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Acute myocardial infarction

BMJ 2014;348:f7696
Acute myocardial infarction has high mortality, but early medical and surgical intervention can be
lifesaving.1 2 3 4 5 6 Previous studies have shown that the time of day or day of the week when
patients seek care can affect outcomes.5 7 8 In most of these studies, patients presenting to hospital
with an acute myocardial infarction during off-hours (evenings and weekends) wait longer for
interventional treatments than those presenting during regular office hours and have a higher mortality.
In a linked paper (doi:10.1136/bmj.f7393), Sorita and colleagues report the first systematic review of
the effect of off-hour presentation on outcomes after acute myocardial infarction.9
The authors evaluated the literature on acute myocardial infarction and off-hour care. Outcomes
included in-hospital and 30 day mortality, as well as door to balloon time for the subset of patients with
ST elevation myocardial infarction. Using a random effects model, they reported pooled odds ratios for
each outcome measure. The pooled results confirmed the presence of a 5% relative increase in
mortality (both in-hospital and 30 day) as well as a delay of nearly 15 minutes in door to balloon time
for patients presenting during off-hours. Meta-regression based on year of data showed an increase in
the risk posed by off-hours care over time.
This novel systematic review advances knowledge on quality of care for patients with myocardial
infarction, although it is limited by the studies it contains. In the absence of randomization, differences
in patient characteristics between compared groups can introduce substantial bias into study results.
Because patients cannot be randomized to present during or outside working hours, a common method
of adjusting for baseline risk is needed to facilitate meaningful comparison between studies. If the
included studies use different methods to control bias, heterogeneity is increased, which limits the
conclusions that can be drawn from pooled analyses.10 These are important considerations when
undertaking any systematic review of observational studies.
The authors were further challenged by clinical and statistical heterogeneity. The definition of the offhour time period differed across studies, and varying geographical settings are likely to lead to
differences in case mix, time to presentation, physician practices, and hospital characteristics. Such
heterogeneity makes it difficult to pool study results and generate a single measure of relative risk.
Publication bias, as demonstrated by the absence of small negative studies in the funnel plot, may
complicate interpretation still further, although, as the authors point out, there was no significant
change in the pooled effect of off-hours presentation after accounting for the missing studies.
Confounding is always a problem in syntheses of observational studies. In Sorita and colleagues
analysis it is particularly important to consider whether patients presenting out of hours are
systematically different from other patients in such a way that increases their risk of death. They might
be sicker, for example, or they may delay calling for medical help for longer. If the last case were true,
then delayed presentation would lead to delayed treatment and potentially worse outcomes, which
would have little to do with the quality of off-hour care. As the authors point out, the results as to
whether time to presentation (delay before reaching hospital) differs significantly between patients
presenting during off-hours and working hours are conflicting. If delay in presentation differs between
groups, this could bias the measured relative mortality associated with off-hour care.
Although differences in underlying patient characteristics, including time to presentation, can
significantly affect mortality, it is less clear how they would affect door to balloon time. Prolongation
of door to balloon time is arguably a more robust measure of altered care during off-hours, because it is

more likely to be directly controlled by the hospital and care providers. In this case, a process measure
(door to balloon time) truly enhances the interpretation of an outcome measure (mortality), albeit for a
subgroup of patients. The nearly 15 minute delay in percutaneous coronary intervention experienced by
patients presenting with ST elevation myocardial infarction during off-hours provides a potentially
causal link between the quality of off-hour care and patient outcomes.
Patients presenting during off-hours experience delays in urgent care and worse outcomes, and the gap
seems to be increasing over time. As healthcare managers in many countries move toward performance
based remuneration, patient outcomes are increasingly being used to gauge the quality of hospital care.
Managers seeking to boost their hospitals performance for patients with acute myocardial infarction
should focus on improving their off-hour care, with the goal of providing consistently high quality care
24 hours a day and seven days a week.
Studies of quality of care and patient outcomes highlight the challenges we face when trying to
measure true hospital performance. Administrative data often do not capture all the factors that
contribute to baseline patient risk. To properly evaluate the quality of healthcare delivered at all times,
we must refine our methods of risk adjustment to include time to presentation and severity of illness.
Future studies should try to identify specific deficits in the care pathway during off-hours, allowing
differences in outcomes to be linked to differences in processes. We look forward to reading about
innovative strategies to deal with this problem. Patients deserve the best possible outcome, at any given
time, and on any given day.
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Sorita A, Ahmed A, Starr SR, Thompson KM, Reed DA, Prokop L, et al. Off-hour presentation and
outcomes in patients with acute myocardial infarction: systematic review and meta-analysis.
BMJ2014;348:f7393.Abstract/FREE Full Text
Reeves BC, Deeks JJ, Higgins JP, Wells GA; on behalf of the Cochrane Non-Randomised Studies
Methods Group. Including non-randomized studies. In: Higgins JPT, Green S, eds. Cochrane handbook
for systematic reviews of interventions version 5.0.1st ed. Cochrane Collaboration, 2008.