Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England.
Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England.
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DOI：
10.1136/bmjqs-2016-005680
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发表时间：
2017-08
影响因子：
5.4
通讯作者：
Sutton M
中科院分区：
文献类型：
--
作者：
Anselmi L;Meacock R;Kristensen SR;Doran T;Sutton M
研究发现，周末入院的患者死亡率较高，这依赖于常规的管理数据来调整死亡风险，但这些数据可能无法充分反映疾病的严重程度。我们研究了救护车到达事故和紧急（A&E）部门的患者比率-疾病严重程度的标志-与住院死亡率的相关性。回顾性观察性研究，2013年4月至2014年2月期间，英格兰140家非专科医院信托基金的3，027，946例住院病例。 病人入院与A&E记录，包括到达的方式和日期和时间出席。我们按一周中的一天和白天（07：00至18：59）与夜间（第二天19：00至06：59）对抵达时间进行分类。我们使用多变量logistic回归分析了与30天内住院死亡率的相关性。 在一周内，20.9%的白天抵达者处于最高风险的五分之一，而夜间抵达者为18.5%。周日白天到达的患者中风险最高的五分之一比例最高，为21.6%。与一周内其他日间时间（57.0%）相比，夜间和周六（61.1%）及周日（60.1%）由救护车送抵的入院病人比例明显较高。在没有调整救护车到达的情况下，夜间到达的患者的风险调整后死亡率高于周三白天的就诊率（0.16个百分点）。与周三白天相比，风险调整后的死亡率在周四晚上也更高（0.15个百分点），从周六白天（0.16个百分点）到周日晚上（0.26个百分点），整个周末都在增加。在调整救护车到达后，死亡率的上升仅在周日白天到达A&E的患者中达到统计学显著性（0.17个百分点）。使用传统的风险调整方法，夜间和周末急诊入院后的死亡风险似乎更高。在考虑到到达医院的方式后，这种模式发生了很大变化，在夜间或除周日白天外的周末任何时间段入院后，死亡风险都没有增加。这表明，基于住院管理数据的风险调整不能充分说明疾病的严重程度，周末和夜间死亡率的升高反映了在这些时间乘坐救护车到达的更严重的患者比例更高。
Studies finding higher mortality rates for patients admitted to hospital at weekends rely on routine administrative data to adjust for risk of death, but these data may not adequately capture severity of illness. We examined how rates of patient arrival at accident and emergency (A&E) departments by ambulance—a marker of illness severity—were associated with in-hospital mortality by day and time of attendance. Retrospective observational study of 3 027 946 admissions to 140 non-specialist hospital trusts in England between April 2013 and February 2014. Patient admissions were linked with A&E records containing mode of arrival and date and time of attendance. We classified arrival times by day of the week and daytime (07:00 to 18:59) versus night (19:00 to 06:59 the following day). We examined the association with in-hospital mortality within 30 days using multivariate logistic regression. Over the week, 20.9% of daytime arrivals were in the highest risk quintile compared with 18.5% for night arrivals. Daytime arrivals on Sundays contained the highest proportion of patients in the highest risk quintile at 21.6%. Proportions of admitted patients brought in by ambulance were substantially higher at night and higher on Saturday (61.1%) and Sunday (60.1%) daytimes compared with other daytimes in the week (57.0%). Without adjusting for arrival by ambulance, risk-adjusted mortality for patients arriving at night was higher than for daytime attendances on Wednesday (0.16 percentage points). Compared with Wednesday daytime, risk-adjusted mortality was also higher on Thursday night (0.15 percentage points) and increased throughout the weekend from Saturday daytime (0.16 percentage points) to Sunday night (0.26 percentage points). After adjusting for arrival by ambulance, the raised mortality only reached statistical significance for patients arriving at A&E on Sunday daytime (0.17 percentage points). Using conventional risk-adjustment methods, there appears to be a higher risk of mortality following emergency admission to hospital at nights and at weekends. After accounting for mode of arrival at hospital, this pattern changes substantially, with no increased risk of mortality following admission at night or for any period of the weekend apart from Sunday daytime. This suggests that risk-adjustment based on inpatient administrative data does not adequately account for illness severity and that elevated mortality at weekends and at night reflects a higher proportion of more severely ill patients arriving by ambulance at these times.
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影响因子：
4.4
作者：
Gutacker, Nils;Bloor, Karen;Cookson, Richard
通讯作者：
Cookson, Richard
影响因子：
17.3
作者：
Freemantle, N.;Richardson, M.;Pagano, D.
通讯作者：
Pagano, D.
影响因子：
158.5
作者：
Bell, CM;Redelmeier, DA
通讯作者：
Redelmeier, DA
影响因子：
168.9
作者：
Lilford, R;Mohammed, MA;Thomson, R
通讯作者：
Thomson, R
影响因子：
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作者：
Aylin, P.;Yunus, A.;Bell, D.
通讯作者：
Bell, D.