Outcomes, Quality of Care Largely Unaffected by Weekend Admission for Heart Failure

October 3, 2008 (Toronto, ON) — Patients with heart failure who are admitted to the hospital on Saturday or Sunday are about as likely to receive evidence-based therapies, have a similar length of stay, and have comparable in-hospital mortality as those admitted on a weekday, according to data from hospitals participating in a quality-improvement program [1].

The analysis, based on almost 60 000 HF admissions at 264 centers participating in the American Heart Association Get with the Guidelines (GWTG) program, did point to a few slight but significant shortfalls in the management of weekend-admission patients, but virtually none of them involved the use of appropriate therapies. They were somewhat less likely, for example, to have their LVEF documented.

Weekend-admission patients were more likely to receive a full set of appropriate instructions at discharge, consistent with weekend-discharge data from the same GWTG cohort: those discharged on weekends were less likely to get the full instructions. But most important quality-of-care and performance measures were unaffected by either admission or discharge during the weekend.

"We don't see any evidence that weekend discharge is putting the patients at a substantial disadvantage, except with regard to the discharge instructions. And that is something that is amenable to additional quality improvement effort," according to Dr Gregg C Fonarow (Ahmanson-University of California, Los Angeles Cardiomyopathy Center), who presented the GWTG analysis last week here at the Heart Failure Society of America 2008 Scientific Meeting.

Those admitted on the weekend, compared with during the week, had the same mean five-day hospital length of stay "and a marginally increased risk of in-hospital mortality, but not significantly so," Fonarow said in his presentation.

"What this shows us is actually somewhat reassuring," he told heartwire. There is evidence from patients with other disorders, including other cardiovascular diagnoses, and concern in patients with heart failure, that the changes in hospital staffing on weekends are associated with poorer quality of care and outcomes, Fonarow observed.

He speculated that a reduced weekend staff with perhaps fewer providers with subspecialty training could account for what differences they did see in patients admitted on the weekend. For example, he said, patients admitted on the weekend would probably be discharged during the week, when heart-failure nurses skilled and experienced in the appropriate counseling and discharge instructions may be more likely present.

GWTG Performance and Quality-of-Care Measures Showing Significant Differences Between Weekend and Weekday Admission

GWTG=Get with the Guidelines; H/ISDN=hydralazine/isosorbide dinitrate; LVSD=left ventricular systolic dysfunction; ICD=implantable cardioverter defibrillator

Of the 59 876 heart-failure admissions in the analysis, 13 191, or about 22%, occurred on a Saturday or Sunday. Compared with the majority who were admitted during the week, they showed comparable rates of receiving beta blockers and ACE inhibitors or angiotensin receptor blockers if they had LV systolic dysfunction; counseling about smoking cessation; and warfarin if they had atrial fibrillation. They had an adjusted in-hospital mortality odds ratio, compared with those admitted on a weekday, of 1.12 (95% CI 0.99-1.26, p=0.06).

Among the several differences between the groups, however, was, for African Americans with LV systolic dysfunction, a reduced likelihood with weekend admission of receiving the combination of hydralazine and isosorbide dinitrate, which was shown to add benefit when given on top of heart-failure medications in the A-HeFT trial.

Also, fewer weekend-admission patients received an implantable cardioverter-defibrillator (ICD) if their LVEF was no higher than 30%. That's "interesting," Fonarow observed, but it's not a formal GWTG quality measure, and there are caveats with the ICD data in the analysis that keep it from rising to the level of a quality measure. "I wouldn't put too much into the ICD finding," he said.

GWTG Performance and Quality-of-Care Measures Showing Significant Differences Between Weekend and Weekday Discharge

GWTG=Get with the Guidelines

Importantly, Fonarow said when presenting the GWTG analysis, his group recently reported that the day of admission significantly influences hospital length of stay in heart failure [2]. Thursday or Friday admissions made for significantly longer stays after adjustment for factors that could influence hospitalization time in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF), a prospective registry of more than 48 000 patients that Fonarow described as the precursor to GWTG.

As reported by heartwire when the OPTIMIZE-HF analysis was published, the shortest average length of stay was 5.39 days for Tuesday admissions, while the longest was 5.88 days for Friday admissions (p<0.001).

"We indeed found that day of admission did not really matter as far as outcomes, but for length of stay it certainly did. For patients who might have been likely to be discharged on Saturday or Sunday, clinicians were less inclined to do that and kept them over until Monday," Fonarow said. "There was a much greater-than-normal distribution for Monday than you'd expect."

Putting the OPTIMIZE-HF and GWTG analyses together, he said, provides reassurance that in heart failure, with the exception of hospital length of stay, few important outcomes measures appear to be influenced by the day of hospital admission.

Fonarow reports that he has been a consultant for and received honoraria from GlaxoSmithKline, Medtronic, and Novartis and research support from GlaxoSmithKline and Novartis. The GWTG program is sponsored by the American Heart Association and supported by GlaxoSmithKline, which also sponsored OPTIMIZE-HF.

1. Horwich T, Fonarow GC, LaBresh K, et al. Weekend hospital admission for heart failure: Influence on quality of care, length of stay, and in-hospital mortality. Heart Failure Society of America 2008 Scientific Meeting; September 22, 2008; Toronto, ON. Abstract 19.
2. Fonarow GC, Abraham WT, Albert NM, et al. Day of admission and clinical outcomes for patients hospitalized for heart failure: Findings from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Circ Heart Fail 2008; 1:50-57.

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