Is There a “Weekend Effect” on In-Hospital Outcomes of Type a Aortic Dissection Repair? A Population-Based Analysis of National Inpatient Sample From 2015-2020

Abstract

Background

“Weekend effect” in type A aortic dissection (TAAD) repair has been identified in several countries where weekend admission is associated with higher mortality rates. However, in the US, findings have been mixed regarding the “weekend effect” on TAAD outcomes. This study aimed to conduct a comprehensive, population-based analysis of the association between weekend admission and the in-hospital outcomes of TAAD repair using a large-scale national registry.

Methods

Patients who underwent TAAD repair were identified in National Inpatient Sample from Q4 2015–2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients admitted on the weekend vs weekday, where demographics, comorbidities, hospital characteristics, primary payer status, and transfer-in status were adjusted.

Results

There were 1007 and 3275 patients who underwent TAAD repair under weekend and weekday admission, respectively. Patients admitted on the weekend were more likely to get transferred in from a different acute care hospital and have renal malperfusion. After multivariable analysis, patients admitted on the weekend and weekday had comparable times from admission to operation (0.88 ± 2.64 vs 0.92 ± 2.99 days, P = 0.64) and in-hospital mortality (15.99% vs 14.84%, aOR = 1.119, 95 CI = 0.914-1.37, P = 0.28). All other in-hospital outcomes, hospital length of stay, and total hospital charge were similar between the 2 cohorts.

Conclusion

Patients admitted on weekends and weekdays had comparable times from admission to operation, as well as similar in-hospital mortality and morbidities. These findings suggest the effectiveness of weekend emergency care protocols for TAAD patients and the lack of a “weekend effect” on TAAD repair in the United States.

Keywords

aortic dissection ascending aorta weekend effect mortality

Introduction

Stanford type A aortic dissection (TAAD) affects the ascending aorta and is a critical surgical emergency due to its proximity to essential coronary and cerebral arteries.^1-3 TAAD has a notably poor prognosis, with in-hospital mortality rates reported between 10% and 25%.^4-8 The urgency of surgical intervention for TAAD is underscored by the rapid increase in mortality risk, which rises by 0.5% for every hour treatment is delayed during the initial 48 hours.⁹ This makes timely diagnosis and surgical management crucial and highlights the importance of recognizing factors that influence outcomes in TAAD to improve patient survival and reduce complications.

“Weekend effect” in surgery refers to the observation that patients admitted during weekends often experience worse outcomes compared to those admitted on weekdays.^10-13 This phenomenon can result from reduced staffing, less experienced personnel on duty, delayed surgical interventions, and limited availability of some procedures during weekends.¹⁴ National studies in Taiwan,¹⁵ Italy,¹⁶ and Japan,¹⁷ respectively, have reported an association between weekend admissions and higher mortality rates in acute aortic dissection/TAAD repair. A multi-institutional study, however, did not reveal the “weekend effect” in TAAD repair among the Nordic countries.¹⁸ In the United States, findings have been mixed regarding the impact of weekend admissions on outcomes for patients undergoing repair for TAAD.^19,20 This study aimed to conduct a comprehensive, population-based analysis of the impact of weekend admission on the in-hospital outcomes of TAAD repair. This study utilized data from the National/Nationwide Inpatient Sample (NIS) database, which is the largest all-payer database in the United States that records approximately 20% of all national hospital discharges.

Methods

Data Source

The NIS database was used to identify patients who underwent TAAD repair from the last quarter of 2015 to the end of 2020. Patient were identified by the diagnosis of aortic dissection [International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes I71.01 and I71.03] and surgical repairs of TAAD [International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) codes 025X0ZZ, 02BX0ZX, 02BX0ZZ, 02QX0ZZ, 02RX07Z, 02RX08Z, 02RX0JZ, 02RX0KZ, 02UX07Z, 02UX08Z, 02UX0JZ, 02UX0KZ, 02VX0CZ, 02VX0DZ, 02VX0EZ, 02VX0FZ, and 02VX0ZZ]. Patients with a diagnosis of aortic aneurysm (ICD-10-CM codes I71.1, I71.2, I71.5, I71.6) or under the age of 18 years were excluded. Patients were stratified into the 2 study cohorts based on weekday or weekend admission as documented in the NIS database.

Preoperative Factors

All preoperative factors are listed in Tables 1 and 2. Table 1 shows age, race and ethnicity, primary payor status, hospital characteristics, and the transfer-in status. Mean household income from the patient’s ZIP code was calculated, and patients were then stratified into 4 quartiles based on the community income. Hospital characteristics included the bed size of the hospital, geographical location (urban/rural), and teaching status. Hospital bed sizes were stratified into small, medium, and large, considering the American Hospital Association’s annual survey, the hospital’s teaching status, and the geographical location. Table 2 shows patients’ All Patients Refined Diagnosis Related Groups (APR-DRG) Risk of Mortality Subclass,²¹ comorbidities, and the relevant clinical conditions. Comorbidities were identified by the Elixhauser measure and the ICD-10-CM codes as listed in Table S1.²²

Table 1.

Demographic, Primary Payer Status, Hospital Characteristics, and Transfer-In Status of Patients Who Underwent TAAD Repair Under Weekend Versus Weekday Admission.

	Weekend (n = 1007)	Weekday (n = 3275)	P-value
Sex
Male	667 (66.24%)	2161 (65.98%)	0.91
Female	340 (33.76%)	1114 (34.02%)	0.91
Age
Age < 45 years	135 (13.41%)	458 (13.98%)	0.68
45 ≤ age < 55 years	212 (21.05%)	612 (18.69%)	0.10
55 ≤ age < 65 years	258 (25.62%)	849 (25.92%)	0.87
65 ≤ age < 75 years	240 (23.83%)	807 (24.64%)	0.62
75 ≤ age < 85 years	140 (13.9%)	490 (14.96%)	0.42
Age ≥ 85 years	22 (2.18%)	59 (1.8%)	0.43
Race and ethnicity
Caucasian	577 (57.3%)	2029 (61.95%)	0.01
African American	221 (21.95%)	634 (19.36%)	0.08
Hispanic	71 (7.05%)	214 (6.53%)	0.56
Asian	44 (4.37%)	124 (3.79%)	0.40
Native Americans	4 (0.4%)	3 (0.09%)	0.06
Other races	33 (3.28%)	119 (3.63%)	0.63
Socioeconomic status
Income 1st quartile (0-25%)	253 (25.12%)	915 (27.94%)	0.08
Income 2nd quartile (25-50%)	248 (24.63%)	758 (23.15%)	0.33
Income 3rd quartile (50-75%)	229 (22.74%)	779 (23.79%)	0.52
Income 4th quartile (75-100%)	263 (26.12%)	761 (23.24%)	0.06
Primary payer status
Medicare	412 (40.91%)	1347 (41.13%)	0.91
Medicaid	176 (17.48%)	445 (13.59%)	<0.01
Private insurance	327 (32.47%)	1141 (34.84%)	0.17
Self-pay	56 (5.56%)	202 (6.17%)	0.54
No charge	7 (0.7%)	12 (0.37%)	0.18
Other payment	29 (2.88%)	110 (3.36%)	0.54
Hospital characteristics
Rural hospital	6 (0.6%)	35 (1.07%)	0.20
Urban private practice	63 (6.26%)	221 (6.75%)	0.61
Urban teaching hospital	938 (93.15%)	3019 (92.18%)	0.34
Small bed size	61 (6.06%)	211 (6.44%)	0.71
Medium bed size	176 (17.48%)	539 (16.46%)	0.47
Large bed size	770 (76.46%)	2525 (77.1%)	0.67
Transfer-in from other hospital facilities
No transfer in	474 (47.07%)	1838 (56.12%)	<0.01
Transferred in from a different acute care hospital	483 (47.96%)	1285 (39.24%)	<0.01
Transferred in from another type of health facility	47 (4.67%)	136 (4.15%)	0.48

Abbreviations: TAAD, type A aortic dissection.

Table 2.

APR-DRG Score, Comorbidities, and Clinical Conditions of Patients Who Underwent TAAD Repair Under Weekend Versus Weekday Admission.

	Weekend (n = 1007)	Weekday (n = 3275)	P-value
APR-DRG risk of mortality Subclass
Class 1	25 (2.48%)	50 (1.53%)	0.05
Class 2	35 (3.48%)	103 (3.15%)	0.61
Class 3	384 (38.13%)	1273 (38.87%)	0.68
Class 4	563 (55.91%)	1849 (56.46%)	0.77
Comorbidities
Acquired immune deficiency syndrome	6 (0.6%)	12 (0.37%)	0.40
Alcohol abuse	62 (6.16%)	158 (4.82%)	0.10
Autoimmune conditions	25 (2.48%)	98 (2.99%)	0.45
Lymphoma	1 (0.1%)	10 (0.31%)	0.48
Leukemia	1 (0.1%)	13 (0.4%)	0.21
Metastatic cancer	1 (0.1%)	18 (0.55%)	0.06
Solid tumor without metastasis, in situ	0 (0%)	1 (0.03%)	1.00
Solid tumor without metastasis, malignant	14 (1.39%)	41 (1.25%)	0.75
Cerebrovascular disease	16 (1.59%)	68 (2.08%)	0.37
Dementia	10 (0.99%)	40 (1.22%)	0.62
Depression	88 (8.74%)	233 (7.11%)	0.09
Diabetes without chronic complications	42 (4.17%)	151 (4.61%)	0.60
Diabetes with chronic complications	94 (9.33%)	282 (8.61%)	0.48
Drug abuse	38 (3.77%)	146 (4.46%)	0.38
Complicated hypertension	340 (33.76%)	1103 (33.68%)	0.97
Uncomplicated hypertension	498 (49.45%)	1539 (46.99%)	0.18
Moderate to advanced liver disease	1 (0.1%)	1 (0.03%)	0.42
Chronic pulmonary disease	167 (16.58%)	534 (16.31%)	0.85
Obesity	209 (20.75%)	722 (22.05%)	0.41
Paralysis	14 (1.39%)	51 (1.56%)	0.77
Advanced renal failure	321 (31.88%)	1204 (36.76%)	<0.01
Peripheral vascular disease	22 (2.18%)	60 (1.83%)	0.51
Hypothyroidism	75 (7.45%)	292 (8.92%)	0.16
Other thyroid disorders	10 (0.99%)	29 (0.89%)	0.71
Valvular disease	52 (5.16%)	199 (6.08%)	0.32
Marfan syndrome	15 (1.49%)	67 (2.05%)	0.29
Hyperlipidemia	351 (34.86%)	1182 (36.09%)	0.50
Anemia	34 (3.38%)	99 (3.02%)	0.60
Thrombocytopenia	322 (31.98%)	1004 (30.66%)	0.44
Sleep apnea	112 (11.12%)	353 (10.78%)	0.77
Tobacco use	411 (40.81%)	1250 (38.17%)	0.14
Clinical conditions
Neurological malperfusion	148 (14.7%)	475 (14.5%)	0.88
Coronary malperfusion	75 (7.45%)	206 (6.29%)	0.19
Mesenteric malperfusion	28 (2.78%)	66 (2.02%)	0.18
Renal malperfusion	527 (52.33%)	1594 (48.67%)	0.04

Abbreviations: APR-DRG, All Patients Refined Diagnosis Related Groups; TAAD, type A aortic dissection.

Postoperative Outcomes

In-hospital outcomes after TAAD repair were compared between patients who were admitted on the weekends and weekdays. The outcomes examined included mortality, major adverse cardiovascular event (MACE), myocardial infarction (MI), stroke, transient ischemic attack (TIA), neurological complications, pericardial complications, pacemaker implantation, cardiogenic shock, respiratory complications, mechanical ventilation, acute kidney injury (AKI), post-procedural renal failure, venous thromboembolism (VTE), pulmonary embolism (PE), hemorrhage/hematoma, infection, sepsis, deep wound complication, superficial wound complication, vascular complication, diaphragmatic paralysis, and reopen surgery for bleeding control. In addition, transfer out rate, time from admission to operation, hospital length of stay (LOS), and total hospital charge were compared between patients who were admitted on weekends and weekdays. The ICD-10-CM/PCS codes used to define the outcomes are listed in Table S2.

Statistical Analysis

The binary preoperative factors were compared by Fisher’s exact test. For the binary postoperative outcomes, multivariable logistic regression was utilized, where preoperative variables that had adequate differences (P < 0.1 in Fisher’s exact test) were adjusted for. Adjusted odds ratios (aORs) and 95% confidence intervals (CI) were estimated. Continuous variables, including the time from admission to operation, hospital LOS, and total hospital charges, were compared using generalized linear models (GLM) while adjusting for differences in all preoperative variables.

All statistical analyses were performed by SAS (version 9.4). A P-value less than 0.05 was considered statistically significant. The authors had full access to the NIS database and took full responsibility for the integrity of all statistical analyses. Since this is a retrospective study and used de-identified data from NIS, this study was exempted from Institutional Review Board (IRB) approval at The George Washington University.

Results

From the last quarter of 2015 to the end of 2020, there were 1007 and 3275 patients who underwent TAAD repair under weekend and weekday admission, respectively.

Table 1 shows the demographic, primary payer status, hospital characteristics, and transfer-in status of patients who underwent TAAD repair under weekend vs weekday admission. Patients who were admitted on the weekend were more likely to use Medicaid (17.48% vs 13.59%, P < 0.01) and get transferred in from a different acute care hospital (47.96% vs 39.24%, P < 0.01). On the other hand, patients with weekend admission were less likely to be Caucasian (57.30% vs 61.95%, P = 0.01) or have no transfer in (47.07% vs 56.12%, P < 0.01).

Table 2 lists the APR-DRG score, comorbidities, and clinical conditions of patients who underwent TAAD repair under weekend vs weekday admission. Patients with weekend admission were more likely to have renal malperfusion (52.33% vs 48.67%, P = 0.04) but less likely to have comorbid advanced renal failure (31.88% vs 36.76%, P < 0.01).

Table 3 summarizes the multivariable analysis of the in-hospital outcomes of patients who underwent TAAD repair under weekend vs weekday admission. Patients who were admitted on the weekend and weekday had comparable times from admission to operation (0.88 ± 2.64 vs 0.92 ± 2.99 days, F = 0.22, P = 0.64) and the rate of in-hospital mortality (15.99% vs 14.84%, aOR 1.119, 95 CI 0.914-1.37, P = 0.28). Major complications, including MI (5.96% vs 5.28%, aOR 1.128, 95 CI 0.83-1.533, P = 0.44), stroke (4.17% vs 4.15%, aOR 1.02, 95 CI 0.714-1.458, P = 0.91), cardiogenic shock (18.27% vs 17.22%, aOR 1.078, 95 CI 0.892-1.303, P = 0.43), AKI (51.64% vs 48.03%, aOR 1.095, 95 CI 0.94-1.274, P = 0.24), and hemorrhage/hematoma (77.36% vs 77.04%, aOR 0.914, 95 CI 0.766-1.091, P = 0.32), were also comparable between patients with weekend and weekday admission. All other in-hospital outcomes, hospital LOS, and total hospital charges were similar between the 2 cohorts.

Table 3.

Multivariable Analysis of the In-Hospital Outcomes of Patients Who Underwent TAAD Repair Under Weekend Versus Weekday Admission.

	Weekend (n = 1007)	Weekday (n = 3275)	aOR for weekend/Weekday (95% CI)	P-value
Mortality	161 (15.99%)	486 (14.84%)	1.119 (0.914-1.37)	0.28
MACE	119 (11.82%)	349 (10.66%)	1.138 (0.91-1.423)	0.26
MI	60 (5.96%)	173 (5.28%)	1.128 (0.83-1.533)	0.44
Stroke	42 (4.17%)	136 (4.15%)	1.02 (0.714-1.458)	0.91
TIA	3 (0.3%)	11 (0.34%)	0.914 (0.252-3.312)	0.89
Neurological complications	49 (4.87%)	155 (4.73%)	1.063 (0.761-1.484)	0.72
Pericardial complications	194 (19.27%)	588 (17.95%)	1.04 (0.865-1.251)	0.68
Pacemaker implantation	11 (1.09%)	52 (1.59%)	0.679 (0.351-1.315)	0.25
Cardiogenic shock	184 (18.27%)	564 (17.22%)	1.078 (0.892-1.303)	0.43
Respiratory complications	222 (22.05%)	721 (22.02%)	1.003 (0.845-1.191)	0.97
Mechanical ventilation	334 (33.17%)	1056 (32.24%)	1.009 (0.863-1.179)	0.91
AKI	520 (51.64%)	1573 (48.03%)	1.095 (0.94-1.274)	0.24
Post-procedural renal failure	17 (1.69%)	48 (1.47%)	1.04 (0.59-1.834)	0.89
VTE	24 (2.38%)	71 (2.17%)	1.155 (0.721-1.851)	0.55
PE	4 (0.4%)	5 (0.15%)	1.943 (0.506-7.464)	0.33
Hemorrhage/hematoma	779 (77.36%)	2523 (77.04%)	0.914 (0.766-1.091)	0.32
Infection	91 (9.04%)	293 (8.95%)	1.045 (0.814-1.342)	0.73
Sepsis	3 (0.3%)	5 (0.15%)	1.975 (0.471-8.289)	0.35
Deep wound complication	6 (0.6%)	21 (0.64%)	0.986 (0.395-2.462)	0.98
Superficial wound complication	19 (1.89%)	57 (1.74%)	1.061 (0.627-1.798)	0.82
Vascular complication	48 (4.77%)	167 (5.1%)	0.977 (0.701-1.363)	0.89
Diaphragmatic paralysis	2 (0.2%)	10 (0.31%)	0.747 (0.159-3.502)	0.71
Reopen surgery	15 (1.49%)	84 (2.56%)	0.581 (0.333-1.014)	0.06
Transfer out	340 (33.76%)	1083 (33.07%)	0.999 (0.851-1.174)	0.99

	Mean ± SD	Mean ± SD	F Score	P-value
Admission to operation (days)	0.88 ± 2.64	0.92 ± 2.99	0.22	0.64
LOS (days)	13.82 ± 11.11	13.95 ± 12.97	0.62	0.43
Total hospital charge (US dollars)	447 051 ± 443 410	439 908 ± 453 981	0.08	0.78

Abbreviations: AKI, acute kidney injury; aOR, adjusted odds ratio; CI, confidence interval; LOS, length of stay; MACE, major adverse cardiovascular event; MI, myocardial infarction; PE, pulmonary embolism; SD, standard deviation; TAAD, type A aortic dissection; TIA, transient ischemic attack; VTE, venous thromboembolism.

Discussion

This study compared the in-hospital outcomes of patients who had weekend and weekend admissions for TAAD repair using the NIS database from the last quarter of 2015 to 2020. Patients admitted on the weekend were more likely to get transferred in from an acute care hospital and have higher renal malperfusion. After multivariable adjustment, patients with weekend and weekday admission had comparable times from admission to operation and in-hospital mortality. All other in-hospital outcomes were also comparable for the weekend patients.

Contrary to the commonly observed “weekend effect” in other surgical procedures,^10-13 findings from this study indicated that weekend admissions did not significantly affect the in-hospital mortality or major complication rates for TAAD repairs. The mortality outcome is consistent with Altujjar et al’s studies that reported no significant weekend effect on the in-hospital mortality rate in TAAD repair.¹⁹ One of the primary strengths of this study was its in-depth analysis of major morbidities following TAAD repair. The study found no significant difference in morbidity between weekday and weekend admissions, which further underscores the absence of observable weekend effects in TAAD repair.

The higher rate of transfer-in from other acute care hospitals during weekend admissions may reflect reduced staffing and/or resources on weekends. However, the absence of a weekend effect on mortality and morbidities in TAAD repair may be attributed to the emergent nature of this condition, which requires immediate surgical intervention regardless of the day of admission. The consistent surgical outcomes between weekend and weekday admissions underscore the effectiveness of emergency care protocols that ensure timely intervention for TAAD patients on a national level. Moreover, the comparable time from admission to operation between weekend and weekday admissions further supports the equivalent efficiency of managing high-risk emergencies during the weekend.

However, the study identified that patients admitted on weekends were more likely to present with renal malperfusion at the time of admission. While the exact reasons for this cannot be determined, it may be related to the higher rates of inter-hospital transfers, which could potentially delay intervention. Despite renal malperfusion being associated with increased operative mortality in TAAD,²³ the adjusted analyses revealed that it did not lead to worse outcomes for weekend admissions. This finding suggests that the care protocols in place for TAAD repair are effective in managing the added complexity associated with weekend admissions.

This study acknowledges several limitations due to the constraints of the NIS database. Primarily, the NIS uses the ICD coding system, which does not record specific clinical details such as the timing of symptom onset, the exact location of the dissection, the extent of the repair, the type of graft used, or the duration of circulatory arrest. Additionally, the database classifies weekend admissions as a binary variable and records the time from admission to operation, but it does not specify if the surgical intervention occurred over the weekend or on a weekday of the following week. The weekend effect may potentially extend to Friday night or Monday morning; however, this cannot be determined using the NIS database. Another limitation is that the NIS only includes in-hospital outcomes and lacks follow-up data after discharge, which restricts the assessment of long-term prognoses for patients with TAAD. Despite these limitations, the NIS is a valuable resource as the largest all-payer healthcare database in the US, which allows a comprehensive analysis of the “weekend effect” on TAAD repair at a national level.

In conclusion, this study investigated the potential “weekend effect” on in-hospital outcomes of TAAD repair using the population-based NIS database. Although TAAD patients admitted on weekends were more likely to experience inter-hospital transfers and present with renal malperfusion, after multivariable analysis, patients admitted on weekends and weekdays had comparable times from admission to operation, as well as similar in-hospital mortality and morbidity rates. These findings suggest the effectiveness of weekends emergency care protocols for TAAD patients and the lack of a “weekend effect” on TAAD repair in the United States.

Supplemental Material

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Supplemental Material for Is There a “Weekend Effect” on In-Hospital Outcomes of Type a Aortic Dissection Repair? A Population-Based Analysis of National Inpatient Sample From 2015-2020 by Renxi Li, BS, and Stephen J. Huddleston, MD, PhD in Vascular and Endovascular Surgery

Footnotes

Acknowledgments

The authors acknowledge Dr Richard Amdur, PhD, for giving statistical support for this project.

Author Contributions

conceptualization: R.L.; methodology: R.L.; formal analysis: R.L.; investigation: R.L.; resources: R.L., S.H.; data curation: R.L.; writing (original draft): R.L.; writing (review & editing): R.L., S.H.; Supervision, S.H.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Statement

ORCID iD

Renxi Li

Supplemental Material

Supplemental material for this article is available online.

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, et al. Renal malperfusion affects operative mortality rather than late death following acute type A aortic dissection repair. Asian J Surg. 2020;43(1):213-219. doi:10.1016/j.asjsur.2019.02.004

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