Increased mortality associated with weekend hospital admission: a case for expanded seven day services?

Freemantle, Nick; Ray, Daniel; McNulty, David; Rosser, David; Bennett, Simon J.; Keogh, Bruce; Pagano, Domenico

doi:10.1136/bmj.h4596

Cited by 234 publications

(242 citation statements)

References 6 publications

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“…Freemantle and co‐workers28 looked at this issue when considering the effect of day of the week in all non‐elective admissions in England, concluding that, although case mix had a significant influence, a strong weekend effect remained; the OR for 30‐day mortality was 1·10 for Saturday admissions and 1·15 for Sunday admissions compared with patients admitted on a Wednesday. Their work was based on the same hospital coding data found to contain coding issues in the context of stroke7, however, so it is likely that significant miscoding bias exists in these results.…”

Section: Discussionmentioning

confidence: 99%

Weekend effect in non-elective abdominal aortic aneurysm repair

et al. 2017

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BackgroundThe ‘weekend effect’ describes the phenomenon where patient outcomes appear worse for those admitted at the weekend. It has been used recently to justify significant changes in UK health policy. Recent evidence has suggested that the effect may be due to a combination of inadequate correction for confounding factors and inaccurate coding. The effects of these factors were investigated in patients with acute abdominal aortic aneurysm (AAA).MethodsPatients undergoing non‐elective AAA repair entered into the UK National Vascular Registry from January 2013 until December 2015 were included in a case–control study. The patients were divided according to whether they were treated during the week (Monday 08.00 hours to Friday 17.00 hours) or at the weekend. Data extracted included demographics, co‐morbidities, preoperative medications and baseline blood test results, as well as outcomes. Coding issues were investigated by looking at patients treated for ruptured, symptomatic or asymptomatic AAA within the non‐elective cohort. The primary outcome was in‐hospital mortality. Secondary outcomes included length of inpatient stay, and cardiac, respiratory and renal complications.ResultsThe mortality rate appeared to be higher at the weekend (odds ratio (OR) 1·69, 95 per cent c.i. 1·47 to 1·94; P < 0·001), but this effect disappeared when confounding factors and coding issues were corrected for (corrected OR for ruptured AAA 1·09, 0·92 to 1·29; P = 0·330). Differences in outcomes were similar for prolonged length of hospital stay (uncorrected OR 1·21, 95 per cent c.i. 1·06 to 1·37, P = 0·005; corrected OR for ruptured AAA 1·06, 0·91 to 1·10, P = 0·478), and morbidity outcomes.ConclusionAfter appropriate correction for confounding factors and coding effects, there was no evidence of a significant weekend effect in the treatment of non‐elective AAA in the UK.

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Section: Discussionmentioning

confidence: 99%

Weekend effect in non-elective abdominal aortic aneurysm repair

et al. 2017

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“…3,[32][33][34][35] However, much of the evidence on the effect of weekend admission has been limited in key respects. First, it tends to be cross-sectional and there is therefore limited information on the trends in disparities over time.…”

Section: Resultsmentioning

confidence: 99%

“…38 The number of patients admitted to hospital in an emergency is markedly reduced at weekends. 15,35 This may be because the population is less likely to seek emergency care, A&E departments are less likely to admit patients and/or the limited availability of services in the community leads to fewer direct admissions to hospital. Higher death rates among the restricted number of patients who are admitted at weekends might reflect a higher average severity of illness among those who are admitted rather than excess avoidable deaths caused by poorer quality of care on admission.…”

Section: Introductionmentioning

confidence: 99%

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14

Han

Meacock

Anselmi

et al. 2017

Health Serv Deliv Res

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Background Patients admitted to hospital outside normal working hours suffer higher complication and mortality rates than patients admitted at times when the hospital is fully operational. This ‘weekend effect’ is well described but poorly understood. It is not clear whether or not the effect extends to other out-of-hours periods, or how far excess mortality for out-of-hours admissions reflects a different presenting population with higher severity of illness and how much is explained by poorer availability and quality of services. Objectives We aimed to assess (1) the costs and benefits of introducing 7-day services, (2) whether or not mortality rates are elevated during all out-of-hours periods, (3) whether or not selection of more severely ill patients for admission out of hours explains elevated mortality rates and (4) whether or not mortality rates out of hours are related to staffing levels. Methods We conducted a series of retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. For the national studies, we analysed emergency admissions to all 140 non-specialist acute hospital trusts in England between April 2013 and February 2014 (over 12 million accident and emergency attendances and 4.5 million emergency admissions). For the single trust, we analysed emergency admissions between April 2004 and March 2014 (240,000 admissions). Deaths within 30 days of attendance or admission were compared for normal working hours and out-of-hours periods. Results We found that, in addition to elevated mortality for weekend admissions, mortality rates are also elevated for patients admitted during night-time periods. Elevated mortality was reduced for stroke patients in a large acute trust when more – and more experienced – nursing staff were present during the first hour of admission. Nationally, we found that excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes when we accounted for severity of patient illness. We also found that the estimated cost of implementing 7-day services exceeds the maximum amount that the National Institute for Health and Care Excellence would recommend the NHS should spend on eradicating excess mortality at weekends. Limitations Our results depend on the accuracy and completeness of data recording by hospital staff. If accuracy of recording is related to time of patient admission, our results may be biased. Results based on data from a single trust should be treated as indicative. Conclusions In addressing variations in patient outcomes across the week, a more nuanced approach, extending services for key specialties over critical periods – rather than implementing whole-system changes – is likely to be the most cost-effective. Future work Future research should aim to develop and use appropriate measures of severity of illness to facilitate meaningful analysis of variations in patient outcomes, and to identify candidate specialties and critical periods for which extending services is likely to be cost-effective. Funding The National Institute for Health Research Health Services and Delivery Research programme.

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“…5,8 This suggests that the reasons for a weekend effect are complex and multi-factorial -and should be solved by greater accumulation of evidence and discussion to bring about strategies to address this.…”

Section: What Is the Drive For Change In The Junior Doctor Contract?mentioning

confidence: 99%

“…What is clear from the original paper is that it is not possible to be clear what proportion of this is preventable or reversible. 5 Key to arguments on the other side is that patients admitted at the weekend are more unwell -so you may expect them to have a higher mortality. The interpretation of the article has been widely questioned.…”

Section: What Is the Drive For Change In The Junior Doctor Contract?mentioning

confidence: 99%

ABCD News

Dashora¹

2016

Br J Diabetes

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Increased mortality associated with weekend hospital admission: a case for expanded seven day services?

Cited by 234 publications

References 6 publications

Weekend effect in non-elective abdominal aortic aneurysm repair

Weekend effect in non-elective abdominal aortic aneurysm repair

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14

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