuous access to endoscopic resources.
Upper gastrointestinal bleeding (UGIB) is a major indication for emergency admission, with an incidence that varies from 48 to 160 cases per 100,000 individuals annually[1], representing at least 50% of the admissions regardinggastrointestinal bleeding [2]. The management of UGIB is a complexprocess, from resuscitation and stabilization to diagnosis and therapy. Endoscopy plays a key role, allowing clinical improvement of the outcomesin patients with UGIB 3.
The “weekendeffect” has been described as an increasedmortality in patientsadmitted during weekend [3-6]. Apparently, this is due to a reducedaccess to specialised medical care. On weekends, comparing to weekdays, hospitals usually operate on a reduced work schedule. This might be due to several reasonsincluding economic constraints, decreased staffing, includingsenior staff. In addition, some of these admissions might be relatedto adverse lifestyle related behaviours during the weekend[3,7-10].
The European Society of Gastrointestinal Endoscopy (ESGE) Guidelines recommends having endoscopyservices available for evaluation and management of UGIB 24-hours/7-days. However, endoscopy units may be closed or operate only on a limited weekend schedule, thereby delaying endoscopy [11,12]. Potentially, this might be one of the major reasons for poorer outcomes among patients who are hospitalized during the weekend [13-15].
In this context, “weekendeffect” closely reflectsthe organisational structure and performance of healthcare services,mainly “out-of-hours”, by identifying the efficiency gaps, so it can help to point improvement needs [6].
In Northern Portugal, located at Centro Hospitalar Universitário do Porto (CHUP) there is an organized gastroenterology emergency modelof care. A team of gastroenterologists from six public institutions and a nursing team from CHUP are responsible for the night shifts, the “out-of-hours” period,
from Monday to Sunday. This way, endoscopy is available seven days a week, 24 hours a day.
The aim of this study is to evaluate the overall weekend effect in patients’ outcomes, namely timing of endoscopy, intensive and intermediate care admission, bleeding recurrence, need for surgery and mortality rates in patients with nonvariceal upper gastrointestinal bleeding.
We conducted a retrospective analysis of hospital records from patients admitted for UGIB, during the period of 1st of January 2016 and 31st of December 2018. The symptomsof UGIB were defined as melaena, hematemesis, hematochezia and/or symptomatic anaemia. Weekend admission was considered as hospitalization from Friday afternoon 3pm to Monday morning 7am. Despite the weekend definition, at CHUP, a gastroenterology team is present24-hours/7-days, to fulfilthe “out-of-hours” period, consisting of an experienced gastroenterologist and an endoscopy nurse. Patients with NVUGIB were included. The nonvariceal UGIB causes are presented on Table I.
| Weekday (n=366) | Weekend (n=179) | All (n=545) | P value | ||||||||
n | % | n | % | n | % | ||||||
| Mean age (SD),years | 68.1 | (17.1) | 68.3 | (15.5) | 0.961 | ||||||
| Sex | |||||||||||
| Male | 273 | 74.6 | 127 | 70.9 | 400 | 73.4 | 0.366 | ||||
| Female | 93 | 25.4 | 52 | 29.1 | 145 | 26.6 | |||||
| Drugs used | |||||||||||
| Anticoagulant | 52 | 16.4 | 24 | 16.2 | 76 | 16.3 | 0.959 | ||||
| Antiplatelet | 104 | 33.0 | 56 | 38.1 | 160 | 34.6 | 0.285 | ||||
| NSAID | 39 | 12.3 | 26 | 17.9 | 65 | 14.1 | 0.106 | ||||
| PPIs | 65 | 20.6 | 25 | 17.2 | 90 | 19.6 | 0.394 | ||||
| Comorbidities | |||||||||||
| Myocardial infarction | 18 | 12.2 | 49 | 15.4 | 67 | 14.4 | 0.352 | ||||
| Congestive heartfailure | 39 | 26.4 | 82 | 25.7 | 121 | 25.9 | 0.882 | ||||
| Chronic liverdisease | 24 | 16.2 | 42 | 13.3 | 66 | 14.2 | 0.400 | ||||
| Chronic renaldisease | 20 | 13.5 | 36 | 11.3 | 56 | 12.0 | 0.498 | ||||
| Diabetes mellitus | 41 | 27.7 | 77 | 24.2 | 118 | 25.3 | 0.420 | ||||
| Cerebrovascular diseases | 21 | 14.6 | 42 | 13.6 | 63 | 13.9 | 0.787 | ||||
| Malignant tumors | 16 | 11.0 | 46 | 14.9 | 62 | 13.7 | 0.265 | ||||
| CCI | |||||||||||
| <6> | 188 | 62.5 | 99 | 68.8 | 287 | 64.5 | 0.194 | ||||
| ≥6 | 113 | 37.5 | 45 | 31.3 | 158 | 35.5 | |||||
| Pre-endoscopy Rockall Score, mean (SD) | 3.4 | (1.7) | 3.3 | (1.7) | 0.715 | ||||||
| Symptoms | |||||||||||
| Melaena | 87 | 26.7 | 33 | 22.3 | 120 | 25.3 | |||||
| Hematemesis | 127 | 39.0 | 51 | 34.5 | 178 | 37.6 | |||||
| Hematochezia | 10 | 3.1 | 3 | 2.0 | 13 | 2.7 | 0.073 | ||||
| Melaena and hematemesis | 34 | 10.4 | 28 | 18.9 | 62 | 13.1 | |||||
| Anemia | 60 | 18.4 | 25 | 16.9 | 85 | 17.9 | |||||
| Other | 8 | 2.5 | 8 | 5.4 | 16 | 3.4 | |||||
| Diagnosis | |||||||||||
| Mallory-Weiss syndrome | 40 | 10.9 | 21 | 11.7 | 61 | 11.2 | |||||
| Gastric ulcer | 110 | 30.1 | 61 | 34.1 | 171 | 31.4 | |||||
| Duodenal ulcer | 98 | 26.8 | 36 | 20.1 | 134 | 24.6 | 0.778 | ||||
| Gastric angioectasia | 29 | 7.9 | 13 | 7.3 | 42 | 7.7 | |||||
| Malignacies | 40 | 10.9 | 22 | 12.3 | 62 | 11.4 | |||||
| Inconclusive | 4 | 1.1 | 2 | 1.1 | 6 | 1.1 | |||||
| Others* | 45 | 12.3 | 24 | 13.4 | 69 | 12.7 | |||||
| Endoscopic treatment | |||||||||||
| Yes | 135 | 36.9 | 70 | 39.1 | 205 | 37.6 | 0.615 | ||||
| No | 231 | 63.1 |  | 109 | 60.9 |  | 340 | 62.4 | |
| |
 |
SD: standard deviation;NSAID: nonsteroidal anti-inflammatory drugs; PPIs: protón-pump inhibitors; CCI: Charlson comorbidity index. *Esophagitis, esophageal ulcer, hemorrhagic gastritis, gastroduodenitis, Dieulafoy’s lesion, duodenal angioectasia, antral vascular ectasia
For each patient, data collected were age, sex, comorbidities and Charlson Comorbidity Index (CCI), symptoms, pre-endoscopy Rockall score, antiplatelet, anticoagulant and nonsteroidal anti-inflammatory drug use,
bleeding cause and need of endoscopic treatment. Different endoscopic treatments were used: submucosal adrenaline injections, sclerosant injections of polidocanol, thermocoagulation (heat probe, argon plasma),
endoscopic clips, and topic hemospray. The CCI was stratified into two groups according to the score (<6>24 hours. Rebleeding was considered in cases of furtherhematemesis, passage of fresh melaenaor hematochezia and/orhypovolemic shock after the first endoscopy. In case of rebleeding, patients were rescoped. If bleeding could not be controlled by endoscopy, patientswere referred for surgery.
Descriptive statistics was calculated for both continuous and discrete variables, stratifying the patientsaccording to weekdayvs. weekend admission. Differences between groups were assessed using the Chi-square and t-testtests. The primaryindependent predictor was the day of admission (weekday vs. weekend.Then, the modelwas adjusted for several risk factors selected based on their potential effect on the outcome.
Patient characteristics
A total of 545 patients with NVUGIB were included in the analysis.Demographic and clinicalcharacteristics according to admission are detailed in Table I. There were 366 patients(273 men and 93 women,mean (SD) age of 68.1 (17.1) years) admitted on weekdays, and 179 patients (127 men and 52 women, mean (SD) age of 68.3 (15.5) years) during the weekend. There was no significant difference between groups for the mean age of patients (p=0.961). Also, no difference was found in the use of anticoagulants, antiplatelets, nonsteroidal anti-inflammatory drugs (NSAIDs) or proton- pump inhibitors (PPIs) according to the day of admission (p=0.959, 0.285, 0.106, 0.394, respectively). In both weekday and weekend admissions, the most common comorbidities were Diabetes mellitus (27.7% vs. 24.2%) and congestive heart failure (26.4% vs. 25.7%). When comparing both groups, most patients had a CCI score <6 p=0.194). p=0.715). p=0.615).>
Outcomes
Outcomes according to admission´s day are reported in Table II.When comparing the timing of endoscopy, no significant differences were observed between weekdays and weekends (p=0.607).Furthermore, most patients performed a very early endoscopy, <12hours>24h, on weekday or weekend, respectively. The intrahospital rebleeding rate was similar between weekdays and weekends (9.3% vs. 6.2%, p=0.289). Additionally, no difference was found in the need for surgeryon weekends versusweekdays, (5.8% vs. 6.3%, p=0.843).Regarding the need and level of care in hospitalization, there was no difference, according to the day of admission, either in intensive or intermediate care units (intensive, 4.8% vs. 6.0%; intermediate, 36.8% vs. 36.8%, p=0.869). Again, no difference was found in in-hospital mortalityrates, considering the day of admission (6.2% vs. 2.4%, p=0.103).
| Weekday (n=366) | Weekend (n=179) | All (n=545) | P value | ||||||||
n | % | n | % | n | % | ||||||
Surgery | 16 | 5.8 | 8 | 6.3 | 24 | 6.0 | 0.843 | ||||
Endoscopy timing | |||||||||||
Very early <12h> | 184 | 62.0 | 79 | 57.2 | 263 | 60.5 | 0.607 | ||||
Early ≤24h | 72 | 24.2 | 36 | 26.1 | 108 | 24.8 | |||||
Delayed >24h | 41 | 13.8 | 23 | 16.7 | 64 | 14.7 | |||||
Rebleeding, in-hospital | |||||||||||
Yes | 26 | 9.3 | 8 | 6.2 | 34 | 8.3 | 0.289 | ||||
No | 255 | 90.7 | 122 | 93.8 | 377 | 91.7 | |||||
Hospitalisation | |||||||||||
Intermediate care unit | 107 | 36.8 | 49 | 36.8 | 156 | 36.8 | 0.869 | ||||
Intensive careunit | 14 | 4.8 | 8 | 6.0 | 22 | 5.2 | |||||
No | 170 | 58.4 | 76 | 57.1 | 246 | 58.0 | |||||
Death, in-hospital | |||||||||||
Yes | 17 | 6.2 | 3 | 2.4 | 20 | 5.0 | 0.103 | ||||
No | 259 | 93.8 | 124 | 97.6 | 383 | 95.0 | |||||
Table 2: Outcomes of 545 patientsadmitted for nonvariceal upper gastrointestinal bleedingaccording to weekday vs. weekend admission
We conducted a study of a large series of patients admitted for NVUGIB during a 3-year period. We did not find any significant relation between weekend admission and increased mortality, nor with other outcomes.
The literature on the “weekend effect” is rapidly growing and large studies have been commissioned to investigate the magnitude and mechanisms of this effect[16]. Although the causes of the “weekendeffect” remain unclear,it is thought to be mediated through differences in the process of care and staffing between weekdays and weekends[17].
Several studieshave addressed the issue of the so-called“weekend effect” in patients admittedfor NVUGIB with inconsistent results[4,8,10,18-21]. Some reported a significant weekend effect in relation to the NVUGIB [4,10,19,21], whereas othersdid not find increased mortalityamong patients admitted on the weekend [8,18]. However, it is important to distinguish between varicealand nonvariceal bleeding.As the management and prognosisof variceal and nonvariceal bleedingdiffer significantly, this could influence the interpretation of the results. Data published suggests that thereis no weekend effect in variceal UGIB [8,20]. In contrast, what is known about the “weekendeffect” in patientswith NVUGIB is contradictory. Threestudies reported a significant weekendeffect in relationto NVUGIB
[10,19,20], whereas two did not [8,18]. In our study, we did not find any “weekend effect” in relation to mortality. On the contrary, mortality was lower.
The “weekend effect” can strongly reflect organisational differences among different healthcare systems. Most UGIB studieshave been conducted in the United States of America (USA) so far [10,20]. Ananthakrishnan et al. [20], documented a significant “weekend effect” in patients with nonvariceal bleeding. In addition, Shaheenet al. [10] performed one of the largest studiesin the USA, with over 200,000 patients admitted for peptic ulcer related UGIB, reporting a significantly higher mortality rate for patients admitted during the weekends. Regarding Europe, most studiescame from the United Kingdom(UK) [8,19]. A study conductedin Wales strengthened the “weekend effect” [19], but another one from the UK, Jairath et al. [8], concluded otherwise. More inconsistent resultscame from Europe.An Italian study [18] did not report differences in mortality rates based on the day of admission, whereas a Dutch study found a significant association [21]. Thus, information on this subject significantly differs not just between countries, but also between continents. This makes clear that asymmetries in patient’s management, in the set of UGIB, explain differences on patient’s outcomes.The day of admission is one variable in the process of care.
Previous studies have shown that endoscopy timing is significantly related to weekday or weekend admission. On one hand,according to some studies, endoscopy timing duringweekday admissions was significantly inferiorthan for weekend admissions [4,5,8,10,19,20]. On the other hand, a few studies showed that the timing of endoscopy for weekend admissions is shorter when compared to weekday admissions [22,23]. We found no difference in the timing of endoscopy, regardless the day of the week. These results can be explained by the model of CHUP’s gastroenterology emergencycare organization. In fact, as mentioned above, a gastroenterology specialized team is presentcontinuously. Therefore, no differences in endoscopy timingare observed betweenweekdays and weekends.
We also observed that in NVUGIB patients, the “weekend effect” is not associated with rebleeding. This finding is consistent with studies which also analysed rebleeding in UGIB patients [8,18,19].
Additionally, we did not find a difference in patients who underwent surgerybased on the day of admission. Despite our finding, Shaheen et al. [10] reported that patients with NVUGIB underwent more frequently a surgical intervention when admitted during the weekend. It seems that, at CHUP, endoscopy therapy is equally effective during the week comparing to the weekend.
Moreover, the need and level of hospitalization, according to our findings, was also not related to the day of admission. Additionally, the same number of patients with NVUGIB were hospitalized during the week and weekend, regardless the level of care. In the end, most patients were not hospitalized, nor during the week, nor during the weekend. This could be explained by another of our findings: our mean pre-endoscopy Rockall score. In fact, in both groups,the mean pre-endoscopy Rockall score was low, describing our patients’ sample with a very low chance of mortality, thus diminishing the need forhospitalization.
Our studyhas some limitations. Firstly, this is a northerncentre study whichlimits the possibility to generalize our conclusions to a nationallevel. Secondly, endoscopic and admission reportslacked some information, leaving us with some missing cases. The strengths of our study are the high number of patients includedand how it gives us a better understanding of the effectiveness of care in acute nonvariceal bleeders. Overall, our findings have significant implications for the understanding of gastroenterology emergency models of care.
We did not identify any differences in the clinical outcomes of patients admitted for NVUGIB during weekdays or weekends. Therefore, our data support that endoscopy units working 24 hours a day, seven days a week, may address this specific healthcare need in an efficient way.
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