A 13-year nationwide analysis of “the weekend effect” on outcomes of esophageal variceal bleed

Introduction

Esophageal variceal bleeding (EBV) is a severe medical condition caused by the rupture of varices in the esophagus. EVB is the third most common cause of upper gastrointestinal bleeding (UGIB), accounting for 5% to 30% of cases (1). It is a result of resistance to portal flow or portal hypertension, which is commonly caused by cirrhosis of the liver and underlying conditions (2). The varices within the esophagus become dilated and enlarged, potentially leading to bleeding and other complications (3). Increased venous pressure causes the development of portosystemic collateral vessels, which have high resistance (4). The collaterals drain into the azygos vein, leading to the formation of esophageal varices. Esophageal varices typically have no symptoms until they rupture, causing hematemesis or melena (3). People with poor liver function, continued alcohol use, red whale marking on endoscopies, and large varices are all at increased risk of developing EBV (5). This condition is linked to significant morbidity and mortality, posing considerable challenges to healthcare providers in timely diagnosis and appropriate management. In recent years, weekend hospital admissions have emerged as a potentially crucial factor affecting the prognosis of patients with UGIB (6-15). The weekend effect refers to worse outcomes for patients admitted during weekends than on weekdays. This may be due to limited staff availability, facility access, or differences in clinical decision-making (6-15). The impact of weekend admission on outcomes for patients with EVB is still uncertain and needs further investigation.

Our retrospective cohort study aims to examine the differences in all-cause mortality, endoscopy timing, and TIPS between patients admitted on weekends vs. weekdays. We used NIS data from 2008–2020 and rigorous methodology involving International Classification of Disease (ICD) coding and statistical analyses to examine the incidence and outcomes of patients with EVB admitted on both weekdays and weekends. We present this article in accordance with the STROBE reporting checklist (available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-12/rc).

Methods

Data source

Our study is a retrospective cohort study using the National Inpatient Sample (NIS) from 2008 through 2020, which was used to identify patients over 18 with a primary diagnosis of EVB using the ICD 9 and 10 codes. The NIS is an initiative provided by the Healthcare Cost and Utilization Project (HCUP) (16). The NIS is one of the largest all-payer databases available in the United States and is maintained by the Agency for Healthcare Research and Quality (AHRQ) (16). It comprises over 7 million unweighted records and over 35 million weighted hospital encounters annually (16). The data provided in the database is initially unweighted, then using an algorithm provided by HCUP, it is converted to weighted data, which allows for estimates on a national level (16). Institutional review board (IRB) was not required for this study as the NIS includes patient information that has been de-identified and made publicly available. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Study population

The NIS includes a 20% random sample of all inpatient hospitalizations from over 45 states and contains one primary diagnosis and up to 39 secondary diagnoses using the International Classification of Diseases, Tenth Revision (ICD-10), and 29 secondary diagnoses with the ICD-9-CM codes (16). ICD codes were used to identify patients with admission during the weekday and weekend for new or prior EBV (ICD-9 code: 456.0; ICD-10 code: 185.01) the subject population were patients on weekends and the control population were weekday patients. Thes patients were analyzed for baseline characteristics such as age, gender, race, insurance status, and various comorbidities. Outcomes included mortality, shock, acute myocardial infarction (AMI), acute kidney injury (AKI), and the composite of these four. Secondary outcomes include length of stay (LOS), hospital charges, whether endoscopy or transjugular intrahepatic portosystemic shunt (TIPS) was performed, and the timeliness of these procedures. Outcomes were compared between groups, and odds ratios (ORs) were calculated using weighted logistic regression. ORs were adjusted for common co-founders, such as age, gender, race, hospital characteristics, region, and the Charlson Comorbidity Index (CCI).

Statistical analysis

The Pearson Chi-squared and Student’s t-test assessed categorical and continuous variables. The linear-by-linear association test analyzed the trends in the frequency of esophagogastroduodenoscopy (EGD) or TIPS in hospitalized EVB patients. After adjusting for baseline characteristics and comorbidities to account for confounding variables, a two-step hierarchical multivariate regression model was used, emphasizing variables with P<0.05. These variables included age, gender, race, CCI, insurance payer status. Stata Version 17 by StataCorp LLC (College Station, TX) was utilized for all statistical analyses.

Results

This study included a weighted total of 322,155 patients admitted for EVB. Of these, 82,293 were admitted on the weekend, and 239,862 were admitted during the weekday. Age in mean years for weekend admissions were 56.38 years and for weekday admissions 56.17 years (P=0.07) (Table 1). Then 68.02% male and 31.98% female for weekend and 67.86% male and 32.14% female for weekday (P=0.71) (Table 1). Race for weekend was 65.15% White (P=0.39), 6.87% Black (P=0.91), 20.37% Hispanic (P=0.46), and 7.61% other (P=0.76); while, weekday was 65.52% white, 6.84% black, 20.10% Hispanic, 7.53% other. Insurance status for weekend were 56.96% Medicare/Medicaid and 12.02% self-pay; while, weekday were 56.60% Medicare/Medicaid (P=0.42) and 11.73% self-pay (P=0.32). Weekend patients; 8.97% had coronary artery disease (CAD) (P=0.07), 13.96% had hyperlipidemia (HLD) (P=0.18), 35.14% had hypertension (HTN) (P=0.36), 31.42% had diabetes mellitus (DM) type 2 (P=0.20), 4.45% had Congestive heart failure (CHF) (P=0.56), 15.46% had anemia (P=0.04), 1.54% had end stage renal disease (ESRD) (P=0.93), 9.58% were obese (P=0.10), 27.71% smoked (P=0.005), 14.97% had gastroesophageal reflux disease (GERD) (P=0.18), 24.99% had liver cirrhosis (P=0.32), 41.48% had alcohol use disorder (P=0.002). Weekday patient; 9.43% had CAD, 14.39% had HLD, 34.75% had HTN, 31.95% had DM type 2, 4.56% had CHF, 16.14% had anemia, 1.53% had ESRD, 9.16% were obese, 26.59% were smokers, 15.40% had GERD, 25.39% had liver cirrhosis, 40.11% alcohol use disorder. Weekend patients and weekday patients of relatively equal complexity (CCI score of 5.30 weekend vs. 5.25 weekday, P=0.03).

We found that patients with EVB admitted on weekdays and weekends had similar rates of all-cause in-hospital mortality (6.26% weekend vs. 5.94% on weekday, OR 1.06, 95% CI: 0.98–1.14, P=0.14), AMI (1.11% weekend vs. 0.99% weekday, OR 1.13, 95% CI: 0.95–1.34, P=0.18), and AKI (17.40% weekend vs. 16.87% weekday, OR 1.04, 95% CI: 0.99–1.09, P=0.14) (Table 2). However, patients admitted on the weekend had higher odds of shock (11.15% weekend vs. 9.79% weekday, OR 1.14, 95% CI: 1.08–1.21, P<0.001) and composite outcome (OR 1.08, 95% CI: 1.04–1.13, P<0.001) (Table 2). Accordingly, patients admitted on weekends had lower odds of receiving an endoscopic intervention on hospital day zero (35.95% weekends vs. 38.33% weekdays, OR 0.90, 95% CI: 0.86–0.94, P<0.001) but no difference in the endoscopy being done (85.81% weekend vs. 85.02% weekday, OR 1.03, 95% CI: 0.98–1.08, P=0.30). Also, TIPS before day four was more likely on weekdays (52.94% weekend vs. 59.14% weekday, OR 0.778, 95% CI: 0.65–0.94, P=0.009). TIPS for weekend and weekday had the same odds of being done (3.96% vs. 4.19%, OR 0.952, 95% CI: 0.87–1.04, P=0.30). The LOS (5.27 days on weekend vs. 5.17 days on weekdays, OR 0.0102, 95% CI: 0.01–0.19, P=0.03) and hospital charges ($62,005 vs. $60,211, OR<0.0001, 95% CI: 188–2,868, P=0.03) was relatively similar between weekend and weekday admissions.

A subanalysis of non-shock EVB patients was performed. The secondary outcomes were analyzed, the following outcomes of mortality (OR 0.962, 95% CI: 0.867–1.068, P=0.47), AMI (OR 1.214, 95% CI: 0.983–1.499, P=0.07), AKI (OR 1.03, 95% CI: 0.975–1.089, P=0.29), composite (OR 1.034, 95% CI: 0.982–1.089, P=0.20), endoscopy (OR 1.015, 95% CI: 0.960–1.073, P=0.60), and total charges (OR 1,102.85, 95% CI: −89,717 to 2,295.41, P=0.07) were insignificant between weekend and weekday patients (Table 3, Figure 1). The LOS was greater (OR 0.101, 95% CI: 0.017–0.185, P=0.02) (Table 3, Figure 1). Patients who did not receive endoscopy on day 0 had higher odds of shock (OR 1.892, 95% CI: 1.786–2.004, P<0.05), mortality (OR 1.540, 95% CI: 1.421–1.667, P<0.05), LOS (OR 2.14, 95% CI: 1.94–2.34, P<0.05), and costs ($59,524, 95% CI: $56,154–$62,894, P<0.05) (Tables 4,5).

Figure 1 Graph representation of the main results of Table 2. AKI, acute kidney injury; AMI, acute myocardial infarction; TIPS, transjugular intrahepatic portosystemic shunt.

Discussion

EBV is a serious medical condition that can have severe consequences. It is a medical emergency that can lead to massive blood loss and increase the risk of mortality if not diagnosed and treated quickly. Esophageal varices are a common complication of cirrhosis, with 90% of patients developing them within ten years of diagnosis (17). Moreover, esophageal varices are responsible for 60–65% of hemorrhagic episodes in cirrhotic patients, and these episodes account for up to 20% mortality (18,19). It is important to emphasize the significance of preventing bleeding and ensuring early diagnosis and treatment. Weekend admissions pose a particular limitation to hospitals and the resources that are accessible to them. Thus, they have been frequently associated with higher mortality rates worldwide (20). It is important to understand the factors that can impact the outcomes of patients with EVB, particularly those admitted on weekends. Our study highlights potential disparities in outcomes for EVB patients admitted on the weekend compared to those admitted during the weekdays.

In this study, patients admitted on weekends faced a markedly higher risk of shock and worse overall outcomes compared to those admitted on weekdays. Weekend admissions were associated with statistically significantly lower odds of receiving timely endoscopy on the day of admission and TIPS before day 4. However, the likelihood of undergoing TIPS remained consistent across both groups. A subanalysis was conducted of patients who did not receive endoscopy on day 0, showing higher odds of shock and mortality, and greater LOS and total costs. These findings underscore a critical gap in adherence to current American Society for Gastrointestinal Endoscopy (ASGE) guidelines, which advocate for endoscopic intervention within 12 hours of admission to optimize survival outcomes, as supported by robust evidence (21). Furthermore, contemporary literature emphasizes rescue TIPS as the cornerstone of treatment for severe rebleeding following endoscopic therapy (22,23).

A suggested reason for this occurrence was elucidated through further analysis, which analyzed the outcomes based on weekends and weekdays by removing shock EVB patients. Controlling for shock revealed a marginal difference in LOS and total costs, suggesting an inherent delay between EVB admissions on weekdays and weekends. The failure to deliver these time-sensitive interventions likely exacerbates adverse outcomes, potentially driven by the “weekend effect”—a phenomenon rooted in diminished hospital staffing, prolonged procedural wait times, delayed recognition of critically ill patients, and suboptimal coordination among essential specialists and support teams⁷. This systemic shortfall demands urgent attention to ensure equitable, high-quality care regardless of the day of admission.

Current guidelines for the initial management of gastrointestinal (GI) bleeding include the following measures: establishing intravenous access and administering fluids, providing supplemental oxygenation, and ensuring airway protection (24). In the case of hematemesis, initial care involves the use of a nasogastric tube, erythromycin antibiotics, and blood products if active bleeding and hypovolemia occur. Prophylactic antibiotics, such as ceftriaxone, are recommended to reduce mortality risk, infections (e.g., spontaneous bacterial peritonitis, urinary tract infections), and rebleeding (25,26). For patients suspected of having varices, pharmacologic therapy such as octreotide and sometimes terlipressin is given during presentation to decrease portal blood flow and improve hemostasis in patients with acute variceal bleeding (27). Terlipressin is the only medication shown to reduce in-hospital mortality (28). In addition, in most cases, balloon tamponade therapy, a non-pharmacologic temporary measure, can also be used for management (29).

Upper endoscopy is the definitive treatment for GI bleeding, and it should be performed within 12 hours of hospital admission (22,30,31). Endoscopic variceal ligation (EVL) is the preferred treatment option, and if EVL fails, endoscopic sclerotherapy is used (32). Delayed endoscopy leads to an increased rate of rebleeding and mortality (22). In case endoscopy is delayed beyond 12 hours, intravenous proton-pump inhibitor (PPI) therapy is recommended to reduce the risk of bleeding (33). However, PPI use after endoscopy does not show a benefit (34,35). Finally, it is recommended to wait for 48–72 hours after controlling the bleed before restarting feeds due to the risk of an increase in splanchnic blood flow causing rebleeding (36,37).

The TIPS is a second-line alternative therapy after endoscopic treatment. TIPS can be used to manage esophageal varices bleeding in patients with persistent or severe re-bleeding. One study found that uncontrolled variceal bleeding, requiring TIPS placement, was associated with increased mortality in patients post-transplant (38). Our study similarly indicates that mortality outcomes were nearly identical for TIPS treatment regarding both patient groups admitted on weekdays versus the weekends.

Patients in both respective groups were controlled for baseline characteristics of age, gender, race, and insurance status. The OR, calculated using weighted logistic regression, was adjusted for other common factors, including hospital characteristics, region, and the CCI. This method allowed for accurate differentiation in outcomes solely based on the timing of the intervention. There is no significant difference in mortality between weekends and weekdays. Factors that impact mortality can include individual-based severity of bleeding, comorbidities, and the adequacy of subsequent management strategies. The limitations of this study must be addressed. With this data set, specific patient encounters cannot be traced; the only way they are traced is through admissions and not the number of times they are admitted; hence, there is a possibility of over-calculation. The specific causes of death are unknown, the data can only be differentiated using ICD-9 and ICD-10 diagnosis codes. Since the data is organized by coding, subtle differences can occur based on the provider’s coding style, which can alter the data. Unfortunately, measuring various scores like model for end-stage liver disease (MELD)/Child-Pugh is impossible with the NIS dataset, as this information is not reflected in billing codes. This would be an interesting topic to investigate in a single-center EMR-Extract dataset. Finally, the NIS does not detail important clinical predictors, intraoperative complications, medications, or laboratory values.

Further research is needed to understand these factors better and identify potential solutions to improve outcomes for patients admitted with EVB on weekends. Clinicians should be aware of these potential disparities and work towards optimizing treatment strategies for patients admitted on weekends to improve outcomes and reduce morbidity and mortality associated with EVB.

Conclusions

We found that patients admitted with EVB on weekends had lower odds of having an endoscopy performed on the day of admission and TIPS before day four compared to those admitted on weekdays. Previous studies have stated how the “weekend effect” plays an important role in lowering the quality of patient care. Our study demonstrated no significant difference in hospital mortality between patients admitted on weekdays compared to those admitted on weekends. However, an increased risk of shock, composite score, LOS, and hospital costs can be noted in patients admitted on weekends. Therefore, further research must determine how the weekend effect can be mitigated in admitted EVB patients.

Acknowledgments

The project was submitted and accepted as an abstract to Digestive Disease Week (DDW), then presented at DDW on 5/19/2024 in Washington, D.C..

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-12/rc

Peer Review File: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-12/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-12/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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