Study queStionWhat is the association between day of delivery and measures of quality and safety of maternity services, particularly comparing weekend with weekday performance? MethodSThis observational study examined outcomes for maternal and neonatal records (1 332 835 deliveries and 1 349 599 births between 1 April 2010 and 31 March 2012) within the nationwide administrative dataset for English National Health Service hospitals by day of the week. Groups were defined by day of admission (for maternal indicators) or delivery (for neonatal indicators) rather than by day of complication. Logistic regression was used to adjust for case mix factors including gestational age, birth weight, and maternal age. Staffing factors were also investigated using multilevel models to evaluate the association between outcomes and level of consultant presence. The primary outcomes were perinatal mortality and-for both neonate and mother-infections, emergency readmissions, and injuries. Study anSwer and liMitationSPerformance across four of the seven measures was significantly worse for women admitted, and babies born, at weekends. In particular, the perinatal mortality rate was 7.3 per 1000 babies delivered at weekends, 0.9 per 1000 higher than for weekdays (adjusted odds ratio 1.07, 95% confidence interval 1.02 to 1.13). No consistent association between outcomes and staffing was identified, although trusts that complied with recommended levels of consultant presence had a perineal tear rate of 3.0% compared with 3.3% for non-compliant services (adjusted odds ratio 1.21, 1.00 to 1.45). Limitations of the analysis include the method of categorising performance temporally, which was mitigated by using a midweek reference day (Tuesday). IntroductionPrevious studies, across a range of countries, have identified higher mortality in patients admitted on weekends (compared with weekdays) across a range of medical conditions-a phenomenon termed the "weekend effect." [1][2][3][4][5][6] This calls into question the idea that quality of care is equal irrespective of when someone presents at hospital. However, not all studies have identified an association between poor outcomes and out of hours periods. [7][8][9] MacFarlane published a paper in 1978 that showed a seven day cycle in birth numbers across England (and Wales) and that perinatal mortality was higher among babies born at weekends. 10 Similar studies in the 1970s found similar phenomena in other developed countries. 11 12 The delivery of obstetric care has changed dramatically since that time; however, where the weekend effect has been evaluated, this has predominantly been based on mortality. In setting out key challenges in obstetric care-albeit in a broader, global context-a paper from the World Health Organization highlighted ineffective referral to, and inadequate availability of, 24 hour quality services to emergency obstetric care services. 13 We investigated the association between day of delivery and the quality and safety of care and, in particular, compared...

BackgroundAccording to clinical guidelines, every patient affected by stroke should be given a brain-imaging scan (BIS) - Computerized Tomography or Magnetic Resonance Imaging - immediately after being admitted to hospital.Aim of the studyTo describe the variation in use of BIS among English public hospitals and identify any patient groups being excluded from appropriate care.MethodsWe collected hospital administrative data for all patients admitted to any English public hospital with a principal diagnosis of stroke from 2006 to 2009. We calculated the proportion of patients treated with BIS in the whole sample and after stratification by hospital. We compared hospitals' performance using funnel plots. We performed a multiple logistic regression analysis using BIS as outcome and age, gender, socio-economic deprivation, and comorbidity as covariates.ResultsIn English public hospitals there are about 70,000 emergency admissions for stroke per year. Nationally, only 35% receive a BIS immediately, and only 84% receive it within the admission. There is large variation in the use of BIS for stroke patients among English public hospitals, with some of them approaching the recommended 100% and some having very low rates. Young (P<0.001), male (P = 0.012), and least socio-economically deprived patients (P = 0.001), as well as patients with fewer comorbidities (P<0.001) appear to have more chance of being selected for a brain scan.ConclusionSome English public hospitals appear to be falling well below the clinical guideline standards for scanning stroke patients and inappropriate patient selection criteria may be being applied, leading to health inequalities.

Patients: Patients during the study period accounted for 93 621 admissions. We used logistic regression to adjust the outcome measures for case mix. Main Outcome Measures: Quality and safety measurements using 6 indicators spanning the hospital care pathway, from timely brain scans to emergency readmissions after discharge. Results: Performance across 5 of the 6 measures was significantly lower on weekends (confidence level, 99%). One of the largest disparities was seen in rates of same-day brain scans, which were 43.1% on weekends compared with 47.6% on weekdays (unadjusted odds ratio, 0.83 [95% CI, 0.81-0.86]). In particular, the rate of 7-day in-hospital mortality for Sunday admissions was 11.0% (adjusted odds ratio, 1.26 [95% CI, 1.16-1.37], with Monday used as a reference) compared with a mean of 8.9% for weekday admissions. Conclusions: Strong evidence suggests that, nationally, stroke patients admitted on weekends are less likely to receive urgent treatments and have worse outcomes across a range of indicators. Although we adjusted the results for case mix, we cannot rule out some of the effect being due to unmeasured differences in patients admitted on weekends compared with weekdays. The findings suggest that approximately 350 in-hospital deaths each year within 7 days are potentially avoidable, and an additional 650 people could be discharged to their usual place of residence within 56 days if the performance seen on weekdays was replicated on weekends.

The literature on patient safety measures derived from routinely collected hospital data was reviewed to inform indicator development. MEDLINE and Embase databases and Web sites were searched. Of 1738 citations, 124 studies describing the application, evaluation, or validation of hospital-based medical error or complication of care measures were reviewed. Studies were frequently conducted in the United States (n = 88) between 2005 and 2009 (n = 77) using Agency for Healthcare Research and Quality patient safety indicators (PSIs; n = 79). The most frequently cited indicators included "postoperative hemorrhage or hematoma" and "accidental puncture and laceration." Indicator refinement is supported by international coding algorithm translations but is hampered by data issues, including coding inconsistencies. The validity of PSIs and similar adverse event screens beyond internal measurement and the effects of organizational factors on patient harm remain uncertain. Development of PSIs in ambulatory care settings, including general practice and psychiatric care, needs consideration.