Association between time of hospitalization with acute myocardial infarction and in-hospital mortality
Why the study?
The association between the time of hospitalization and in-hospital mortality for acute myocardial infarction required evaluation.
Does the time of hospitalization affect in-hospital mortality in patients with acute myocardial infarction?
Structured PICO
Does the time of hospitalization affect in-hospital mortality in patients with acute myocardial infarction?
P
Population
615,035 patients admitted with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) across 243 hospitals in England and Wales between 1 January 2004 and 31 March 2013, median age 70.0 years, 66.0% men.
I
Intervention
Hospitalization during different 4-hourly time periods over the 24-h clock
C
Comparator
Hospitalization between 00:00 and 03:59
O
Outcome
In-hospital mortalityhard clinical
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“There has been a great deal of anxiety about the ability of hospitals to treat their patients outside of regular working hours, but our study suggests they are managing quite well. These data suggest that heart attacks are being treated equally well no matter what time of day you arrive at hospital.”
“Heart attack treatment is time-critical. We know that early treatment saves lives, and our study offers some reassurance that patients are getting the care they need around the clock. This excellent care is made possible by 24 hour a day provision of guideline-indicated treatment for heart attack patients across the UK, and we now need to ensure other common medical emergencies are equally well treated.”
Implication
Variation in in-hospital mortality for AMI by time of admission is largely explained by differences in case mix and the use of acute treatments rather than the time of day itself.
Abstract
AIMS: To study the association between time of hospitalization and in-hospital mortality for acute myocardial infarction (AMI). METHODS AND RESULTS: Patients admitted with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) across 243 hospitals in England and Wales between 1 January 2004 and 31 March 2013 were included. The outcome measure was in-hospital mortality. Adjusted odds ratios (ORs) for in-hospital mortality were estimated across six 4-hourly time periods over the 24-h clock using multilevel logistic regression, inverse-probability weighting propensity score, and instrumental variable analysis. Among 615 035 patients [median age 70.0 years, interquartile range 59.0-80.0 years; 406 519 (66.0%) men], there were 52 777 (8.8%) in-hospital deaths. At night, patients with NSTEMI were more frequently comorbid, and for STEMI had longer symptom-onset-to-reperfusion times. For STEMI, unadjusted in-hospital mortality was highest between 20:00 and 23:59 [4-h period range 8.4-9.9%; OR compared with 00:00-03:59 reference 1.13, 95% confidence interval (CI) 1.07-1.20], and for NSTEMI highest between 12:00 and 15:59 (8.0-8.8%; OR compared with 00:00-03:59 reference 1.07, 95% CI 1.03-1.12). However, these differences were only apparent in the earlier years of the study, and were attenuated by adjustment for demographics, comorbidities, and clinical presentation. Differences were not statistically significant after adjustment for acute clinical treatment provided. CONCLUSION: There is little evidence to support an association between time of hospitalization and in-hospital mortality for AMI; variation in in-hospital mortality may be explained by case mix and the use of treatments.
Discussion
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Cite This Study
Wu et al. (2018) studied this question.