Abstract
Abstract
Objectives
To examine whether longer holidays are associated with worse quality of care for patients with ST-segment elevation myocardial infarction (STEMI) compared with weekday admissions and to evaluate the impact of holiday duration on both process indicators and mortality outcomes.
Design
Retrospective observational study.
Setting
Nationwide study across 3278 hospitals in China participating in the China Cardiovascular Association Database-Chest Pain Centre Registry.
Participants
A total of 616 382 STEMI episodes from 1 January 2016 to 31 December 2021 were included.
Primary and secondary outcome measures
Primary outcome was in-hospital mortality. Secondary outcomes included process indicators: initial ECG acquisition within 10 min, thrombolytic treatment within 30 min and door-to-balloon time within 90 min. Admissions were categorised as weekday (reference), weekend, short-term holiday (3–5 days) or long-term holiday (7–10 days).
Results
Long-term holidays were associated with a 10% increased risk of in-hospital mortality (OR=1.10, 95% CI: 1.02 to 1.18, p<0.05), with a 17% increased risk during the Spring Festival (OR=1.17, 95% CI: 1.09 to 1.25, p<0.01). Weekends showed a 5% increased mortality risk (OR=1.05, 95% CI: 1.02 to 1.09, p<0.01). Initial ECG acquisition within 10 min improved during long-term holidays (OR=1.15, 95% CI: 1.10 to 1.21, p<0.001). However, short-term holidays were associated with worse performance for thrombolytic treatment within 30 min (OR=0.83, 95% CI: 0.76 to 0.91, p<0.01) and door-to-balloon time within 90 min (OR=0.83, 95% CI: 0.80 to 0.87, p<0.01). Primary-secondary hospitals showed lower odds of timely percutaneous coronary intervention during long-term holidays (OR=0.83, 95% CI: 0.75 to 0.92, p<0.001), while tertiary hospitals were more affected during short-term holidays (OR=0.82, 95% CI: 0.79 to 0.86, p<0.001).
Conclusions
Longer holidays, particularly the Spring Festival, are associated with slightly worse outcomes for patients with STEMI in China. While initial assessments may be expedited during holidays, delays occur in providing definitive treatment. These findings highlight the need for targeted strategies to maintain high-quality STEMI care during extended holiday periods.
Keywords: Quality in health care; Health Services; Emergency Service, Hospital; Myocardial infarction; China
Strengths and limitations of this study.
The study uses a large, ‘real-world’ sample of over 600 000 ST-segment elevation myocardial infarction (STEMI) episodes from a comprehensive nationwide database, providing sufficient precision for analyses across various holiday durations.
The analysis includes both process indicators and outcome measures, offering a comprehensive assessment of STEMI care quality during different time periods.
The study is limited by the lack of post-discharge mortality data, which could provide further insights into the long-term impacts of the observed ‘holiday effect’.
Introduction
Acute myocardial infarction (AMI) is a common cause of hospitalisation and death worldwide.1 2 The burden of cardiovascular disease, particularly acute ST-segment-elevation myocardial infarction (STEMI), is increasing at an unprecedented rate in low- and middle-income countries.3 In China, over the past two decades, there has been a substantial rise in STEMI hospital admissions, yet in-hospital mortality rates have not shown a corresponding decrease.4 5 STEMI is a life-threatening cardiovascular emergency requiring prompt diagnosis and treatment. Timely reperfusion therapy is crucial for improving patient outcomes and reducing mortality. However, the quality of care for patient with STEMI can be significantly influenced by system-level factors,6 7 such as a lack of interventionists resulting in a treatment delay during non-working hours.8
Holidays are commonly associated with reduced hospital staffing, limited resources or staffing with less experienced personnel.9,11 Previous studies have demonstrated higher mortality rates for patients with AMI admitted during weekends or holidays compared with weekdays.12 13 Some cultures observe extended holiday periods, such as the 2 week Nowruz holiday in Iran, the 9 day Eid al-Adha holiday in Turkey and the week-long Chinese Spring Festival. Many people, including hospital staff, prefer to spend longer holidays celebrating with family. This variation in holiday duration raises an important question: do longer holidays have a more significant impact on the quality of healthcare? Theoretically, extended holiday periods could exacerbate staffing shortages and resource limitations, potentially leading to poorer patient outcomes. However, evidence specifically related to STEMI care during holidays of varying lengths remains limited.
China’s holiday calendar features distinct periods of varying lengths, ranging from 3 to 5 day breaks to extended week-long periods such as the Spring Festival and National Day. These diverse holiday durations may lead to different alterations in hospital operations and staffing levels, potentially impacting the management of patients with STEMI. The unique structure of China’s holiday system provides an ideal setting to investigate how holiday duration affects the quality of care for patients with STEMI. While previous research has explored the ‘weekend/holiday effect’ on AMI mortality outcomes in China,14 15 there is limited understanding of how longer holiday periods specifically influence the quality of care for patients with STEMI.
A previous study analysed data from one single hospital with a total of 441 patients with STEMI,16 which may limit tgeneralisabilityity of the findings. Another provincial-level study used data from inpatient medical records in tertiary hospitals, which lacked detailed clinical data.14 Here, we use data from the nationwide China Cardiovascular Association (CCA) Database-Chest Pain Centre Registry, which provides comprehensive clinical information. This allows us to contribute new evidence on the quality evaluation of STEMI care. Investigating these issues may help to further understand the inconsistency in healthcare services.
This study aims to address a critical question: do longer holidays worsen the quality of care for patients with STEMI? We hypothesise that longer holidays represent a vulnerable time for hospital admissions, potentially associated with worse quality of STEMI care. Specifically, we seek to (1) examine the impact of time of admission (weekday, weekend, short-term holiday and long-term holiday) on patient care and (2) evaluate the holiday impact on processes of STEMI care and the outcomes of mortality. The findings of this study may have important implications for healthcare policy and resource allocation during extended holidays, potentially leading to strategies to mitigate any identified gaps in STEMI care quality during these periods.
Methods
Setting and data sources
We obtained data for hospital admissions of patients with STEMI across China from the CCA Database-Chest Pain Centre. The CCA Database-Chest Pain Centre is a nationwide web-based unified register data system established by the National Chest Pain Centres Programme, which aims to monitor and improve the quality of care for patients with acute chest pain.17 Information on patient characteristics, pre-hospital treatment and presenting features, in-hospital medication and reperfusion therapy, and in-hospital outcomes and discharge was collected. The CCA Executive Committee routinely performs strict quality control for data entry. Detailed information about the CCA database has been described elsewhere.17 18 Many studies have used this database,19,22 demonstrating its representativity and reliability.
This study was conducted according to the guidelines of Strengthening the Reporting of Observational Studies in Epidemiology. The study protocol was approved by the Data Management Committee of the CCA Database-Chest Pain Centre. This study was approved by the Biomedical Ethics Committee of West China Hospital, Sichuan University (2022–534). The requirement for informed consent was waived by the ethics committee due to the retrospective nature of the study. All data in the study were de-identified and used under an agreement to protect patient privacy and confidentiality.
Study population
From 1 January 2016 to 31 December 2021, a total of 1 081 144 episodes diagnosed with STEMI from 3499 accredited hospitals were registered in the database. Given that the main objective of the study is to evaluate the impact of holidays on the initial quality of care for patients with STEMI, we excluded (1) 258 233 episodes that were transferred from another hospital after the symptom onset, because these patients may have received initial treatment elsewhere, making it difficult to accurately assess the impact of holidays on their initial care, and (2) 24 600 episodes that had the symptom onset while in the hospital, because their care pathway differs significantly from those admitted from outside the hospital. We included patients who arrived at the hospital on their own and who arrived via emergency medical services. For measuring key time indicators, we excluded 92 608 episodes that did not record the time of admission, the time of first medical contact and the time of diagnosis. We also excluded 89 321 episodes with missing, invalid or anomalous values for key variables. Finally, 616 382 episodes were included in the study.
Holiday admission
The principal exposure was the timing of hospital admission. In the control group (weekday group), weekday admission was defined as occurring between Monday and Friday on working days. In the exposed group (holidays group), holiday admission was defined as occurring on weekends and national statutory holidays, which are described in table 1. Holidays are classified into short-term holidays (3–5 days) and long-term holidays (7–10 days), based on the actual number of holiday days in a given year.
Table 1. Descriptions of the holidays included in this study.
| Holiday | Holiday duration (days) | |||||
|---|---|---|---|---|---|---|
| 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | |
| New Year’s Day | 3 | 3 | 3 | 3 | 3 | 3 |
| Spring Festival (Chinese New Year) | 7 | 7 | 7 | 7 | 10 | 7 |
| Qingming Festival (Tomb-Sweeping Day) | 3 | 3 | 3 | 3 | 3 | 3 |
| Labour Day | 3 | 3 | 3 | 4 | 5 | 5 |
| Dragon Boat Festival | 3 | 3 | 3 | 3 | 3 | 3 |
| Mid-Autumn Festival | 3 | 8 | 3 | 3 | 8 | 3 |
| National Day | 7 | 7 | 7 | 7 | ||
The holidays were stratified based on the actual number of holiday days in a given year, according to holiday arrangements by the General Office of the State Council of the People’s Republic of China. When the Mid-Autumn Festival and National Day overlap, the holidays last for a total of 8 days.
Patient and hospital characteristics
We collected information on potential patient and hospital-level confounders. The variables on patients included demographics (age, sex), disease severities (comorbidity, symptoms and Killip level) and time from onset to admission. The variables on hospitals included hospital levels (primary, secondary and tertiary; see the notes in table 2 for definitions of hospital levels), Chest Pain Centres accreditation version (primary and standard, see the notes in table 2 for definitions of accreditation version) and located regions (eastern, central and western, representing the level of regional economic development).
Table 2. Patient-level and hospital-level characteristics of ST-segment elevation myocardial infarction episodes.
| Characteristics | Total (n=6 16 382) | Weekday (n=4 22 713) | Weekend (n=1 43 752) | Short-term holiday (≤5 days) (n=24 562) | Long-term holiday (≥7 days) (n=25 355) | P |
|---|---|---|---|---|---|---|
| Age | <0.001 | |||||
| <50 | 103 923 (16.86%) | 70 902 (16.77%) | 24 643 (17.14%) | 4189 (17.05%) | 4189 (16.52%) | |
| 50–59 | 150 837 (24.47%) | 103 030 (24.37%) | 35 527 (24.71%) | 6069 (24.71%) | 6211 (24.50%) | |
| 60–69 | 172 269 (27.95%) | 118 289 (27.98%) | 39 786 (27.68%) | 6909 (28.13%) | 7285 (28.73%) | |
| 70–79 | 129 245 (20.97%) | 89 216 (21.11%) | 29 836 (20.76%) | 4971 (20.24%) | 5222 (20.60%) | |
| ≥80 | 60 108 (9.75%) | 41 276 (9.77%) | 13 960 (9.71%) | 2424 (9.87%) | 2448 (9.65%) | |
| Sex | <0.001 | |||||
| Male | 472 467 (76.65%) | 323 563 (76.54%) | 110 634 (76.96%) | 18 953 (77.16%) | 19 317 (76.19%) | |
| Female | 143 915 (23.35%) | 99 150 (23.46%) | 33 118 (23.04%) | 5609 (22.84%) | 6038 (23.81%) | |
| Comorbidity | <0.001 | |||||
| 0 | 442 690 (71.82%) | 303 538 (71.81%) | 102 979 (71.64%) | 17 928 (72.99%) | 18 245 (71.96%) | |
| 1 | 122 859 (19.93%) | 84 046 (19.88%) | 29 041 (20.20%) | 4714 (19.19%) | 5058 (19.955%) | |
| 2 | 36 101 (5.86%) | 24 908 (5.89%) | 8349 (5.80%) | 1368 (5.57%) | 1476 (5.82%) | |
| ≥3 | 14 732 (2.39%) | 10 221 (2.42%) | 3383 (2.36%) | 552 (2.25%) | 576 (2.27%) | |
| Chest tightness/chest pain | <0.001 | |||||
| Persistent chest tightness/chest pain | 467 888 (75.91%) | 319 133 (75.50%) | 110 411 (76.81%) | 18 922 (77.04%) | 19 422 (76.60%) | |
| Intermittent chest tightness/chest pain | 126 633 (20.54%) | 88 291 (20.89%) | 28 499 (19.82%) | 4826 (19.65%) | 5017 (19.79%) | |
| Symptoms are relieved | 21 861 (3.55%) | 15 289 (3.61%) | 4842 (3.47%) | 814 (3.31%) | 916 (3.61%) | |
| Killip level | 0.021 | |||||
| Level I (no CHF) | 485 383 (78.75%) | 332 686 (78.70%) | 113 397 (78.88%) | 19 204 (78.19%) | 20 096 (79.26%) | |
| Level II (rales and/or JVD) | 78 989 (12.81%) | 54 458 (12.88%) | 18 127 (12.61%) | 3260 (13.27%) | 3144 (12.40%) | |
| Level III (pulmonary oedema) | 22 576 (3.66%) | 15 428 (3.65%) | 5302 (3.69%) | 899 (3.66%) | 947 (3.73%) | |
| Level IV (cardiogenic shock) | 29 434 (4.78%) | 20 141 (4.77%) | 6926 (4.82%) | 1199 (4.88%) | 1168 (4.61%) | |
| Time from onset to admission | <0.001 | |||||
| <100 mins | 199 910 (32.43%) | 136 097 (32.20%) | 47 384 (32.96%) | 8103 (32.99%) | 8326 (32.84%) | |
| 100–350 mins | 215 373 (34.94%) | 146 995 (34.77%) | 50 868 (35.39%) | 8626 (35.12%) | 8884 (35.04%) | |
| ≥350 mins | 201 099 (32.63%) | 139 621 (33.03%) | 45 500 (31.65%) | 7833 (31.89%) | 8145 (32.12%) | |
| Hospital level† | 0.122 | |||||
| Primary and secondary | 187 231 (30.38%) | 128 731 (30.45%) | 43 545 (30.29%) | 7350 (29.92%) | 7605 (29.99%) | |
| Tertiary | 429 151 (69.62%) | 29 3982 (69.54%) | 100 207 (69.71%) | 17 212 (70.08%) | 17 750 (70.01%) | |
| CPC accreditation version* | <0.001 | |||||
| Standard | 443 698 (71.98%) | 303 519 (71.80%) | 103 869 (72.25%) | 17 835 (72.61%) | 18 475 (72.87%) | |
| Primary | 172 684 (28.02%) | 119 194 (28.20%) | 39 883 (27.75%) | 6727 (27.39%) | 6880 (27.13%) | |
| Regions | <0.001 | |||||
| Eastern | 274 230 (44.49%) | 187 765 (44.42%) | 64 300 (44.73%) | 10 933 (44.51%) | 11 232 (44.30%) | |
| Central | 221 308 (35.90%) | 151 393 (35.81%) | 51 595 (35.89%) | 8912 (36.28%) | 9408 (37.11%) | |
| Western | 120 844 (19.61%) | 83 555 (19.77%) | 27 857 (19.38%) | 4717 (19.21%) | 4715 (18.59%) | |
The CPCs are categorised into two versions: the standard version is appropriate for hospitals with an annual percutaneous coronary intervention (PCI) operation volume ≥200, an annual emergency PCI operation volume ≥50, at least two physicians who can independently perform emergency PCI operations, and hospitals that ensure that emergency PCI operations can be performed 24 hours a day; the primary version is appropriate for hospitals that receive or refer ≥30 patients with acute myocardial infarction per year.
The hospitals in China are categorised into three levels: (1) primary hospitals include community health service centres and township hospitals that contain less than 100 beds. (2) Secondary hospitals are regional hospitals or district hospitals that tend to be affiliated with a medium-sized city, county or district and contain more than 100 beds, but less than 500. (3) Tertiary hospitals are comprehensive, referral, general hospitals at the city, provincial or national level with a bed capacity exceeding 500.
CHF, Congestive Heart Failure; CPC, Chest Pain Centres; JVD, Jugular Venous Distension.
Key indicators of quality of care
The quality of care was measured by outcome indicators and process indicators. The outcome indicator was in-hospital mortality for consistency with previous studies,12 23 as it is often used as a patient safety indicator to measure the quality of care. Process indicators in this study included (1) initial ECG acquisition within 10 min of arrival, which measures the percentage of patients who receive the first ECG test within 10 min of hospital arrival; (2) thrombolytic treatment within 30 min of arrival, which measures the percentage of eligible patients without contraindications who take the thrombolytic drugs within 30 min of hospital arrival; and (3) door-to-balloon within 90 min of arrival, which measures the percentage of patients treated with primary percutaneous coronary intervention (PCI) (balloon inflation) within 90 min of hospital arrival (door). These are critical clinical process indicators selected to explain the quality of healthcare delivery.
Statistical analysis
The baseline patient-level and hospital-level characteristics of the study population were described as categorical variables, presented as the number (percentage). The indicators of quality of care were described by the percentages. We calculated process indicators only in patients who were eligible for treatment. The denominator of the indicator comprised patients who were eligible without contraindications for the treatment, and the numerator comprised eligible patients who received the treatment. For example, initial ECGs within 10 min were calculated as ECG acquisitions within 10 min divided by total ECG acquisitions.
To identify the impact of admission time on the quality of care, we calculated the adjusted ORs of all the quality indicators using a multilevel logistic regression model, including patient-level covariates and hospital-level random intercepts. The comparison of indicators was conducted among our three study groups (holiday, weekend and weekday groups), with the weekday group being the reference group. Additionally, further subgroup analyses were performed to compare hospital levels across different holidays. A two-tailed p<0.05 was considered statistically significant in all analyses. ORs are presented with their 95% CIs. R 4.2.1 software was used for all statistical analyses.
Results
Baseline characteristics
The study comprised a total of 616 382 STEMI episodes admitted to 3278 hospitals from 2016 to 2021. Among them, 143 752 (23.32%) were weekend admissions, 24 562 (3.98%) were short-term holiday admissions, 25 355 (4.11%) were long-term holiday admissions and 422 713 (68.58%) were weekday admissions. Over half (58.67%) of the episodes were older adults (more than 60 years old). The majority (76.65%) were male. Over a quarter (28.18%) had comorbid conditions. Most episodes reported persistent chest tightness/chest pain (75.91%) and were in Killip level 1 (78.75%). The most frequent time from onset to admission was 100–350 min (34.94%). Approximately two-thirds were treated at tertiary hospitals (69.62%), and 71.98% were admitted to facilities with standard accreditation. The summary statistics for patient-level and hospital-level characteristics of the episodes are presented in table 2.
Descriptions of quality of care indicators
Table 3 presents data on the quality of care indicators for episodes during weekdays and holidays. The highest in-hospital mortality rate was observed during long-term holidays at 3.71%, followed by weekends at 3.60%. As for the process indicators, a higher percentage indicates better performance. Initial ECG acquisition within 10 min was highest during long-term holidays (82.29%). Both for the thrombolytic treatment and the door-to-balloon indicators, short-term holidays had the lowest percentage of timely treatment at 47.56% and 68.07%, respectively.
Table 3. Quality of care descriptions between weekday and holidays.
| Weekday | Holiday | |||
|---|---|---|---|---|
| Weekend | Short-term holiday (3–5 days) |
Long-term holiday (7–10 days) |
||
| Initial ECG acquisition within 10 min | 80.08% (189108/236159) |
81.12% (65589/80854) |
80.97% (10778/13311) |
82.29% (11957/14530) |
| Thrombolytic treatment within 30 min | 50.87% (22573/44371) |
49.68% (7691/15480) |
47.56% (1289/2710) |
50.73% (1383/2726) |
| Door-to-balloon within 90 min | 70.84% (158008/223059) |
68.84% (52541/76321) |
68.07% (8808/12940) |
68.41% (9115/13324) |
| In-hospital mortality | 3.45% (14595/422713) |
3.60% (5180/143752) |
3.50% (860/24562) |
3.71% (941/25355) |
Data are % (n / N).
Adjusted ORs in quality of care indicators
After adjusting for potential patient and hospital-level confounders, long-term holidays, particularly the Spring Festival, were associated with significantly higher in-hospital mortality risks, followed by weekends. Compared with those admitted on weekdays, patients admitted on long-term holidays had a 10% increased risk of in-hospital mortality (OR=1.10, p<0.05), especially those admitted during the Spring Festival, who had a 17% increased risk of in-hospital mortality (OR=1.17, p<0.01). Patients admitted on weekends also had a 5% increased risk of in-hospital mortality (OR=1.05, p<0.01) (table 4 and figure 1).
Table 4. Adjusted ORs in quality of care indicators.
| Indicator | Weekday† | Weekend | Short-term holiday (3–5 days) |
Long-term holiday (7–10 days) |
|---|---|---|---|---|
| Total | ||||
| Initial ECG acquisition within 10 min | 1 | 1.06 (1.04 to 1.08)*** | 1.05 (1.00 to 1.10)* | 1.15 (1.10 to 1.21)*** |
| Thrombolytic treatment within 30 min | 1 | 0.95 (0.91 to 0.99)* | 0.83 (0.76 to 0.91)** | 0.92 (0.84 to 1.01) |
| Door-to-balloon within 90 min | 1 | 0.88 (0.87 to 0.90)* | 0.83 (0.80 to 0.87)** | 0.86 (0.82 to 0.89)** |
| In-hospital mortality | 1 | 1.05 (1.02 to 1.09)** | 1.02 (0.95 to 1.09) | 1.10 (1.02 to 1.18)* |
| Primary and secondary hospital | ||||
| Initial ECG acquisition within 10 min | 1 | 1.05 (1.01 to 1.08)** | 1.06 (0.98 to 1.14) | 1.17 (1.09 to 1.26)*** |
| Thrombolytic treatment within 30 min | 1 | 0.95 (0.91 to 1.00)* | 0.86 (0.77 to 0.95)** | 0.92 (0.83 to 1.01) |
| Door-to-balloon within 90 min | 1 | 0.92 (0.88 to 0.96)*** | 0.87 (0.79 to 0.96)** | 0.83 (0.75 to 0.92)*** |
| In-hospital mortality | 1 | 1.07 (1.01 to 1.13)* | 1.01 (0.88 to 1.15) | 1.16 (1.02 to 1.31)* |
| Tertiary hospital | ||||
| Initial ECG acquisition within 10 min | 1 | 1.07 (1.04 to 1.10)*** | 1.05 (0.99 to 1.11) | 1.14 (1.07 to 1.21)*** |
| Thrombolytic treatment within 30 min | 1 | 0.96 (0.87 to 1.05) | 0.74 (0.61 to 0.91)** | 0.94 (0.77 to 1.15) |
| Door-to-balloon within 90 min | 1 | 0.88 (0.86 to 0.9)*** | 0.82 (0.79 to 0.86)*** | 0.86 (0.82 to 0.90)*** |
| In-hospital mortality | 1 | 1.04 (1.00 to 1.09)* | 1.02 (0.94 to 1.12) | 1.07 (0.98 to 1.16) |
Data are adjusted ORs (95% CI).
p<0.05, **p<0.01, ***p<0.001.
Reference category.
Figure 1. Adjusted ORs in quality of care indicators across various holidays. Note. The reference category is weekday. *p<0.05, **p<0.01, ***p<0.001. Data are adjusted ORs (95% CI).
The odds of initial ECG acquisition within 10 min were significantly higher on long-term holidays (OR=1.15, p<0.001), particularly the National Day holiday, followed by weekends (OR=1.06, p<0.001). The odds of thrombolytic treatment within 30 min were significantly lower on short-term holidays (OR=0.83, p<0.01), followed by weekends (OR=0.95, p<0.05). The odds of achieving the indicator of door-to-balloon within 90 min were significantly lower on short-term holidays (OR=0.83, p<0.01), especially during the Dragon Boat Festival, followed by long-term holidays (OR=0.86, p<0.01) (table 4 and figure 1).
In the hospital-level subgroup analysis, the effect of weekends and long-term holidays on in-hospital mortality was more pronounced in primary and secondary hospitals (OR=1.07, p<0.05 for weekends; OR=1.16, p<0.05 for long-term holidays) compared with tertiary hospitals (OR=1.04, p<0.05 for weekends; no significant difference for long-term holidays). The odds of achieving door-to-balloon within 90 min were lowest during long-term holidays in primary and secondary hospitals (OR=0.83, p<0.001) but lowest during short-term holidays in tertiary hospitals (OR=0.82, p<0.001) compared with weekdays.
Discussion
Principal findings
This nationwide study examined the impact of holiday duration on the quality of care for patients with STEMI in China. Our key findings reveal that (1) long-term holidays, particularly the Spring Festival, were associated with significantly higher in-hospital mortality risks for patients with STEMI compared with weekday admissions; (2) short-term holidays were associated with lower odds of receiving timely thrombolytic treatment and primary PCI, while the odds of receiving an initial ECG within 10 min were higher during long-term holidays; (3) the impact of weekends and holidays on quality of care varied across hospital levels, with the most interesting difference being that the odds of achieving door-to-balloon within 90 min were lowest during long-term holidays in primary-secondary hospitals but lowest during short-term holidays in tertiary hospitals.
Our results show that patients admitted during long-term holidays had a 10% increased risk of in-hospital mortality, especially during the Spring Festival, where the risk rose by 17%. This ‘holiday effect’ appears more pronounced than the well-documented ‘weekend effect’ (6% increased risk),24 suggesting that longer holidays may indeed pose greater challenges for maintaining optimal STEMI care. The finding aligns with previous studies showing higher mortality for patients with AMI admitted during holidays or weekends,12 14 25 but extends this knowledge by demonstrating a more severe effect for longer holiday periods. Lin et al also found this ‘Spring Festival effect’ on patients admitted to internal medicine departments, which showed an increased mortality risk of 38% during the Chinese New Year holidays compared with weekday admissions.26 This implies that this holiday effect may be widespread across various medical conditions, and the underlying factors contributing to this effect may impact healthcare delivery broadly, not just in acute cardiac care.
The more pronounced effect observed during longer holidays, particularly the Spring Festival, may be attributed to several factors. First, extended holiday periods often lead to prolonged staffing shortages,27 with many healthcare professionals taking leave simultaneously. This can result in reduced availability of experienced personnel, potentially affecting the speed and quality of care delivery. Second, the Spring Festival, as the most important traditional holiday in China, often involves extensive travel and family gatherings, which may delay patients’ decision to seek medical care or hinder timely transportation to appropriate medical facilities.
The improved performance in initial ECG acquisition during holidays is an interesting and unexpected finding. This may be attributed to hospitals prioritising rapid triage for acute cases like STEMI during holidays, despite increased ED visits, as observed in other settings.28 29 Alternatively, patients presenting with more severe symptoms during holidays may prompt faster ECG acquisition. However, this initial efficiency does not appear to translate into better overall outcomes. Both thrombolytic treatment within 30 min and door-to-balloon time within 90 min worsened during holidays, especially short-term holidays. This suggests that while initial assessments may be expedited, delays occur in providing definitive treatment. Tarun et al reported similar effects, indicating that it was later to receive timely PCI during off-hours than on-hours, but there was no difference in door-to-ECG examination between off-hours and on-hours.30
This finding further supports the hypothesis that an increase in the performance of the clinical process was associated with a decline in in-hospital mortality,23 and acute interventions such as PCI treatment within 90 min and thrombolytic treatment within 30 min may improve outcomes after STEMI.31,33 While we are unable to identify these causal factors, we might generate hypotheses for future studies on how to organise emergency care services more effectively and improve outcomes after STEMI. The lower odds of timely reperfusion therapy (both thrombolysis and primary PCI) during short-term holidays is concerning. This may reflect staffing challenges during these brief holiday periods, where hospitals might struggle to maintain full ccatheterisation lab capabilities.
The ‘holiday effect’ on the timeliness of primary PCI may be influenced by hospital level, with primary-secondary hospitals being more affected by long-term holidays and tertiary hospitals being more affected by short-term holidays. A possible explanation for the variation in the ‘holiday effect’ on the timeliness of primary PCI across hospital levels may be related to differences in PCI volumes, staff experience, case complexity and patient characteristics. Tertiary hospitals, with higher PCI volumes and more experienced staff, may be better equipped to maintain care quality during long-term holidays but more susceptible to short-term disruptions due to the higher complexity of cases and risk profiles of their patients. In contrast, primary-secondary hospitals, with lower PCI volumes and less experienced staff, may be more vulnerable to the prolonged impact of long-term holidays on staffing and resources, resulting in lower odds of timely primary PCI.
Strengths and limitations
Strengths of the study include a comprehensive nationwide CCA database for STEMI data as well as varying holiday periods in China, setting the study in a good position to examine the impact of holiday duration on STEMI care quality. Using the CCA database with sufficient clinical information allows a large sample size of over 600 000 STEMI episodes and a combination of process and outcome measures. The variation in care quality across different holiday periods within China is a novel finding. This granularity provides valuable insights for targeted interventions and resource allocation during specific high-risk periods.
Several limitations of this study should be acknowledged. First, the retrospective methodology of our study means that we relied on data that were not collected for our specific research questions. Although the CCA database is known for its high quality, we did not have the opportunity to prospectively monitor the data acquisition process, particularly for time-sensitive indicators. Additionally, the database only captures in-hospital times, lacking data on pre-hospital times (such as ‘symptom onset to balloon’ or ‘total ischaemia time’), which are also likely to be affected by holiday periods. We believe this is a possible subject of future research. Second, while we adjusted for numerous patient and hospital-level factors, unmeasured confounders may still exist, such as discrete variables (eg, diabetes, hypertension, renal failure). Third, the exclusion of a substantial number of patients from the initial dataset due to transfers, in-hospital symptom onset or missing data may limit the generalisability of our findings to these groups. While the large sample size and nationwide scope of the CCA database support the representativeness of the included population, unmeasured differences between included and excluded patients could introduce bias, which warrants further investigation in future studies. Fourth, the CCA database does not capture post-discharge mortality. Nevertheless, the in-hospital mortality rate is a recognised measure of healthcare quality. Fifth, we did not have data on staffing levels or specific resource availability during holiday periods. Future studies incorporating these factors could help elucidate the mechanisms behind our observed ‘holiday effect’.
Conclusions
This nationwide study provides evidence that longer holidays, particularly the Spring Festival, are associated with slightly worse outcomes for patients with STEMI in China. While initial ECG acquisition improved during holidays, both thrombolytic treatment and door-to-balloon times worsened, especially during short-term holidays. The odds of achieving door-to-balloon within 90 min were lowest during long-term holidays in primary-secondary hospitals but lowest during short-term holidays in tertiary hospitals. These results highlight the need for healthcare systems to implement targeted strategies to maintain high-quality STEMI care during extended holiday periods. Future research should focus on identifying specific factors contributing to poorer outcomes during holidays and evaluating interventions to mitigate these effects.
Acknowledgements
We are grateful for the data support of the China Cardiovascular Association.
Footnotes
Funding: This work was supported by the China Postdoctoral Science Foundation (no.2023M732419) and the Humanities and Social Sciences Research Project of the Ministry of Education (24YJCZH275).
Prepublication history for this paper is available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-094691).
Patient consent for publication: Not applicable.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Ethics approval: This study was approved by the Biomedical Ethics Committee of West China Hospital, Sichuan University (2022–534).
Data availability statement
Data may be obtained from a third party and are not publicly available.
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