Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke

Abstract

Objectives: To determine the accuracy of coding of admissions for stroke on weekdays versus weekends and any impact on apparent outcome.

Design: Prospective population based stroke incidence study and a scoping review of previous studies of weekend effects in stroke.

Setting: Primary and secondary care of all individuals registered with nine general practices in Oxfordshire, United Kingdom (OXVASC, the Oxford Vascular Study).

Participants: All patients with clinically confirmed acute stroke in OXVASC identified with multiple overlapping methods of ascertainment in 2002-14 versus all acute stroke admissions identified by hospital diagnostic and mortality coding alone during the same period.

Main outcomes measures: Accuracy of administrative coding data for all patients with confirmed stroke admitted to hospital in OXVASC. Difference between rates of "false positive" or "false negative" coding for weekday and weekend admissions. Impact of inaccurate coding on apparent case fatality at 30 days in weekday versus weekend admissions. Weekend effects on outcomes in patients with confirmed stroke admitted to hospital in OXVASC and impacts of other potential biases compared with those in the scoping review.

Results: Among 92 728 study population, 2373 episodes of acute stroke were ascertained in OXVASC, of which 826 (34.8%) mainly minor events were managed without hospital admission, 60 (2.5%) occurred out of the area or abroad, and 195 (8.2%) occurred in hospital during an admission for a different reason. Of 1292 local hospital admissions for acute stroke, 973 (75.3%) were correctly identified by administrative coding. There was no bias in distribution of weekend versus weekday admission of the 319 strokes missed by coding. Of 1693 admissions for stroke identified by coding, 1055 (62.3%) were confirmed to be acute strokes after case adjudication. Among the 638 false positive coded cases, patients were more likely to be admitted on weekdays than at weekends (536 (41.0%) v 102 (26.5%); P<0.001), partly because of weekday elective admissions after previous stroke being miscoded as new stroke episodes (267 (49.8%) v 26 (25.5%); P<0.001). The 30 day case fatality after these elective admissions was lower than after confirmed acute stroke admissions (11 (3.8%) v 233 (22.1%); P<0.001). Consequently, relative 30 day case fatality for weekend versus weekday admissions differed (P<0.001) between correctly coded acute stroke admissions and false positive coding cases. Results were consistent when only the 1327 emergency cases identified by "admission method" from coding were included, with more false positive cases with low case fatality (35 (14.7%)) being included for weekday versus weekend admissions (190 (19.5%) v 48 (13.7%), P<0.02). Among all acute stroke admissions in OXVASC, there was no imbalance in baseline stroke severity for weekends versus weekdays and no difference in case fatality at 30 days (adjusted odds ratio 0.85, 95% confidence interval 0.63 to 1.15; P=0.30) or any adverse "weekend effect" on modified Rankin score at 30 days (0.78, 0.61 to 0.99; P=0.04) or one year (0.76, 0.59 to 0.98; P=0.03) among incident strokes.

Conclusion: Retrospective studies of UK administrative hospital coding data to determine "weekend effects" on outcome in acute medical conditions, such as stroke, can be undermined by inaccurate coding, which can introduce biases that cannot be reliably dealt with by adjustment for case mix.

Fig 1 Case fatality at 30 days in weekday v weekend admissions stratified by different coding selection criteria

Fig 2 Number of patients with stroke by day of week of onset stratified by stroke severity (NIHSS score)

Fig 3 Number of patients with stroke (admitted v not admitted) by day of week of presentation for medical attention stratified by stroke severity (NIHSS score)

Fig 4 Distribution of stroke severity (NIHSS score) in patients admitted during weekend v weekdays in OXVASC (odds ratio 0.97, 95% confidence interval 0.77 to 1.23; P=0.82)

Fig 5 Modified Rankin scale (mRS) at 30 days in patients admitted during weekend v weekdays in OXVASC