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

Background Esophageal variceal bleeding (EVB) is a common gastrointestinal (GI) emergency associated with a high risk of morbidity and mortality. Esophageal varices are a result of portal hypertension, commonly caused by cirrhosis. When these varices rupture, they cause rapid exsanguination if not intervened on quickly. Hospital admissions during the weekend are associated with worse outcomes in many categories of emergent GI pathology, including upper GI hemorrhage. However, the relationship between weekend admission and hospital outcomes for EVB patients remains controversial. Our study aims to investigate this potential disparity further using a large nationwide sample. Methods The National Inpatient Sample (NIS) [2008–2020] was used, patients over 18 with a primary EVB diagnosis using ICD-9/10 codes were selected. Patients were grouped by weekend or weekday admission. Baseline characteristics (age, gender, race, insurance, comorbidities) were compared. Outcomes included mortality, shock, acute myocardial infarction (AMI), acute kidney injury (AKI), composite outcome, length of stay (LOS), hospital charges, endoscopy/TIPS performance, and procedure timeliness. Weighted logistic regression calculated odds ratios (ORs), adjusted for age, gender, race, hospital characteristics, region, and Charlson Comorbidity Index (CCI). Results Of 322,155 EVB patients, 82,293 were weekend admissions, and 239,862 were weekday admissions. Baseline characteristics [age (P=0.07), gender (P=0.71), race (P>0.05), insurance (P>0.05)) were similar. Patients admitted on weekends had lower rates of anemia but higher smoking (P=0.005), alcohol use disorder (P=0.002), more medically complex (CCI 5.30 vs. 5.25, P=0.03). The two groups had similar rates of mortality (P=0.14), AMI (P=0.18), and AKI (P=0.14). Weekends had higher odds of shock (OR 1.14, CI 1.08-1.21, P<0.001) and composite outcome (OR 1.08, CI 1.04-1.13, P<0.001). Weekends had lower odds of receiving an endoscopic intervention on hospital day 0 [OR 0.90, 95% confidence interval (CI) 0.86–0.94, P<0.001) or TIPS before day four (OR 0.778, 95% CI 0.65–0.94, P=0.009). 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, 95% CI: −89,717 to 2,295.41, P=0.07) between the two groups. Conclusions The increased risk of shock in these patients, but no difference in hospital mortality, could be explained by the lower odds of having an endoscopy done on the day of admission and TIPS before day four, compared to patients admitted on weekdays. Thus, more research is needed to determine how the weekend effect can be mitigated in admitted EVB patients.