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Eur J Intern Med. 2014 Apr;25(4):394-400. doi: 10.1016/j.ejim.2014.03.012. Epub 2014 Apr 12.

Off-hour presentation and outcomes in patients with acute ischemic stroke: a systematic review and meta-analysis.

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Division of Preventive Medicine, Mayo Clinic, Rochester, MN, United States.
Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, United States.
Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States.
Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States.
Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, United States.
Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, United States.
Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States.
Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States.
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States. Electronic address:



Studies have suggested that patients with acute ischemic stroke who present to the hospital during off-hours (weekends and nights) may or may not have worse clinical outcomes compared to patients who present during regular hours.


We searched Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus through August 2013, and included any study that evaluated the association between time of patient presentation to a healthcare facility and mortality or modified Rankin Scale in acute ischemic stroke. Quality of studies was assessed with the Newcastle-Ottawa Scale. A random-effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I(2). A priori subgroup analyses were used to explain observed heterogeneity.


A total of 21 cohort studies (23 cohorts) with fair quality enrolling 1,421,914 patients were included. Off-hour presentation for patients with acute ischemic stroke was associated with significantly higher short-term mortality (OR, 1.11, 95% CI 1.06-1.17). Presenting at accredited stroke centers (OR 1.04, 95% CI 0.98-1.11) and countries in North America (OR 1.05, 95% CI 1.01-1.09) were associated with smaller increase in mortality during off-hours. The results were not significantly different between adjusted (OR, 1.11, 95% CI 1.05-1.16) and unadjusted (OR, 1.13, 95% CI 0.95-1.35) outcomes. The proportion of patients with modified Rankin Scale at discharge ≥ 2-3 was higher in patients presenting during off-hours (OR, 1.14, 95% CI 1.06-1.22).


The evidence suggests that patients with acute ischemic stroke presenting during off-hours have higher short-term mortality and greater disability at discharge.


Acute ischemic stroke; Meta-analysis; Modified Rankin Scale; Mortality; Off-hours; Systematic review

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