The enigma of the weekend effect

Mathew, Anoop; Fyyaz, Saad; Carter, Paul Richard; Potluri, Rahul

doi:10.21037/jtd.2017.12.115

Cited by 20 publications

(24 citation statements)

References 27 publications

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“…This is motivated by 15 years of attention placed on the enigmatic ‘weekend effect’ and other temporal variations,7 scrutinising mortality and other outcomes for those admitted at the weekend compared with during the week 5 8–14. Varying features that may explain differential outcomes include staffing levels8 and patient mix,15 leading to widespread interest in studying weekend organisational features 7 16…”

Section: Introductionmentioning

confidence: 99%

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

et al. 2019

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ObjectivesSeven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs).DesignInterview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al).SettingEight HASUs in London.ParticipantsWe interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week.ResultsStaff were able to deliver ‘front door’ interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of ‘front door’ interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays.ConclusionsEvidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for ‘front door’ interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services.

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Section: Introductionmentioning

confidence: 99%

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

et al. 2019

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“…Level of consciousness on arrival at the hospital, n (%) a Alert (84) Not alert, but respond to minor stimulation (9) Not alert, requires repeated stimulation 65 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.…”

Section: Resultsmentioning

confidence: 99%

“…6,7,9,31,[80][81][82][83] Varying features that may explain differential outcomes include staffing levels 31 and patient mix, 25 leading to widespread interest in studying weekend organisational features. 22,84 In Chapter 3 we showed that HASU patients' mortality and disability outcomes are consistent according to the time of their admission. However, there were some variations in the delivery of care.…”

Section: What This Analysis Adds Introductionmentioning

confidence: 98%

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

Simister

Black

Melnychuk

et al. 2020

Health Serv Deliv Res

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Background Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units. Objectives To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations. Design This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data. Setting The setting was acute stroke services in London hyperacute stroke units. Participants A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours). Intervention Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. Main outcome measures Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay. Data sources Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period. Results We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions. Limitations We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled. Conclusions Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence. Future work Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.

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“…It is a phenomenon which is often highlighted to associate poor outcomes in weekend hospitalizations. It has been proposed that it might be a result of lack of healthcare management organizations to improve practices of care, which includes ensuring round the clock accessibility to life-saving procedures (Mathew et al, 2018). Also, published meta-analysis has associated poor outcomes in patients admitted with myocardial infarction and other medical conditions (Sorita et al, 2014).…”

Section: Discussionmentioning

confidence: 99%

Outcomes of hospitalizations with atrial fibrillation-flutter on a weekday versus weekend: an analysis from a 2014 nationwide inpatient sample

Voruganti

Shantha

Deshmukh

et al. 2019

PeerJ

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BackgroundPatients with atrial fibrillation-flutter (AF) admitted on the weekends were initially reported to have poor outcomes. The primary purpose of this study is to re-evaluate the outcomes for weekend versus weekday AF hospitalization using the 2014 Nationwide Inpatient Sample (NIS).MethodsIncluded hospitalizations were aged above 18 years. The hospitalizations with AF were identified using the international classification of diseases 9 (ICD-9) codes (427.31, 427.32). In-hospital mortality, length of stay (LOS), other co-morbidities, cardioversion procedures, and time to cardioversion were recorded. All analysis was performed using SAS 9.4 statistical software (Cary, North Carolina).ResultsA total of 453,505 hospitalizations with atrial fibrillation and flutter as primary discharge diagnosis were identified. Among the total hospitalizations with a primary diagnosis of AF, 20.3% were admitted on the weekend. Among the weekend hospitalizations, 0.19% died in hospital compared to 0.74% among those admitted during the week. After adjusting for patient characteristics, hospital characteristics and disease severity, the adjusted odds for in-hospital mortality were not significantly different for weekend vs. weekday hospitalizations (OR = 0.91, 95% CI [0.77–1.11]; p = 0.33). The weekend admissions were associated with significantly lower odds of cardioversion procedures (OR = 0.72, 95% CI [0.69–0.76], P < 0.0001), lower cost of hospitalization (USD 8265.8 on weekends vs. USD 8966.5 on the weekdays, P < 0.001), slightly lower rate of anticoagulation (17.09% on the weekends vs. 18.73% on the weekdays. P < 0.0001), and slightly increased time to cardioversion (1.94 days on the weekend vs. 1.73 days on weekdays, P < 0.0005). The mean length of hospital stay (LOS) was statistically not different in both groups: (3.49 days ± 3.70 (SD) in the weekend group vs. 3.47 days ± 3.50 (SD) in the weekday group, P = 0.42)DiscussionThe weekend AF hospitalizations did not have a clinically significant difference in mortality and LOS compared to those admitted on a weekday. However, the use of cardioversion procedures and cost of hospitalization was significantly lower on the weekends.

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The enigma of the weekend effect

Cited by 20 publications

References 27 publications

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

Outcomes of hospitalizations with atrial fibrillation-flutter on a weekday versus weekend: an analysis from a 2014 nationwide inpatient sample

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