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Wu J, Hall M, Dondo TB, Wilkinson C, Ludman P, DeBelder M, Fox KAA, Timmis A, Gale CP. Association between time of hospitalization with acute myocardial infarction and in-hospital mortality. Eur Heart J 2019; 40:1214-1221. [PMID: 30698766 DOI: 10.1093/eurheartj/ehy835] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/01/2018] [Accepted: 11/26/2018] [Indexed: 11/13/2022] Open
Abstract
AIMS To study the association between time of hospitalization and in-hospital mortality for acute myocardial infarction (AMI). METHODS AND RESULTS Patients admitted with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) across 243 hospitals in England and Wales between 1 January 2004 and 31 March 2013 were included. The outcome measure was in-hospital mortality. Adjusted odds ratios (ORs) for in-hospital mortality were estimated across six 4-hourly time periods over the 24-h clock using multilevel logistic regression, inverse-probability weighting propensity score, and instrumental variable analysis. Among 615 035 patients [median age 70.0 years, interquartile range 59.0-80.0 years; 406 519 (66.0%) men], there were 52 777 (8.8%) in-hospital deaths. At night, patients with NSTEMI were more frequently comorbid, and for STEMI had longer symptom-onset-to-reperfusion times. For STEMI, unadjusted in-hospital mortality was highest between 20:00 and 23:59 [4-h period range 8.4-9.9%; OR compared with 00:00-03:59 reference 1.13, 95% confidence interval (CI) 1.07-1.20], and for NSTEMI highest between 12:00 and 15:59 (8.0-8.8%; OR compared with 00:00-03:59 reference 1.07, 95% CI 1.03-1.12). However, these differences were only apparent in the earlier years of the study, and were attenuated by adjustment for demographics, comorbidities, and clinical presentation. Differences were not statistically significant after adjustment for acute clinical treatment provided. CONCLUSION There is little evidence to support an association between time of hospitalization and in-hospital mortality for AMI; variation in in-hospital mortality may be explained by case mix and the use of treatments.
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Affiliation(s)
- Jianhua Wu
- Division of Applied Health and Clinical Translation, School of Dentistry, University of Leeds,Leeds, UK
| | - Marlous Hall
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds UK
| | - Tatendashe B Dondo
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds UK
| | - Chris Wilkinson
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds UK
| | - Peter Ludman
- Cardiology Department, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Mark DeBelder
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Adam Timmis
- NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, London, UK
| | - Chris P Gale
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds UK
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Metcalfe D, Castillo-Angeles M, Rios-Diaz AJ, Havens JM, Haider A, Salim A. Is there a "weekend effect" in emergency general surgery? J Surg Res 2019; 222:219-224. [PMID: 29273370 DOI: 10.1016/j.jss.2017.10.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/25/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Weekend admission is associated with increased mortality across a range of patient populations and health-care systems. The aim of this study was to determine whether weekend admission is independently associated with serious adverse events (SAEs), in-hospital mortality, or failure to rescue (FTR) in emergency general surgery (EGS). METHODS An observational study was performed using the National Inpatient Sample in 2012-2013; the largest all-payer inpatient database in the United States, which represents a 20% stratified sample of hospital discharges. The inclusion criteria were all inpatients with a primary EGS diagnosis. Outcomes were SAE, in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed an SAE). Multivariable logistic regression were used to adjust for patient- (age, sex, race, payer status, and Charlson comorbidity index) and hospital-level (trauma designation and hospital bed size) characteristics. RESULTS There were 1,344,828 individual patient records (6.7 million weighted admissions). The overall rate of SAE was 15.1% (15.1% weekend, 14.9% weekday, P < 0.001), FTR 5.9% (6.2% weekend, 5.9% weekday, P = 0.010), and in-hospital mortality 1.4% (1.5% weekend, 1.3% weekday, P < 0.001). Within logistic regression models, weekend admission was an independent risk factor for development of SAE (adjusted odds ratio 1.08, 1.07-1.09), FTR (1.05, 1.01-1.10), and in-hospital mortality (1.14, 1.10-1.18). CONCLUSIONS This study found evidence that outcomes coded in an administrative data set are marginally worse for EGS patients admitted at weekends. This justifies further work using clinical data sets that can be used to better control for differences in case mix.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.
| | - Manuel Castillo-Angeles
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joaquim M Havens
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
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Halliday N, Martin K, Collett D, Allen E, Thorburn D. Is liver transplantation 'out-of-hours' non-inferior to 'in-hours' transplantation? A retrospective analysis of the UK Transplant Registry. BMJ Open 2019; 9:e024917. [PMID: 30787089 PMCID: PMC6398642 DOI: 10.1136/bmjopen-2018-024917] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Increased morbidity and mortality have been associated with weekend and night-time clinical activity. We sought to compare the outcomes of liver transplantation (LT) between weekdays and weekends or night-time and day-time to determine if 'out-of-hours' LT has acceptable results compared with 'in-hours'. DESIGN, SETTING AND PARTICIPANTS We conducted a retrospective analysis of patient outcomes for all 8816 adult, liver-only transplants (2000-2014) from the UK Transplant Registry. OUTCOME MEASURES Outcome measures were graft failure (loss of the graft with or without death) and transplant failure (either graft failure or death with a functioning graft) at 30 days, 1 year and 3 years post-transplantation. The association of these outcomes with weekend versus weekday and day versus night transplantation were explored, following the construction of a risk-adjusted Cox regression model. RESULTS Similar patient and donor characteristics were observed between weekend and weekday transplantation. Unadjusted graft failure estimates were 5.7% at 30 days, 10.4% at 1 year and 14.6% at 3 years; transplant failure estimates were 7.9%, 15.3% and 21.3% respectively.A risk-adjusted Cox regression model demonstrated a significantly lower adjusted HR (95% CI) of transplant failure for weekend transplant of 0.77 (0.66 to 0.91) within 30 days, 0.86 (0.77 to 0.97) within 1 year, 0.89 (0.81 to 0.99) within 3 years and for graft failure of 0.81 (0.67 to 0.97) within 30 days. For patients without transplant failure within 30 days, there was no weekend effect on transplant failure. Neither night-time procurement nor transplantation were associated with an increased hazard of transplant or graft failure. CONCLUSIONS Weekend and night-time LT outcomes were non-inferior to weekday or day-time transplantation, and we observed a possible small beneficial effect of weekend transplantation. The structure of LT services in the UK delivers acceptable outcomes 'out-of-hours' and may offer wider lessons for weekend working structures.
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Affiliation(s)
- Neil Halliday
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute for Liver and Digestive Health, London, UK
- Institute of Immunity and Transplantation, University College London, London, UK
| | - Kate Martin
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - David Collett
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Elisa Allen
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute for Liver and Digestive Health, London, UK
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Brown LR, McLean RC, Perren D, O'Loughlin P, McCallum IJ. Evaluating the effects of surgical subspecialisation on patient outcomes following emergency laparotomy: A retrospective cohort study. Int J Surg 2019; 62:67-73. [PMID: 30673595 DOI: 10.1016/j.ijsu.2019.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/27/2018] [Accepted: 01/12/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND General surgeons have become increasingly subspecialised in their elective practice. Emergency laparotomies, however, are performed by a range of subspecialists who may or may not have an interest in the affected area of gastrointestinal tract. This retrospective cohort study evaluates the impact of surgical subspecialisation on patient outcomes following emergency laparotomy. METHODS Data was collected for patients who underwent an emergency abdominal procedure on the gastrointestinal tract in the North of England from 2001 to 2016. This included demographics, co-morbidities, diagnoses and procedures undertaken. Patients were grouped according to consultants' subspecialist interest. The primary outcome of interest was 30-day postoperative mortality. RESULTS 24,291 emergency laparotomies were performed with an associated 30-day postoperative mortality of 11.7%. Laparotomies undertaken by upper gastrointestinal (UGI) or colorectal surgeons have significantly lower mortality (10.1%) when compared with other subspecialities (13.5%). More specifically, mortality was decreased for UGI (7.9% vs. 12.9%) and colorectal procedures (10.9% vs. 14.2%) when performed by surgeons with a specialist interest in the relevant area of the gastrointestinal tract (both p < 0.001). The utilisation of laparoscopic surgery is higher, in both UGI (21.8% vs. 9.0%) and colorectal procedures (7.2% vs. 3.5%), when the causative pathology is relevant to the surgeon's subspeciality (both p < 0.001). CONCLUSION Mortality following emergency laparotomy is improved when performed under the care of gastrointestinal surgeons. Both UGI and colorectal emergency procedures have improved outcomes, with lower mortality and higher rates of laparoscopy, when under the care of a surgeon with a subspecialist interest in the affected area of the gastrointestinal tract.
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Affiliation(s)
- Leo R Brown
- Health Education England North East, Waterfront 4 Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK.
| | - Ross C McLean
- Health Education England North East, Waterfront 4 Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK
| | - Daniel Perren
- Health Education England North East, Waterfront 4 Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK
| | - Paul O'Loughlin
- Department of Colorectal Surgery, Queen Elizabeth Hospital, Gateshead, NE9 6SX, UK
| | - Iain Jd McCallum
- Department of Colorectal Surgery, North Tyneside Hospital, North Shields, Northumbria, NE29 8NH, UK
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Hospital admission on weekends for patients who have surgery and 30-day mortality in Ontario, Canada: A matched cohort study. PLoS Med 2019; 16:e1002731. [PMID: 30695035 PMCID: PMC6350956 DOI: 10.1371/journal.pmed.1002731] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 12/19/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Healthcare interventions on weekends have been associated with increased mortality and adverse clinical outcomes, but these findings are inconsistent. We hypothesized that patients admitted to hospital on weekends who have surgery have an increased risk of death compared with patients who are admitted and have surgery on weekdays. METHODS AND FINDINGS This matched cohort study included 318,202 adult patients from Ontario health administrative and demographic databases, admitted to acute care hospitals from 1 January 2005 to 31 December 2015. A total of 159,101 patients who were admitted on weekends and underwent noncardiac surgery were classified by day of surgery (weekend versus weekday) and matched 1:1 to patients who both were admitted and had surgery on a weekday (Tuesday to Thursday); matching was based on age (in years), anesthesia basic unit value for the surgical procedure, median neighborhood household income quintile, resource utilization band (a ranking system of overall morbidity), rurality of home location, year of admission, and urgency of admission. Of weekend admissions, 16.2% (25,872) were elective and 53.9% (85,744) had surgery on the weekend of admission. The primary outcome was all-cause mortality within 30 days of the date of hospital admission. The 30-day all-cause mortality for patients admitted on weekends who had noncardiac surgery was 2.6% (4,211/159,101) versus 2.5% (3,901/159,101) for those who were admitted and had surgery on weekdays (adjusted odds ratio [OR] 1.05; 95% CI 1.00 to 1.11; P = 0.03). However, there was significant heterogeneity in the increased odds of death according to the urgency of admission and when surgery was performed (weekend versus weekday). For urgent admissions on weekends (n = 133,229), there was no significant increase in odds of mortality when surgery was performed on the weekend (adjusted OR 1.02; 95% CI 0.95 to 1.09; P = 0.7) or on a subsequent weekday (adjusted OR 1.05; 95% CI 0.98 to 1.12; P = 0.2) compared to urgent admissions on weekdays. Elective admissions on weekends (n = 25,782) had increased risk of death both when surgery was performed on the weekend (adjusted OR 3.30; 95% CI 1.98 to 5.49; P < 0.001) and when surgery was performed on a subsequent weekday (adjusted OR 2.70; 95% CI 1.81 to 4.03; P < 0.001). The main limitations of this study were the lack of data regarding reason for admission and cause of increased time interval from admission to surgery for some cases, the small number of deaths in some subgroups (i.e., elective surgery), and the possibility of residual unmeasured confounding from increased illness severity for weekend admissions. CONCLUSIONS When patients have surgery during their hospitalization, admission on weekends in Ontario, Canada, was associated with a small but significant proportional increase in 30-day all-cause mortality, but there was significant heterogeneity in outcomes depending on the urgency of admission and when surgery was performed. An increased risk of death was found only for elective admissions on weekends; whether this is a function of patient-level factors or represents a true weekend effect needs to be further elucidated. These findings have potential implications for resource allocation in hospitals and the redistribution of elective surgery to weekends.
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Malanchini G, Stefanini GG, Malanchini M, Lombardi F. Higher in-hospital mortality during weekend admission for acute coronary syndrome: a large-scale cross-sectional Italian study. J Cardiovasc Med (Hagerstown) 2018; 20:74-80. [PMID: 30540646 DOI: 10.2459/jcm.0000000000000743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS An increased mortality risk during weekend hospital admission has been consistently observed. In the present study, we evaluated whether the current improvement in management of acute coronary syndromes (ACS) has reduced this phenomenon. METHODS AND RESULTS We extracted data from the Italian National Healthcare System Databank of 80 391 ACS admissions in the region of Lombardia between 2010 and 2014. ICD-9 codes were used to assess the diagnosis. We performed a multiple logistic regression analysis to compare the mortality rates between weekend and weekday admissions.Mean age of the study population was 67.6 years; 30.1% of patients were women. ST segment elevation myocardial infarction (STEMI) accounts for 42.2% of admissions. The total in-hospital mortality was 3.05% and was positively predicted by weekend admission [odds ratio (OR) 1.13, P = 0.006], age and female sex. The weekend effect on mortality was only significant for STEMI (OR 1.11, P = 0.04) in comparison to non-STEMI (NSTEMI) or unstable angina.The trend of the risk of death was found to be negatively correlated with age: the risk of death was significantly higher in all age clusters younger than 75 (OR 1.22, P < 0.01) and even greater in the very young subgroup under 45 years of age (OR 2.09, P = 0.03). CONCLUSION Our data indicate that increased mortality risk is still present during weekend admissions. This phenomenon is particularly evident in younger patients and in individuals admitted for STEMI.
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Affiliation(s)
- Giovanni Malanchini
- Cardiologia, Fondazione IRCCS Ospedale Maggiore Policlinico, University of Milan, Milan
| | | | | | - Federico Lombardi
- Cardiologia, Fondazione IRCCS Ospedale Maggiore Policlinico, University of Milan, Milan
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Honeyford K, Cecil E, Lo M, Bottle A, Aylin P. The weekend effect: does hospital mortality differ by day of the week? A systematic review and meta-analysis. BMC Health Serv Res 2018; 18:870. [PMID: 30458758 PMCID: PMC6245775 DOI: 10.1186/s12913-018-3688-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/05/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The concept of a weekend effect, poorer outcomes for patients admitted to hospitals at the weekend is not new, but is the focus of debate in England. Many studies have been published which consider outcomes for patients on admitted at the weekend. This systematic review and meta-analysis aims to estimate the effect of weekend admission on mortality in UK hospitals. METHODS This is a systematic review and meta-analysis of published studies on the weekend effect in UK hospitals. We used EMBASE, MEDLINE, HMIC, Cochrane, Web of Science and Scopus to search for relevant papers. We included systematic reviews, randomised controlled trials and observational studies) on patients admitted to hospital in the UK and published after 2001. Our outcome was death; studies reporting mortality were included. Reviewers identified studies, extracted data and assessed the quality of the evidence, independently and in duplicate. Discrepancy in assessment was considered by a third reviewer. All meta-analyses were performed using a random-effects meta-regression to incorporate the heterogeneity into the weighting. RESULTS Forty five articles were included in the qualitative synthesis. 53% of the articles concluded that outcomes for patients either undergoing surgery or admitted at the weekend were worse. We included 39 in the meta-analysis which contributed 50 separate analyses. We found an overall effect of 1.07 [odds ratio (OR)] (95%CI:1.03-1.12), suggesting that patients admitted at the weekend had higher odds of mortality than those admitted during the week. Sub-group analyses suggest that the weekend effect remained when measures of case mix severity were included in the models (OR:1.06 95%CI:1.02-1.10), but that the weekend effect was not significant when clinical registry data was used (OR:1.03 95%CI: 0.98-1.09). Heterogeneity was high, which may affect generalisability. CONCLUSIONS Despite high levels of heterogeneity, we found evidence of a weekend effect in the UK, even after accounting for severity of disease. Further work is required to examine other potential explanations for the "weekend effect" such as staffing levels and other organisational factors. TRIAL REGISTRATION PROSPERO International Prospective Register of Systematic Reviews -registration number: CRD42016041225 .
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Affiliation(s)
- Kate Honeyford
- Department of Primary Care and Public Health, Dr Foster Unit at Imperial College, 3 Dorset Rise, London, EC4Y 8EN, UK.
| | - Elizabeth Cecil
- Department of Primary Care and Public Health, Dr Foster Unit at Imperial College, 3 Dorset Rise, London, EC4Y 8EN, UK
| | - Michelle Lo
- Department of Family Medicine and Primary Healthcare, Hospital Authority, Hong Kong, Hong Kong
| | - Alex Bottle
- Department of Primary Care and Public Health, Dr Foster Unit at Imperial College, 3 Dorset Rise, London, EC4Y 8EN, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, Dr Foster Unit at Imperial College, 3 Dorset Rise, London, EC4Y 8EN, UK
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Weekend admissions may be associated with poorer recording of long-term comorbidities: a prospective study of emergency admissions using administrative data. BMC Health Serv Res 2018; 18:863. [PMID: 30445942 PMCID: PMC6240268 DOI: 10.1186/s12913-018-3668-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 10/31/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many studies have investigated the presence of a 'weekend effect' in mortality following hospital admission, and these frequently use diagnostic codes from administrative data for information on comorbidities for risk adjustment. However, it is possible that coding practice differs between week and weekend. We assess patients with a confirmed history of certain long-term health conditions and investigate how well these are recorded in subsequent week and weekend admissions. METHODS We selected six long-term conditions that are commonly assessed when risk-adjusting mortality rates, via the Charlson and Elixhauser indices. Using Hospital Episode Statistics data from England for the period April 2009 to March 2011, we identified patients with the condition recorded at least twice, on separate emergency admissions. Then we assessed how often each condition was recorded on subsequent emergency admissions between April 2011 and March 2013. We then compared coding between week and weekend admissions using the Cochran-Mantel-Haenszel test, stratifying by hospital. RESULTS We studied 111,457 patients with chronic pulmonary disease, 106,432 with diabetes, 36,447 with congestive heart failure, 30,996 with dementia, 7808 with hemiplegia or paraplegia and 5877 with metastatic cancer. Across the entire week, between April 2011 and March 2013, coding completeness ranged from 89% for diabetes to 43% for hemiplegia/paraplegia. Compared with weekday admissions, congestive heart failure was less likely to be recorded as a secondary diagnosis at the weekend (odds ratio 0.92, 95% CI, 0.88 to 0.97), with smaller but statistically significant differences also detected for chronic pulmonary disease (odds ratio 0.96, 95% CI, 0.93 to 0.99) and diabetes (odds ratio 0.95, 95% CI 0.91 to 0.99). There was no statistically significant difference in recording between week and weekend admissions for dementia (odds ratio 1.04, 95% CI 0.97 to 1.11), hemiplegia/paraplegia (odds ratio 0.99, 95% CI 0.89 to 1.10) or metastatic cancer (odds ratio 1.04, 95% CI 0.90 to 1.20). CONCLUSIONS Long-term conditions are often not recorded on administrative data and the lack of recording may be worse for weekend admissions. Studies of the weekend effect that rely on administrative data might have underestimated the health burden of patients, particularly if admitted at the weekend.
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Marfil-Garza BA, Belaunzarán-Zamudio PF, Gulias-Herrero A, Zuñiga AC, Caro-Vega Y, Kershenobich-Stalnikowitz D, Sifuentes-Osornio J. Risk factors associated with prolonged hospital length-of-stay: 18-year retrospective study of hospitalizations in a tertiary healthcare center in Mexico. PLoS One 2018; 13:e0207203. [PMID: 30408118 PMCID: PMC6224124 DOI: 10.1371/journal.pone.0207203] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/26/2018] [Indexed: 11/24/2022] Open
Abstract
Background Hospital length-of-Stay has been traditionally used as a surrogate to evaluate healthcare efficiency, as well as hospital resource utilization. Prolonged Length-of-stay (PLOS) is associated with increased mortality and other poor outcomes. Additionally, these patients represent a significant economic problem on public health systems and their families. We sought to describe and compare characteristics of patients with Normal hospital Length-of-Stay (NLOS) and PLOS to identify sociodemographic and disease-specific factors associated with PLOS in a tertiary care institution that attends adults with complicated diseases from all over Mexico. Materials and methods We conducted a retrospective analysis of hospital discharges from January 2000-December 2017 using institutional databases of medical records. We compared NLOS and PLOS using descriptive and inferential statistics. PLOS were defined as those above the 95th percentile of length of hospitalization. Results We analyzed 85,904 hospitalizations (1,069,875 bed-days), of which 4,427 (5.1%) were PLOS (247,428 bed-days, 23.1% of total bed-days). Hematological neoplasms were the most common discharge diagnosis and surgery of the small bowel was the most common type of surgery. Younger age, male gender, a lower physician-to-patient ratio, emergency and weekend admissions, surgery, the number of comorbidities, residence outside Mexico City and lower socioeconomic status were associated with PLOS. Bone marrow transplant (OR 18.39 [95% CI 12.50–27.05, p<0.001), complex infectious diseases such as systemic mycoses and parasitoses (OR 4.65 [95% CI 3.40–6.63, p<0.001), and complex abdominal diseases such as intestinal fistula (OR 2.57 [95% CI 1.98–3.32) had the greatest risk for PLOS. Risk of mortality in patients with PLOS increased more than threefold (3.7% vs 13.3%, p<0.001). Conclusions We report some key sociodemographic and disease-specific differences in patients with PLOS. These could serve to develop a specific model of directed hospital healthcare for patients identified as in risk of PLOS.
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Affiliation(s)
| | - Pablo F. Belaunzarán-Zamudio
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alfonso Gulias-Herrero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Antonio Camiro Zuñiga
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Yanink Caro-Vega
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - José Sifuentes-Osornio
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- * E-mail:
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Eindhoven DC, Wu HW, Kremer SWF, van Erkelens JA, Cannegieter SC, Schalij MJ, Borleffs CJW. Mortality differences in acute myocardial infarction patients in the Netherlands: The weekend-effect. Am Heart J 2018; 205:70-76. [PMID: 30176441 DOI: 10.1016/j.ahj.2018.07.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 07/24/2018] [Indexed: 11/18/2022]
Abstract
Objective Several studies have shown that patients admitted with an acute myocardial infarction during the weekends have a higher mortality rate than those admitted during weekdays, possibly attributable to less trained personnel available and a lower use of medical procedures. The current study aimed to assess this ‘weekend-effect’ in a nationwide registry. Methods In the Netherlands, all inhabitants are, by law, obliged to have health insurance and all claim data are centrally registered. In 2012 and 2013, all national diagnose-codings of STEMI and NSTEMI patients were acquired. One-year mortality rates and treatment with percutaneous coronary intervention (PCI) were compared between weekdays and weekends (holidays included). Results In total, 59,534 patients (67 ± 13 years, 39,545(66%) male) were included of whom 33,904(57%) had a NSTEMI. Overall 6857(12%) patients died in the year following the acute myocardial infarction registration. In STEMI patients, no differences in one-year mortality rates were observed between admission on weekdays or weekends. In NSTEMI patients, one-year mortality was higher in those admitted during weekends (weekdays 11% versus weekends 13%, P < .001). Furthermore, STEMI patients admitted during weekends were more often treated with PCI (weekdays 77% versus weekends 81%, P < .001). Conversely, NSTEMI patients admitted during weekends were less often treated with PCI (weekdays 35% versus weekends 32%, P < .001). Conclusion Differences in treatment and mortality rates exist between acute myocardial infarction patients admitted during weekdays and weekends. NSTEMI patients admitted during weekends are less often treated with PCI and have a higher mortality rate than patients admitted during weekdays.
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Affiliation(s)
- Daniëlle C Eindhoven
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hoi W Wu
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Stijn W F Kremer
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Suzanne C Cannegieter
- Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
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Sun J, Girling AJ, Aldridge C, Evison F, Beet C, Boyal A, Rudge G, Lilford RJ, Bion J. Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust. BMJ Qual Saf 2018; 28:223-230. [PMID: 30301873 PMCID: PMC6560459 DOI: 10.1136/bmjqs-2018-008219] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/22/2022]
Abstract
Objective To determine whether the higher weekend admission mortality risk is attributable to increased severity of illness. Design Retrospective analysis of 4 years weekend and weekday adult emergency admissions to a university teaching hospital in England. Outcome measures 30-day postadmission weekend:weekday mortality ratios adjusted for severity of illness (baseline National Early Warning Score (NEWS)), routes of admission to hospital, transfer to the intensive care unit (ICU) and demographics. Results Despite similar emergency department daily attendance rates, fewer patients were admitted on weekends (mean admission rate 91/day vs 120/day) because of fewer general practitioner referrals. Weekend admissions were sicker than weekday (mean NEWS 1.8 vs 1.7, p=0.008), more likely to undergo transfer to ICU within 24 hours (4.2% vs 3.0%), spent longer in hospital (median 3 days vs 2 days) and less likely to experience same-day discharge (17.2% vs 21.9%) (all p values <0.001). The crude 30-day postadmission mortality ratio for weekend admission (OR=1.13; 95% CI 1.08 to 1.19) was attenuated using standard adjustment (OR=1.11; 95% CI 1.05 to 1.17). In patients for whom NEWS values were available (90%), the crude OR (1.07; 95% CI 1.01 to 1.13) was not affected with standard adjustment. Adjustment using NEWS alone nullified the weekend effect (OR=1.02; 0.96–1.08). NEWS completion rates were higher on weekends (91.7%) than weekdays (89.5%). Missing NEWS was associated with direct transfer to intensive care bypassing electronic data capture. Missing NEWS in non-ICU weekend patients was associated with a higher mortality and fewer same-day discharges than weekdays. Conclusions Patients admitted to hospital on weekends are sicker than those admitted on weekdays. The cause of the weekend effect may lie in community services.
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Affiliation(s)
- Jianxia Sun
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alan J Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Cassie Aldridge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Felicity Evison
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chris Beet
- Intensive Care, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Amunpreet Boyal
- Research & Development, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Julian Bion
- Intensive Care Medicine, University of Birmingham, Birmingham, UK
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Comparison of outcome in stroke patients admitted during working hours vs. off-hours; a single-center cohort study. J Neurol 2018; 266:782-789. [DOI: 10.1007/s00415-018-9079-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
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Papachristofi O, Klein AA, Mackay J, Nashef S, Fletcher NS, Sharples LD. Does the "Weekend Effect" for Postoperative Mortality Stand Up to Scrutiny? Association for Cardiothoracic Anesthesia and Critical Care Cohort Study of 110,728 Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2018; 32:2178-2186. [PMID: 29753669 DOI: 10.1053/j.jvca.2018.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Ongoing debate focuses on whether patients admitted to the hospital on weekends have higher mortality than those admitted on weekdays. Whether this apparent "weekend effect" reflects differing patient risk, care quality differences, or inadequate adjustment for risk during analysis remains unclear. This study aimed to examine the existence of a "weekend effect" for risk-adjusted in-hospital mortality after cardiac surgery. DESIGN Retrospective analysis of prospectively collected cardiac registry data. SETTING Ten UK specialist cardiac centers. PARTICIPANTS A total of 110,728 cases, undertaken by 127 consultant surgeons and 190 consultant anesthetists between April 2002 and March 2012. INTERVENTIONS Major risk-stratified cardiac surgical operations. MEASUREMENTS AND MAIN RESULTS Crude in-hospital mortality rate was 3.1%. Multilevel multivariable models were employed to estimate the effect of operative day on in-hospital mortality, adjusting for center, surgeon, anesthetist, patient risk, and procedure priority. Weekend elective cases had significantly lower mortality risk compared to Monday elective cases (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42, 0.96) following risk adjustment by the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and procedure priority; differences between weekend and Monday for urgent and emergency/salvage cases were not significant (OR 1.12, 95% CI 0.73, 1.72, and 1.07, 95% CI 0.79, 1.45 respectively). Considering only the logistic EuroSCORE but not procedure priority yielded 29% higher odds of death for weekend cases compared to Monday operations (OR 1.29, 95% CI 1.08, 1.54). CONCLUSIONS This study suggests that undergoing cardiac surgery during the weekend does not affect negatively patient survival, and highlights the importance of comprehensive risk adjustment to avoid detecting spurious "weekend effects."
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Affiliation(s)
- Olympia Papachristofi
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - John Mackay
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Samer Nashef
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Nick S Fletcher
- Department of Anaesthesia and Intensive Care, St George's Hospital, London, UK
| | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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Re-evaluating the Weekend Effect on SAH: A Nationwide Analysis of the Association Between Mortality and Weekend Admission. Neurocrit Care 2018; 30:293-300. [DOI: 10.1007/s12028-018-0609-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Duvald I, Moellekaer A, Boysen MA, Vest-Hansen B. Linking the severity of illness and the weekend effect: a cohort study examining emergency department visits. Scand J Trauma Resusc Emerg Med 2018; 26:72. [PMID: 30185223 PMCID: PMC6125948 DOI: 10.1186/s13049-018-0542-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 08/31/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite extensive research on the "weekend effect" i.e., the increased mortality associated with hospital admission during weekend, knowledge about disease severity in previous studies is limited. The aim of this study is to examine patient characteristics, including disease severity, 30-day mortality, and length of stay (LOS), according to time of admission to an emergency department. METHODS Our study encompassed all patients admitted to a Danish emergency department in 2014-2015. Using data from electronic patient records, this study examines patient characteristics including age, gender, Charlson Comorbidity Index score, triage score, and primary diagnosis. Triage score and transfer to intensive care unit (ICU) were used as indicators of disease severity. LOS within the department and within the hospital was examined. Age- and sex-standardized 30-day mortality rates comparing patients with the same triage score admitted at daytime, evening, and nighttime on weekdays and on weekends were computed. To test differences, a Cox regression analysis was added. RESULTS We included 35,459 patient visits, of which 10,435 (32%) started on a weekend. There were no large differences in baseline characteristics between patients admitted on weekdays and those admitted on weekends. The relative risk (RR) for being triaged orange or red was 1.16 (95% confidence interval (CI) 1.06-1.28, P = 0.0017) for weekend admissions as compared with weekday admissions. Weekend admissions were twice as likely as weekday admissions to be transferred to the ICU (RR, 1.96; 95% CI 1.53-2.52, P = 0.0000). No significant changes were found in LOS. The 30-day mortality rate increased with disease severity regardless of time of admission. When comparing the 30-day mortality rate for patients with the same triage score, the trend was toward a higher mortality when admission occurred during the weekend. Increasing mortality rate was significant for patients admitted at evening on weekends with a hazard ratio of 1.32 (95% CI 1.03-1.70, P = 0.027) when compared with patients admitted on daytime on weekdays. CONCLUSIONS When comparing weekday and weekend admissions, the 30-day mortality rate increased for patients admitted at evening on weekends after adjusting for comorbidity and triage score, indicating that the weekend effect was independent of changes in illness severity.
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Affiliation(s)
- Iben Duvald
- Interdisciplinary Centre for Organizational Architecture, Department of Management, Business and Social Sciences, Aarhus University, Fuglesangs Allé 4, build. 2610-336, 8210 Aarhus V, Denmark
- DESIGN EM – Research Network for Organizational Design and Emergency Medicine, Fuglesangs Allé 4, build. 2610, 8210 Aarhus V, Denmark
- Department of Business Development and Technology, Business and Social Sciences, Aarhus University, Birk Centerpark 15, 7400 Herning, Denmark
| | - Anders Moellekaer
- DESIGN EM – Research Network for Organizational Design and Emergency Medicine, Fuglesangs Allé 4, build. 2610, 8210 Aarhus V, Denmark
- Research Center for Emergency Medicine, Department of Clininal Medicine, Aarhus University and Department of Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Betina Vest-Hansen
- Research Center for Emergency Medicine, Department of Clininal Medicine, Aarhus University and Department of Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
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Abstract
BACKGROUND Apparent increase in mortality associated with being admitted to hospital on a weekend compared to weekdays has led to controversial policy changes to weekend staffing in the United Kingdom. Studies in the United States have been inconclusive and diagnosis specific, and whether to implement such changes is subject to ongoing debate. OBJECTIVE To compare mortality, length of stay, and cost between patients admitted on weekdays and weekends. DESIGN Retrospective cohort study. SETTING National Inpatient Sample, an administrative claims database of a 20% stratified sample of discharges from all hospitals participating in the Healthcare Cost and Utilization Project. PATIENTS Adult patients who were emergently admitted from 2012 to 2014. INTERVENTION The primary predictor was whether the admission was on a weekday or weekend. MEASUREMENTS The primary outcome was in-hospital mortality and secondary outcomes were length of stay and cost. RESULTS We included 13,505,396 patients in our study. After adjusting for demographics and disease severity, we found a small difference in inpatient mortality rates on weekends versus weekdays (odds ratio [OR] 1.029; 95% confidence interval [CI], 1.020-1.039; P < .001). There was a statistically significant but clinically small decrease in length of stay (2.24%; 95% CI, 2.16-2.33; P < .001) and cost (1.14%; 95% CI, 1.05-1.24; P < .001) of weekend admissions. A subgroup analysis of the most common weekend diagnoses showed substantial heterogeneity between diagnoses. CONCLUSIONS Differences in mortality of weekend admissions may be attributed to underlying differences in patient characteristics and severity of illness and is subject to large between-diagnoses heterogeneity. Increasing weekend services may not result in desired reduction in inpatient mortality rate.
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Affiliation(s)
- Stephanie Q Ko
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
- National University Hospital, Singapore
| | - Jordan B Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Cabral M, Kapasi FT, Ameerally P. Management of oral and maxillofacial infections in a regional unit: a seven day service? Br J Oral Maxillofac Surg 2018; 56:501-504. [PMID: 29804634 DOI: 10.1016/j.bjoms.2018.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 04/18/2018] [Indexed: 11/16/2022]
Abstract
The provision of a seven-day National Health Service (NHS) has been proposed as a means to halt the weekend delay in treatment that has been described in some studies. We tested the emergency services in the Oral and Maxillofacial Surgery Department at Northampton General Hospital to find out whether they provided a seven-day service. Data were collected prospectively and retrospectively for all patients admitted to the Oral and Maxillofacial Department at Northampton General Hospital with infections of the head and neck during a period of 29months (January 2014-May 2016). Duration of hospital stay and waiting time for operation were compared for weekday and weekend admissions to find out if there were changes in either outcomes or waiting times. The severity of infection between the two periods was also assessed using the serum C reactive protein (CRP) concentration as a marker. A total of 293 patients were admitted with head and neck infections, and the mean (range) duration of stay for those admitted on weekdays was 3 (1-14) days and for patients admitted at a weekend was 3 (1-17) days (p=0.14). However, the waiting times for operation were significantly longer during the week (mean (range) 0.6 (0-8) days) than at the weekend (0.5 (0-3) days, p=0.04). We know of no other published studies about provision of a seven-day service in oral and maxillofacial surgery. Our results show that we are already working to that standard, and this raises the question of whether any changes are required to current practice in the NHS, with their associated costs and upheaval.
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Bernal JL, DelBusto S, García-Mañoso MI, de Castro Monteiro E, Moreno Á, Varela-Rodríguez C, Ruiz-lopez PM. Impact of the implementation of electronic health records on the quality of discharge summaries and on the coding of hospitalization episodes. Int J Qual Health Care 2018; 30:630-636. [DOI: 10.1093/intqhc/mzy075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/03/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- José L Bernal
- Management Control Service, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sebastián DelBusto
- Service of Preventive Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - María I García-Mañoso
- Service of Preventive Medicine, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - Ángel Moreno
- Patient Management and Clinical Documentation Service, Hospital Universitario 12 de Octubre, Madrid, Spain
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Baldwin HJ, Marashi-Pour S, Chen HY, Kaldor J, Sutherland K, Levesque JF. Is the weekend effect really ubiquitous? A retrospective clinical cohort analysis of 30-day mortality by day of week and time of day using linked population data from New South Wales, Australia. BMJ Open 2018; 8:e016943. [PMID: 29654003 PMCID: PMC5898331 DOI: 10.1136/bmjopen-2017-016943] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To examine the associations between day of week and time of admission and 30-day mortality for six clinical conditions: ischaemic and haemorrhagic stroke, acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease and congestive heart failure. DESIGN Retrospective population-based cohort analyses. Hospitalisation records were linked to emergency department and deaths data. Random-effect logistic regression models were used, adjusting for casemix and taking into account clustering within hospitals. SETTING All hospitals in New South Wales, Australia, from July 2009 to June 2012. PARTICIPANTS Patients admitted to hospital with a primary diagnosis for one of the six clinical conditions examined. OUTCOME MEASURES Adjusted ORs for all-cause mortality within 30 days of admission, by day of week and time of day. RESULTS A total of 148 722 patients were included in the study, with 17 721 deaths within 30 days of admission. Day of week of admission was not associated with significantly higher likelihood of death for five of the six conditions after adjusting for casemix. There was significant variation in mortality for chronic obstructive pulmonary disease by day of week; however, this was not consistent with a strict weekend effect (Thursday: OR 1.29, 95% CI 1.12 to 1.48; Friday: OR 1.25, 95% CI 1.08 to 1.44; Saturday: OR 1.18, 95% CI 1.02 to 1.37; Sunday OR 1.05, 95% CI 0.90 to 1.22; compared with Monday). There was evidence for a night effect for patients admitted for stroke (ischaemic: OR 1.30, 95% CI 1.17 to 1.45; haemorrhagic: OR 1.58, 95% CI 1.40 to 1.78). CONCLUSIONS Mortality outcomes for these conditions, adjusted for casemix, do not vary in accordance with the weekend effect hypothesis. Our findings support a growing body of evidence that questions the ubiquity of the weekend effect.
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Affiliation(s)
- Heather J Baldwin
- Bureau of Health Information, Chatswood, New South Wales, Australia
- Centre for Epidemiology and Evidence, New South Wales Ministry of Health, Sydney, New South Wales, Australia
| | | | - Huei-Yang Chen
- Bureau of Health Information, Chatswood, New South Wales, Australia
| | - Jill Kaldor
- Bureau of Health Information, Chatswood, New South Wales, Australia
| | - Kim Sutherland
- Bureau of Health Information, Chatswood, New South Wales, Australia
| | - Jean-Frederic Levesque
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
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The “Saturday Effect” in Obstetrics: A Comparison Between Referral Patterns on Saturday and Other Days of the Week. J Obstet Gynaecol India 2018; 68:148-150. [DOI: 10.1007/s13224-017-1086-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 12/26/2017] [Indexed: 11/26/2022] Open
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Holmes J, Rainer T, Geen J, Williams JD, Phillips AO. Adding a new dimension to the weekend effect: an analysis of a national data set of electronic AKI alerts. QJM 2018; 111:249-255. [PMID: 29361145 DOI: 10.1093/qjmed/hcy012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Increased mortality related to differences in delivery of weekend clinical care is the subject of much debate. AIM We compared mortality following detection of acute kidney injury (AKI) on week and weekend days across community and hospital settings. DESIGN A prospective national cohort study, with AKI identified using the Welsh National electronic AKI reporting system. METHODS Data were collected on outcome for all cases of adult AKI in Wales between 1 November 2013 and 31 January 2017. RESULTS There were a total of 107 298 episodes. Weekday detection of AKI was associated with 28.8% (26 439); 90-day mortality compared to 90-day mortality of 31.9% (4551) for AKI detected on weekdays (RR: 1.11, 95% CI: 1.08-1.14, P < 0.001, HR: 1.16 95% CI: 1.12-1.20, P < 0.001). There was no 'weekend effect' for mortality associated with hospital-acquired AKI. Weekday detection of community-acquired AKI (CA-AKI) was associated with a 22.6% (10 356) mortality compared with weekend detection of CA-AKI, which was associated with a 28.6% (1619) mortality (RR: 1.26, 95% CI: 1.21-1.32, P < 0.001, HR: 1.34, 95%CI: 1.28-1.42, P < 0.001). The excess mortality in weekend CA-AKI was driven by CA-AKI detected at the weekend that was not admitted to hospital compared with CA-AKI detected on weekdays which was admitted to hospital (34.5% vs. 19.1%, RR: 1.8, 95% CI: 1.69-1.91, P < 0.001, HR: 2.03, 95% CI: 1.88-2.19, P < 0.001). CONCLUSION 'Weekend effect' in AKI relates to access to in-patient care for patients presenting predominantly to hospital emergency departments with AKI at the weekend.
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Affiliation(s)
- J Holmes
- Welsh Renal Clinical Network, Cwm Taf University Health Board, Cardiff, UK
| | - T Rainer
- Department of Emergency Medicine, University of Cardiff School of Medicine, Cardiff, UK
| | - J Geen
- Department of Clinical Biochemistry, Cwm Taf University Health Board and Faculty of Life Sciences and Education, University of South Wales, Cardiff, UK
| | - J D Williams
- Institute of Nephrology, University of Cardiff School of Medicine, Cardiff, UK
| | - A O Phillips
- Institute of Nephrology, University of Cardiff School of Medicine, Cardiff, UK
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Hsu NC, Huang CC, Shu CC, Yang MC. Implementation of a seven-day hospitalist program to improve the outcomes of the weekend admission: A retrospective before-after study in Taiwan. PLoS One 2018; 13:e0194833. [PMID: 29579132 PMCID: PMC5868823 DOI: 10.1371/journal.pone.0194833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/09/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Patients admitted during weekends may have worse outcomes than those during weekdays. Adjusting the practice of senior physicians over weekends may reduce the weekend effect. Design A controlled before-after study, with propensity score matching (PSM) for potential confounding variables, to compare outcomes between weekday and weekend admissions. Setting A 2000-bed medical centre in Taiwan Participants Hospitalised general medicine patients cared for by traditional internal medicine teams (pre-intervention cohort) and those cared for by hospitalists after introducing a seven-day hospitalist program in the first six-month (post-intervention cohort) and following three-year periods. Main outcome measures Proportion of intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) events, and in-hospital mortality. Results The pre-intervention cohort included 982 patients. Significantly higher mortality rates (11.3% vs. 6.2%, p = 0.032) were recorded in the case of weekend admissions, with similar proportions of ICU admission and CPR events. The post-intervention cohort included 601 patients. No significant difference was recorded in any of the main outcomes between weekday and weekend admissions. PSM for pre-intervention and post-intervention cohort showed shorter LOS after intervention, with no difference in ICU admission, CPR, and morality for the weekday and weekend admissions, respectively. The three-year cohort that followed, consisting of 3315 patients, showed no difference of outcomes between weekday and weekend admissions. After PSM, there were no significant differences in ICU admission rates (1.0% vs. 1.8%), CPR (0.3% vs. 0.2%) events and hospital mortality rates (8.1% vs. 8.5%), when weekday and weekend admissions were compared. Conclusions The seven-day hospitalist program shows potential in providing equally safe care for both weekday and weekend general medicine admissions with sustainable development.
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Affiliation(s)
- Nin-Chieh Hsu
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
| | - Chun-Che Huang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chin-Chung Shu
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chin Yang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
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Holland CM, Lovasik BP, Howard BM, McClure EW, Samuels OB, Barrow DL. Interhospital Transfer of Neurosurgical Patients: Implications of Timing on Hospital Course and Clinical Outcomes. Neurosurgery 2018; 81:450-457. [PMID: 28368528 DOI: 10.1093/neuros/nyw124] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 11/01/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Interhospital transfer of neurosurgical patients is common; however, little is known about the impact of transfer parameters on clinical outcomes. Lower survival rates have been reported for patients admitted at night and on weekends in other specialties. Whether time or day of admission affects neurosurgical patient outcomes, specifically those transferred from other facilities, is unknown. OBJECTIVE To examine the impact of the timing of interhospital transfer on the hospital course and clinical outcomes of neurosurgical patients. METHODS All consecutive admissions of patients transferred to our adult neurosurgical service were retrospectively analyzed for a 1-year study period using data from a central transfer database and the electronic health record. RESULTS Patients arrived more often at night (70.8%) despite an even distribution of transfer requests. The lack of transfer imaging did not affect length of stay, intervention times, or patient outcomes. Daytime arrivals had shorter total transfer time, but longer intenstive care unit and overall length of stay (8.7 and 11.6 days, respectively), worse modified Rankin Scale scores, lower rates of functional independence, and almost twice the mortality rate. Weekend admissions had significantly worse modified Rankin Scale scores and lower rates of functional independence. CONCLUSIONS The timing of transfer arrivals, both by hour or day of the week, is correlated with the time to intervention, hospital course, and overall patient outcomes. Patients admitted during the weekend suffered worse functional outcomes and a trend towards increased mortality. While transfer logistics clearly impact patient outcomes, further work is needed to understand these complex relationships.
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Affiliation(s)
- Christopher M Holland
- Department of Neurological Surgery, Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | | | - Brian M Howard
- Department of Neurological Surgery, Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | | | - Owen B Samuels
- Department of Neurological Surgery, Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University, Atlanta, Georgia
| | - Daniel L Barrow
- Department of Neurological Surgery, Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
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Brouns SHA, Wachelder JJ, Jonkers FS, Lambooij SL, Dieleman JP, Haak HR. Outcome of elderly emergency department patients hospitalised on weekends - a retrospective cohort study. BMC Emerg Med 2018. [PMID: 29514636 PMCID: PMC5842563 DOI: 10.1186/s12873-018-0160-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Studies investigating different medical conditions and settings have demonstrated mixed results regarding the weekend effect. However, data on the outcome of elderly patients hospitalised on weekends is scarce. The objective was to compare in-hospital and two-day mortality rates between elderly emergency department (ED) patients (≥65 years) admitted on weekends versus weekdays. Methods A retrospective cohort study of emergency department visits of internal medicine patients ≥65 years presenting to the emergency department between 01 and 09-2010 and 31–08-2012 was conducted. The weekend was defined as the period from midnight on Friday to midnight on Sunday. Results Data on 3697 emergency department visits by elderly internal medicine patients (mean age 78.6 years old) were included. In total, 2743 emergency department visits (74.2%) resulted in hospitalisation, of which 22.9% occurred on weekends. Comorbidity and urgency levels were higher in patients admitted on weekends. In-hospital mortality was 11.4% for patients admitted on weekends compared with 8.9% on weekdays (OR 1.3, 95%CI 0.99–1.8). Two-day mortality was 3.2% in patients hospitalised on weekends versus 1.9% on weekdays (OR 1.7, 95%CI 0.99–2.9). Multivariable adjustment for age, comorbidity and triage level demonstrated comparable in-hospital and two-day mortality for weekend and week admission (ORadj 1.2, 95%CI 0.9–1.7 and ORadj 1.5, 95%CI 0.8–2.6, resp.). Conclusion A small weekend effect was observed in elderly internal medicine patients, which was not statistically significant. This effect was partly explained by a higher comorbidity and urgency level in elderly patients hospitalised on weekends than during weekdays. Emergency care for the elderly is not compromised by adjusted logistics during the weekend.
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Affiliation(s)
- Steffie H A Brouns
- Department of Internal Medicine, Máxima Medical Centre, 5600 BM, Eindhoven/Veldhoven, the Netherlands. .,Maastricht University, Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, 6229 ER, Maastricht, the Netherlands.
| | - Joyce J Wachelder
- Department of Internal Medicine, Máxima Medical Centre, 5600 BM, Eindhoven/Veldhoven, the Netherlands.,Maastricht University, Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, 6229 ER, Maastricht, the Netherlands
| | - Femke S Jonkers
- Department of Internal Medicine, Máxima Medical Centre, 5600 BM, Eindhoven/Veldhoven, the Netherlands
| | - Suze L Lambooij
- Department of Internal Medicine, Máxima Medical Centre, 5600 BM, Eindhoven/Veldhoven, the Netherlands
| | - Jeanne P Dieleman
- Máxima Medical Centre Academy, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
| | - Harm R Haak
- Department of Internal Medicine, Máxima Medical Centre, 5600 BM, Eindhoven/Veldhoven, the Netherlands.,Maastricht University, Department of Health Services Research, and CAPHRI School for Public Health and Primary Care, 6229 ER, Maastricht, the Netherlands.,Department of Internal Medicine, division of general medicine, section acute medicine, Maastricht University Medical Centre, 6229 HX, Maastricht, the Netherlands
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75
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Smith SA, Yamamoto JM, Roberts DJ, Tang KL, Ronksley PE, Dixon E, Buie WD, James MT. Weekend Surgical Care and Postoperative Mortality: A Systematic Review and Meta-Analysis of Cohort Studies. Med Care 2018; 56:121-129. [PMID: 29251716 PMCID: PMC5770102 DOI: 10.1097/mlr.0000000000000860] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An association between weekend health care delivery and poor outcomes has become known as the "weekend effect." Evidence for such an association among surgery patients has not previously been synthesized. OBJECTIVE To systematically review associations between weekend surgical care and postoperative mortality. METHODS We searched PubMed, EMBASE, and references of relevant articles for studies that compared postoperative mortality either; (1) according to the day of the week of surgery for elective operations, or (2) according to weekend versus weekday admission for urgent/emergent operations. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for postoperative mortality (≤90 d or inpatient mortality) were pooled using random-effects models. RESULTS Among 4027 citations identified, 10 elective surgery studies and 19 urgent/emergent surgery studies with a total of >6,685,970 and >1,424,316 patients, respectively, met the inclusion criteria. Pooled odds of mortality following elective surgery rose in a graded manner as the day of the week of surgery approached the weekend [Monday OR=1 (reference); Tuesday OR=1.04 (95% CI=0.97-1.11); Wednesday OR=1.08 (95% CI=0.98-1.19); Thursday OR=1.12 (95% CI=1.03-1.22); Friday OR=1.24 (95% CI=1.10-1.38)]. Mortality was also higher among patients who underwent urgent/emergent surgery after admission on the weekend relative to admission on weekdays (OR=1.27; 95% CI=1.08-1.49). CONCLUSIONS Postoperative mortality rises as the day of the week of elective surgery approaches the weekend, and is higher after admission for urgent/emergent surgery on the weekend compared with weekdays. Future research should focus on clarifying underlying causes of this association and potentially mitigating its impact.
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Affiliation(s)
| | | | | | | | | | | | | | - Matthew T. James
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
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76
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Zampieri FG, Lisboa TC, Correa TD, Bozza FA, Ferez M, Fernandes HS, Japiassú AM, Verdeal JCR, Carvalho ACP, Knibel MF, Mazza BF, Colombari F, Vieira JM, Viana WN, Costa R, Godoy MM, Maia MO, Caser EB, Salluh JIF, Soares M. Role of organisational factors on the 'weekend effect' in critically ill patients in Brazil: a retrospective cohort analysis. BMJ Open 2018; 8:e018541. [PMID: 29371274 PMCID: PMC5786146 DOI: 10.1136/bmjopen-2017-018541] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Higher mortality for patients admitted to intensive care units (ICUs) during the weekends has been occasionally reported with conflicting results that could be related to organisational factors. We investigated the effects of ICU organisational and staffing patterns on the potential association between weekend admission and outcomes in critically ill patients. METHODS We included 59 614 patients admitted to 78 ICUs participating during 2013. We defined 'weekend admission' as any ICU admission from Friday 19:00 until Monday 07:00. We assessed the association between weekend admission with hospital mortality using a mixed logistic regression model controlling for both patient-level (illness severity, age, comorbidities, performance status and admission type) and ICU-level (decrease in nurse/bed ratio on weekend, full-time intensivist coverage, use of checklists on weekends and number of institutional protocols) confounders. We performed secondary analyses in the subgroup of scheduled surgical admissions. RESULTS A total of 41 894 patients (70.3%) were admitted on weekdays and 17 720 patients (29.7%) on weekends. In univariable analysis, weekend admitted patients had higher ICU (10.9% vs 9.0%, P<0.001) and hospital (16.5% vs 13.5%, P<0.001) mortality. After adjusting for confounders, weekend admission was not associated with higher hospital mortality (OR 1.05, 95% CI 0.99 to 1.12, P=0.095). However, a 'weekend effect' was still observed in scheduled surgical admissions, as well as in ICUs not using checklists during the weekends. For unscheduled admissions, no 'weekend effect' was observed regardless of ICU's characteristics. For scheduled surgical admissions, a 'weekend effect' was present only in ICUs with a low number of implemented protocols and those with a reduction in the nurse/bed ratio and not applying checklists during weekends. CONCLUSIONS ICU organisational factors, such as decreased nurse-to-patient ratio, absence of checklists and fewer standardised protocols, may explain, in part, increases in mortality in patients admitted to the ICU mortality on weekends.
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Affiliation(s)
- Fernando G Zampieri
- Research Institute, Hospital do Coração (IEP- HCor), São Paulo, Brazil
- ICU, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Thiago C Lisboa
- Intensive Care Unit, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | | | - Fernando A Bozza
- Department of Critical Care and Graduate Program in Translational Medicine, D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, Brazil
| | - Marcus Ferez
- ICU, Hospital São Francisco, Ribeirão Preto, Brazil
| | | | - André M Japiassú
- Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, Brazil
- Intensive Care Unit, Rede Amil de Hospitais, Rio de Janeiro, Brazil
| | | | | | | | - Bruno F Mazza
- ICU, Hospital São Luiz Morumbi, São Paulo, Brazil
- ICU, Hospital Samaritano, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Jorge I F Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D’Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Marcio Soares
- Department of Critical Care and Graduate Program in Translational Medicine, D’Or Institute for Research and Education, Rio de Janeiro, Brazil
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77
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Du W, Glasgow N, Smith P, Clements A, Sedrakyan A. Major inpatient surgeries and in-hospital mortality in New South Wales public hospitals in Australia: A state-wide retrospective cohort study. Int J Surg 2017; 50:126-132. [PMID: 29288807 DOI: 10.1016/j.ijsu.2017.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/06/2017] [Accepted: 12/20/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical interventions save lives and are important focus for health services research worldwide. Investigating variation in postoperative mortality may improve understanding of unwarranted variations and promote safety and quality in surgical care. We aimed to evaluate trends of in-hospital mortality rates among adult inpatients receiving major elective surgeries and determine the variation in mortality among New South Wales (NSW) public hospitals. MATERIALS AND METHODS In this study, we used the all-inclusive population-based NSW Admitted Patient Data from July 2001 to June 2014. We retrospectively included adult patients aged 18+ years receiving Abdominal Aortic Aneurysm (AAA) repair, Peripheral bypass, Colorectal surgeries, Joint replacement, Spinal surgeries, or Cardiac surgeries. The primary outcome was in-hospital mortality for selected surgeries. Changes in mortality rates over time and hospital standardised mortality rates were modelled using multivariate logistic regression models adjusting for case-mix factors. RESULTS Over 13-year study period, the in-hospital mortality rates declined annually by 6.4% (95% Confidence Interval (CI): 4.3, 8.4) for Colorectal surgery by 5.7% (95%CI: 2.0, 9.3) for Joint replacement and by 4.2% (95%CI: 1.9, 6.4) for Cardiac surgery. After controlling for patient-level factors, little variation was observed among hospitals for in-hospital mortality. There was a greater variability for cardiac surgery compared with the other surgical groups but no outlier hospital was consistently associated with significantly higher than expected mortality rate. CONCLUSIONS Mortality has declined for major surgeries in the past 15 years. There was some variation among hospitals regarding in-hospital mortality that was mostly explained by patients demographic and admission characteristics. Our findings are reassuring for patients and contribute to knowledge that can help further improve surgical care.
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Affiliation(s)
- Wei Du
- Research School of Population Health, Australian National University, Australia.
| | - Nicholas Glasgow
- Research School of Population Health, Australian National University, Australia
| | - Paul Smith
- Department of Orthopaedic Surgery, The Canberra Hospital, Canberra, Australia; Australian National University Medical School, Canberra, ACT, Australia
| | - Archie Clements
- Research School of Population Health, Australian National University, Australia
| | - Art Sedrakyan
- Research School of Population Health, Australian National University, Australia; Department of Health Care Policy and Research, Weill Cornell Medicine, NY, USA
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78
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Staib A, Sullivan C, Prins JB, Burton-Jones A, Fitzgerald G, Scott I. Uniting emergency and inpatient clinicians across the ED-inpatient interface: The last frontier? Emerg Med Australas 2017; 29:740-745. [PMID: 29090515 DOI: 10.1111/1742-6723.12883] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/28/2017] [Accepted: 06/16/2017] [Indexed: 11/29/2022]
Abstract
Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED-inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system-wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes.
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Affiliation(s)
- Andrew Staib
- Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Mater Medical Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia.,Clinical Excellence Division, Queensland Health, Brisbane, Queensland, Australia
| | - Clair Sullivan
- Mater Medical Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia.,Clinical Excellence Division, Queensland Health, Brisbane, Queensland, Australia.,Department of Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Johannes B Prins
- Mater Research Institute, Metro South Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew Burton-Jones
- Business Information Systems, UQ Business School, The University of Queensland, Brisbane, Queensland, Australia
| | - Gerry Fitzgerald
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ian Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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79
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Roberts SE, Brown TH, Thorne K, Lyons RA, Akbari A, Napier DJ, Brown JL, Williams JG. Weekend admission and mortality for gastrointestinal disorders across England and Wales. Br J Surg 2017; 104:1723-1734. [PMID: 28925499 PMCID: PMC5656931 DOI: 10.1002/bjs.10608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/09/2017] [Accepted: 05/08/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND Little has been reported on mortality following admissions at weekends for many gastrointestinal (GI) disorders. The aim was to establish whether GI disorders are susceptible to increased mortality following unscheduled admission on weekends compared with weekdays. METHODS Record linkage was undertaken of national administrative inpatient and mortality data for people in England and Wales who were hospitalized as an emergency for one of 19 major GI disorders. RESULTS The study included 2 254 701 people in England and 155 464 in Wales. For 11 general surgical and medical GI disorders there were little, or no, significant weekend effects on mortality at 30 days in either country. There were large consistent weekend effects in both countries for severe liver disease (England: 26·2 (95 per cent c.i. 21·1 to 31·6) per cent; Wales: 32·0 (12·4 to 55·1 per cent) and GI cancer (England: 21·8 (19·1 to 24·5) per cent; Wales: 25·0 (15·0 to 35·9) per cent), which were lower in patients managed by surgeons. Admission rates were lower at weekends than on weekdays, most strongly for severe liver disease (by 43·3 per cent in England and 51·4 per cent in Wales) and GI cancer (by 44·6 and 52·8 per cent respectively). Both mortality and the weekend mortality effect for GI cancer were lower for patients managed by surgeons. DISCUSSION There is little, or no, evidence of a weekend mortality effect for most major general surgical or medical GI disorders, but large weekend effects for GI cancer and severe liver disease. Lower admission rates at weekends indicate more severe cases. The findings for severe liver disease may suggest a lack of specialist hepatological resources. For cancers, reduced availability of end-of-life care in the community at weekends may be the cause.
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Affiliation(s)
- S E Roberts
- Swansea University Medical School, Swansea University, Swansea, UK
- Farr Institute of Health Informatics Research, Swansea University, Swansea, UK
| | - T H Brown
- Swansea University Medical School, Swansea University, Swansea, UK
| | - K Thorne
- Swansea University Medical School, Swansea University, Swansea, UK
| | - R A Lyons
- Swansea University Medical School, Swansea University, Swansea, UK
- Farr Institute of Health Informatics Research, Swansea University, Swansea, UK
| | - A Akbari
- Swansea University Medical School, Swansea University, Swansea, UK
- Farr Institute of Health Informatics Research, Swansea University, Swansea, UK
| | - D J Napier
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - J L Brown
- Swansea University Medical School, Swansea University, Swansea, UK
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - J G Williams
- Swansea University Medical School, Swansea University, Swansea, UK
- Farr Institute of Health Informatics Research, Swansea University, Swansea, UK
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80
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Outcomes After Weekend Admission for Deceased Donor Kidney Transplantation: A Population Cohort Study. Transplantation 2017; 101:2244-2252. [PMID: 27755501 DOI: 10.1097/tp.0000000000001522] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Outcomes for weekend hospital admissions or emergency procedures have become a topical and controversial issue for the UK National Health Service. Deceased-donor kidney transplantation is frequently performed at weekends and evidence for its relative safety are lacking. METHODS We undertook a population-based cohort analysis, obtaining data from every deceased-donor kidney-alone transplant procedure performed in England between January 2003 and December 2014. Data were extracted from Hospital Episode Statistics, with linkage to the Office for National Statistics to create a comprehensive dataset for mortality, rehospitalization and kidney allograft failure/rejection for weekend (defined as Friday to Sunday) versus weekday transplantation. RESULTS Data were extracted for 12 902 deceased-donor kidney alone transplants performed in all 19 English transplant centres between 2003 and 2014. Based on initial χ tests, no significant difference was observed when comparing weekend versus weekday transplantation in 30-day (0.9% vs 1.2%; P = 0.126) or 1-year mortality (3.7% vs 3.8%; P = 0.788), 1-year kidney allograft failure/rejection (16.7% vs 16.8%; P = 0.897), delayed graft function (29.97% vs 29.36%; P = 0.457) or 1-year risk for readmission (63.5% vs 63.3%; P = 0.774). In a Cox regression model, transplantation at the weekend was not associated with any increased risk for 1-year mortality, rehospitalization, or allograft failure/rejection. CONCLUSIONS Deceased-donor kidney transplants performed at the weekend do not have inferior short-term outcomes on the basis of 1-year risk for rehospitalization, mortality, or allograft failure/rejection. Our data are reassuring for patients and professionals alike, but may also provide speculative insight into models of care that attenuate the weekend effect.
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81
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Haines TP, Bowles KA, Mitchell D, O’Brien L, Markham D, Plumb S, May K, Philip K, Haas R, Sarkies MN, Ghaly M, Shackell M, Chiu T, McPhail S, McDermott F, Skinner EH. Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials. PLoS Med 2017; 14:e1002412. [PMID: 29088237 PMCID: PMC5663333 DOI: 10.1371/journal.pmed.1002412] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/21/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Disinvestment (removal, reduction, or reallocation) of routinely provided health services can be difficult when there is little published evidence examining whether the services are effective or not. Evidence is required to understand if removing these services produces outcomes that are inferior to keeping such services in place. However, organisational imperatives, such as budget cuts, may force healthcare providers to disinvest from these services before the required evidence becomes available. There are presently no experimental studies examining the effectiveness of allied health services (e.g., physical therapy, occupational therapy, and social work) provided on weekends across acute medical and surgical hospital wards, despite these services being routinely provided internationally. The aim of this study was to understand the impact of removing weekend allied health services from acute medical and surgical wards using a disinvestment-specific non-inferiority research design. METHODS AND FINDINGS We conducted 2 stepped-wedge cluster randomised controlled trials between 1 February 2014 and 30 April 2015 among patients on 12 acute medical or surgical hospital wards spread across 2 hospitals. The hospitals involved were 2 metropolitan teaching hospitals in Melbourne, Australia. Data from n = 14,834 patients were collected for inclusion in Trial 1, and n = 12,674 in Trial 2. Trial 1 was a disinvestment-specific non-inferiority stepped-wedge trial where the 'current' weekend allied health service was incrementally removed from participating wards each calendar month, in a random order, while Trial 2 used a conventional non-inferiority stepped-wedge design, where a 'newly developed' service was incrementally reinstated on the same wards as in Trial 1. Primary outcome measures were patient length of stay (proportion staying longer than expected and mean length of stay), the proportion of patients experiencing any adverse event, and the proportion with an unplanned readmission within 28 days of discharge. The 'no weekend allied health service' condition was considered to be not inferior if the 95% CIs of the differences between this condition and the condition with weekend allied health service delivery were below a 2% increase in the proportion of patients who stayed in hospital longer than expected, a 2% increase in the proportion who had an unplanned readmission within 28 days, a 2% increase in the proportion who had any adverse event, and a 1-day increase in the mean length of stay. The current weekend allied health service included physical therapy, occupational therapy, speech therapy, dietetics, social work, and allied health assistant services in line with usual care at the participating sites. The newly developed weekend allied health service allowed managers at each site to reprioritise tasks being performed and the balance of hours provided by each professional group and on which days they were provided. Analyses conducted on an intention-to-treat basis demonstrated that there was no estimated effect size difference between groups in the proportion of patients staying longer than expected (weekend versus no weekend; estimated effect size difference [95% CI], p-value) in Trial 1 (0.40 versus 0.38; estimated effect size difference 0.01 [-0.01 to 0.04], p = 0.31, CI was both above and below non-inferiority margin), but the proportion staying longer than expected was greater with the newly developed service compared to its no weekend service control condition (0.39 versus 0.40; estimated effect size difference 0.02 [0.01 to 0.04], p = 0.04, CI was completely below non-inferiority margin) in Trial 2. Trial 1 and 2 findings were discordant for the mean length of stay outcome (Trial 1: 5.5 versus 6.3 days; estimated effect size difference 1.3 days [0.9 to 1.8], p < 0.001, CI was both above and below non-inferiority margin; Trial 2: 5.9 versus 5.0 days; estimated effect size difference -1.6 days [-2.0 to -1.1], p < 0.001, CI was completely below non-inferiority margin). There was no difference between conditions for the proportion who had an unplanned readmission within 28 days in either trial (Trial 1: 0.01 [-0.01 to 0.03], p = 0.18, CI was both above and below non-inferiority margin; Trial 2: -0.01 [-0.02 to 0.01], p = 0.62, CI completely below non-inferiority margin). There was no difference between conditions in the proportion of patients who experienced any adverse event in Trial 1 (0.01 [-0.01 to 0.03], p = 0.33, CI was both above and below non-inferiority margin), but a lower proportion of patients had an adverse event in Trial 2 when exposed to the no weekend allied health condition (-0.03 [-0.05 to -0.004], p = 0.02, CI completely below non-inferiority margin). Limitations of this research were that 1 of the trial wards was closed by the healthcare provider after Trial 1 and could not be included in Trial 2, and that both withdrawing the current weekend allied health service model and installing a new one may have led to an accommodation period for staff to adapt to the new service settings. Stepped-wedge trials are potentially susceptible to bias from naturally occurring change over time at the service level; however, this was adjusted for in our analyses. CONCLUSIONS In Trial 1, criteria to say that the no weekend allied health condition was non-inferior to current weekend allied health condition were not met, while neither the no weekend nor current weekend allied health condition demonstrated superiority. In Trial 2, the no weekend allied health condition was non-inferior to the newly developed weekend allied health condition across all primary outcomes, and superior for the outcomes proportion of patients staying longer than expected, proportion experiencing any adverse event, and mean length of stay. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12613001231730 and ACTRN12613001361796.
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Affiliation(s)
- Terry P. Haines
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
- * E-mail:
| | - Kelly-Ann Bowles
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
| | - Deb Mitchell
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
| | - Lisa O’Brien
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
- Department of Occupational Therapy, Monash University, Frankston, Victoria, Australia
| | - Donna Markham
- Monash Medical Centre, Allied Health, Monash Health, Clayton, Victoria, Australia
| | - Samantha Plumb
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kerry May
- Monash Medical Centre, Allied Health, Monash Health, Clayton, Victoria, Australia
| | - Kathleen Philip
- Department of Health and Human Services, Melbourne, Victoria, Australia
| | - Romi Haas
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
| | - Mitchell N. Sarkies
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
| | - Marcelle Ghaly
- Department of Physiotherapy, Footscray Hospital, Western Health, Footscray, Victoria, Australia
| | - Melina Shackell
- Department of Physiotherapy, Footscray Hospital, Western Health, Footscray, Victoria, Australia
| | - Timothy Chiu
- Footscray Hospital, Western Health, Footscray, Victoria, Australia
| | - Steven McPhail
- Institute of Biomedical Innovation, Queensland University of Technology and Centre for Functioning and Health Research, Buranda, Queensland, Australia
| | - Fiona McDermott
- Department of Social Work, Monash Medical Centre, Monash Health and Monash University, Clayton, Victoria, Australia
| | - Elizabeth H. Skinner
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Department of Physiotherapy, Footscray Hospital, Western Health, Footscray, Victoria, Australia
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Mohammed M, Faisal M, Richardson D, Howes R, Beatson K, Speed K, Wright J. Impact of the level of sickness on higher mortality in emergency medical admissions to hospital at weekends. J Health Serv Res Policy 2017; 22:236-242. [DOI: 10.1177/1355819617720955] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Routine administrative data have been used to show that patients admitted to hospitals over the weekend appear to have a higher mortality compared to weekday admissions. Such data do not take the severity of sickness of a patient on admission into account. Our aim was to incorporate a standardized vital signs physiological-based measure of sickness known as the National Early Warning Score to investigate if weekend admissions are: sicker as measured by their index National Early Warning Score; have an increased mortality; and experience longer delays in the recording of their index National Early Warning Score. Methods We extracted details of all adult emergency medical admissions during 2014 from hospital databases and linked these with electronic National Early Warning Score data in four acute hospitals. We analysed 47,117 emergency admissions after excluding 1657 records, where National Early Warning Score was missing or the first (index) National Early Warning Score was recorded outside ±24 h of the admission time. Results Emergency medical admissions at the weekend had higher index National Early Warning Score (weekend: 2.53 vs. weekday: 2.30, p < 0.001) with a higher mortality (weekend: 706/11,332 6.23% vs. weekday: 2039/35,785 5.70%; odds ratio = 1.10, 95% CI 1.01 to 1.20, p = 0.04) which was no longer seen after adjusting for the index National Early Warning Score (odds ratio = 0.99, 95% CI 0.90 to 1.09, p = 0.87). Index National Early Warning Score was recorded sooner (−0.45 h, 95% CI −0.52 to −0.38, p < 0.001) for weekend admissions. Conclusions Emergency medical admissions at the weekend with electronic National Early Warning Score recorded within 24 h are sicker, have earlier clinical assessments, and after adjusting for the severity of their sickness, do not appear to have a higher mortality compared to weekday admissions. A larger definitive study to confirm these findings is needed.
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Affiliation(s)
- Mohammed Mohammed
- Professor of Healthcare Quality & Effectiveness, Faculty of Health Studies, Bradford Institute for Health Research, University of Bradford, UK
| | - Muhammad Faisal
- Senior Research Fellow in Medical Statistics, Faculty of Health Studies, Bradford Institute for Health Research, University of Bradford, UK
| | - Donald Richardson
- Consultant Renal Physician, Department of Renal Medicine, York Teaching Hospital NHS Foundation Trust Hospital, UK
| | - Robin Howes
- Operational Manager for Electronic Patient Records, Department of Strategy & Planning, Northern Lincolnshire and Goole Hospitals, UK
| | - Kevin Beatson
- Development Manager, York Teaching Hospital NHS Foundation Trust, UK
| | - Kevin Speed
- Consultant Haematologist, Northern Lincolnshire and Goole Hospitals, UK
| | - John Wright
- Professor in Clinical Epidemiology, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
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Roberts CM, Lowe D, Skipper E, Steiner MC, Jones R, Gelder C, Hurst JR, Lowrey GE, Thompson C, Stone RA. Effect of time and day of admission on hospital care quality for patients with chronic obstructive pulmonary disease exacerbation in England and Wales: single cohort study. BMJ Open 2017; 7:e015532. [PMID: 28882909 PMCID: PMC5588982 DOI: 10.1136/bmjopen-2016-015532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 05/23/2017] [Accepted: 06/29/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To evaluate if observed increased weekend mortality was associated with poorer quality of care for patients admitted to hospital with chronic obstructive pulmonary disease (COPD) exacerbation. DESIGN Prospective case ascertainment cohort study. SETTING 199 acute hospitals in England and Wales, UK. PARTICIPANTS Consecutive COPD admissions, excluding subsequent readmissions, from 1 February to 30 April 2014 of whom 13 414 cases were entered into the study. MAIN OUTCOMES Process of care mapped to the National Institute for Health and Care Excellence clinical quality standards, access to specialist respiratory teams and facilities, mortality and length of stay, related to time and day of the week of admission. RESULTS Mortality was higher for weekend admissions (unadjusted OR 1.20, 95% CI 1.00 to 1.43), and for case-mix adjusted weekend mortality when calculated for admissions Friday morning through to Monday night (adjusted OR 1.19, 95% CI 1.00 to 1.43). Median time to death was 6 days. Some clinical processes were poorer on Mondays and during normal working hours but not weekends or out of hours. Specialist respiratory care was less available and less prompt for Friday and Saturday admissions. Admission to a specialist ward or high dependency unit was less likely on a Saturday or Sunday. CONCLUSIONS Increased mortality observed in weekend admissions is not easily explained by deficiencies in early clinical guideline care. Further study of out-of-hospital factors, specialty care and deaths later in the admission are required if effective interventions are to be made to reduce variation by day of the week of admission.
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Affiliation(s)
- Christopher Michael Roberts
- Barts Health, Queen Mary University of London, London, UK
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Derek Lowe
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Emma Skipper
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Michael C Steiner
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Respiratory Biomedical Sciences Research Unit, Institute for Lung Health, Glenfield Hospital NHS Trust, Leicester, Leicestershire, United Kingdom
| | - Rupert Jones
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Clinical Trials & Health Research - Institute of Translational & Stratified Medicine, Plymouth University, Plymouth, Devon, United Kingdom
| | - Colin Gelder
- Department of respiratory medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Warwickshire, United Kingdom
| | - John R Hurst
- UCL Respiratory, University College London, London, London, United Kingdom
| | - Gillian E Lowrey
- Department of respiratory medicine, Derby Teaching Hospitals NHS Foundation Trust, Derby, Derbyshire, United Kingdom
| | | | - Robert A Stone
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Somerset Lung Centre, Musgrove Park Hospital, Taunton, Somerset, UK
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Richardson LC, Lehnbom EC, Baysari MT, Walter SR, Day RO, Westbrook JI. A time and motion study of junior doctor work patterns on the weekend: a potential contributor to the weekend effect? Intern Med J 2017; 46:819-25. [PMID: 27094756 DOI: 10.1111/imj.13120] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/02/2016] [Accepted: 04/06/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients admitted to hospital on weekends have a greater risk of mortality compared to patients admitted on weekdays. Junior medical officers (JMO) make up the majority of medical staff on weekends. No previous study has quantified JMO work patterns on weekends. AIM To describe and quantify JMO work patterns on weekends and compare them with patterns previously observed during the week. METHODS Observational time and motion study of JMO working weekends using the Work Observation Method by Activity Timing (WOMBAT; Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia) software. Descriptive statistics were used to determine the proportion of total observed time spent in tasks. RESULTS Weekend JMO predominately spent time in indirect care (32.0%), direct care (23.0%) and professional communication (22.1%). JMO spent 20.9% of time multitasking and were interrupted, on average, every 9 min. Weekend JMO spent significantly more time in direct care compared with weekdays (13.0%; P < 0.001) and nights (14.3%; P < 0.001). Weekend JMO spent significantly less time on breaks (8.5%), with less than 1 h in an 11-h shift, compared with JMO during weekdays (16.4%; P = 0.004) and nights (27.6%; P = <0.001). Weekend JMO were interrupted at a higher rate (6.6/h) than on weekdays (rate ratio (RR) 2.9, 95% confidence intervals (CI) 2.6, 3.3) or nights (RR 5.1, 95% CI 4.2, 6.1). Multitasking on weekends (20.9%) was comparable to weekdays (18.9%; P = 0.19) but significantly higher than nights (6.4%; P = <0.001). CONCLUSION On weekends, JMO had few breaks, were interrupted frequently and engaged in high levels of multitasking. This pattern of JMO work could be a potential contributing factor to the weekend effect in terms of JMO abilities to respond safely and adequately to care demands.
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Affiliation(s)
- L C Richardson
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - E C Lehnbom
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - M T Baysari
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - S R Walter
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - R O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,UNSW Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - J I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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85
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Gan HW, Wong DJN, Dean BJF, Hall AS. Do expanded seven-day NHS services improve clinical outcomes? Analysis of comparative institutional performance from the "NHS Services, Seven Days a Week" project 2013-2016. BMC Health Serv Res 2017; 17:552. [PMID: 28797268 PMCID: PMC5553994 DOI: 10.1186/s12913-017-2505-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The cause of adverse weekend clinical outcomes remains unknown. In 2013, the "NHS Services, Seven Days a Week" project was initiated to improve access to services across the seven-day week. Three years on, we sought to analyse the impact of such changes across the English NHS. METHODS Aggregated trust-level data on crude mortality rates, Summary Hospital-Level Mortality Indicator (SHMI), mean length of stay (LOS), A&E admission and four-hour breach rates were obtained from national Hospital Episode Statistics and A&E datasets across the English NHS, excluding mental and community health trusts. Trust annual reports were analysed to determine the presence of any seven-day service reorganisation in 2013-2014. Funnel plots were generated to compare institutional performance and a difference in differences analysis was performed to determine the impact of seven-day changes on clinical outcomes between 2013 and 2014, 2014-2015 and 2015-2016. Data was summarised as mean (SD). RESULTS Of 159 NHS trusts, 79 (49.7%) instituted seven-day changes in 2013-2014. Crude mortality rates, A&E admission rates and mean LOS remained relatively stable between 2013 and 2016, whilst A&E four-hour breach rates nearly doubled from 5.3 to 9.7%. From 2013 to 2014 to 2014-2015 and 2015-2016, there were no significant differences in the change in crude mortality (2014-2015 p = 0.8, 2015-2016 p = 0.9), SHMI (2014-2015 p = 0.5, 2015-2016 p = 0.5), mean LOS (2014-2015 p = 0.5, 2015-2016 p = 0.4), A&E admission (2014-2015 p = 0.6, 2015-2016 p = 1.0) or four-hour breach rates (2014-2015 p = 0.06, 2015-2016 p = 0.6) between trusts that had implemented seven-day changes compared to those which had not. CONCLUSIONS Adverse weekend clinical outcomes may not be ameliorated by large scale reorganisations aimed at improving access to health services across the week. Such changes may negatively impact care quality without additional financial investment, as demonstrated by worsening of some outcomes. Detailed prospective research is required to determine whether such reallocation of finite resources is clinically effective.
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Affiliation(s)
- Hoong-Wei Gan
- Section for Genetics & Epigenetics in Health & Disease, Genetics & Genomic Medicine Programme, University College London Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK. .,The London Centre for Paediatric Endocrinology & Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Danny Jon Nian Wong
- National Institute of Academic Anaesthesia Health Services Research Centre, Department of Applied Health Research, University College London, London, UK
| | - Benjamin John Floyd Dean
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences (NDORMS), Botnar Research Institute, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
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Parikh K, Shah M, Mehta D, Arora S, Patel N, Liu D. Increased Mortality Among Patients With Acute Leukemia Admitted on Weekends Compared to Weekdays. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:e33-e43. [PMID: 28864171 DOI: 10.1016/j.clml.2017.07.256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The association between weekend admission and patient outcomes has been reported in several acute illnesses but is unknown in acute leukemia. PATIENTS AND METHODS We used the 2002 to 2014 Nationwide Inpatient Sample to identify patients admitted with a primary diagnosis of acute leukemia. Admissions were classified as weekend or weekday admissions for comparison. Hierarchical logistic regression models were used to analyze predictors of hospital mortality. RESULTS There was a 22.3% decline in acute leukemia admissions in 2014 compared to 2002 and a 4% decline in in-hospital mortality (19.0%-14.9%; P < .001). A total of 82,833 admissions were included in the study, and 14,241 (17.19%) occurred over the weekend. Hospital mortality was higher for weekend than weekday admissions (18.8% vs. 16.1%; P < .001). Weekend admissions were less likely to undergo early bone marrow biopsy than their weekday counterparts (27.5% vs. 46.3%; P < .01). Bone marrow biopsy (adjusted odds ratio 0.36; 95% confidence interval [CI], 0.33-0.39; P < .001) and admission to a teaching hospital (adjusted odds ratio, 0.65; 95% CI, 0.56-0.75; P < .001) independently predicted lower hospital mortality. Weekend admission was associated with higher hospital mortality (adjusted odds ratio, 1.12; 95 CI, 1.02-1.23; P = .01) and more complications (50.6% vs. 47.8%; P < .001) than weekday admissions. CONCLUSION There was significantly increased mortality among weekend admissions for acute leukemia. Mortality was reduced among patients admitted to teaching hospitals.
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Affiliation(s)
- Kaushal Parikh
- Department of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY
| | - Mahek Shah
- Department of Cardiology, Lehigh Valley Hospital, Allentown, PA
| | - Dhruv Mehta
- Department of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY
| | - Shilpkumar Arora
- Department of Medicine, Mount Sinai-St Luke's-Roosevelt Hospital, New York, NY
| | - Nilay Patel
- Department of Medicine, St Peter's University Hospital, New Brunswick, NJ
| | - Delong Liu
- Department of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY.
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87
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Gallerani M, Fedeli U, Pala M, De Giorgi A, Fabbian F, Manfredini R. Weekend Versus Weekday Admission and In-Hospital Mortality for Pulmonary Embolism: A 14-Year Retrospective Study on the National Hospital Database of Italy. Angiology 2017; 69:236-241. [PMID: 28683557 DOI: 10.1177/0003319717718706] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We assessed the association between weekday (WD) or weekend (WE) admission and mortality for patients hospitalized with acute pulmonary embolism (PE). Weekend included holidays. We analyzed hospital administrative data of all patients discharged with a diagnosis of PE extracted from the Italian Health Ministry database (January 2001 to December 2014). A total of 265 035 hospitalizations with a diagnosis of PE were retrieved, in which PE was the primary diagnosis in 198 565 (74.9%); 200 166 (75.5%) patients were admitted on WD and 64 869 (24.5%) on WE. Admissions for PE were more frequent on Mondays (41 917 admissions, 15.8% of all events) and less frequent on Saturdays (32 295 admissions, 12.2%) and Sundays (32 574 admissions, 12.3%). Patients admitted on WE were on average 1 year older, presented more frequently with respiratory failure, and had more common comorbidities. After adjustment for age, gender, comorbidities, and presence of respiratory failure, in-hospital mortality for patients admitted on WE was greater (odds ratio: 1.15, 95% confidence interval: 1.13-1.18; P < .001). This study supports that, in Italy, hospitalization for PE on WE is associated with a significantly higher mortality rate than on WD.
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Affiliation(s)
- Massimo Gallerani
- 1 Department of Internal Medicine, Hospital of Ferrara, Azienda Ospedaliero-Universitaria, Ferrara, Italy
| | - Ugo Fedeli
- 2 Epidemiological Department, Veneto Region, Padova, Italy
| | - Marco Pala
- 1 Department of Internal Medicine, Hospital of Ferrara, Azienda Ospedaliero-Universitaria, Ferrara, Italy
| | - Alfredo De Giorgi
- 3 Department of Medical Sciences, Clinica Medica Unit, University of Ferrara and Azienda Ospedaliero-Universitaria, Ferrara, Italy
| | - Fabio Fabbian
- 3 Department of Medical Sciences, Clinica Medica Unit, University of Ferrara and Azienda Ospedaliero-Universitaria, Ferrara, Italy
| | - Roberto Manfredini
- 3 Department of Medical Sciences, Clinica Medica Unit, University of Ferrara and Azienda Ospedaliero-Universitaria, Ferrara, Italy
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Nijland LMG, Karres J, Simons AE, Ultee JM, Kerkhoffs GMMJ, Vrouenraets BC. The weekend effect for hip fracture surgery. Injury 2017; 48:1536-1541. [PMID: 28539236 DOI: 10.1016/j.injury.2017.05.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/03/2017] [Accepted: 05/15/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Increased mortality rates have been reported for emergency admissions during weekends and outside office hours. Research on the weekend effect in hip fracture patients is however limited and demonstrates conflicting results. The aim of this study was to determine the effect of weekend admission and weekend surgery on 30-day and 1-year mortality following hip fracture surgery. PATIENTS AND METHODS All patients who underwent hip fracture surgery in our hospital between 2004 and 2015 were included in this retrospective study. Patient characteristics including age, gender, fracture type, American Society of Anesthesiologists (ASA) score, Nottingham Hip Fracture Score (NHFS), Charlson Comorbidity Index (CCI) and length of stay were collected. Information on admission and surgery date and time of day was recorded, as were in-hospital, 30-day and 1-year mortality. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day and 1-year mortality. RESULTS A total of 1803 patients were included, 546 patients (30.3%) were admitted during the weekend. Patient characteristics did not differ between weekday and weekend admissions. Surgical delay was less frequent in patients undergoing weekend surgery. Multivariable analysis demonstrated that older age, higher ASA score, higher NHFS and increased surgical delay were independently associated with 30-day mortality. One-year mortality was associated with age, gender, ASA score, CCI and surgical delay. Weekend admission and weekend surgery were not associated with increased 30-day or 1-year mortality. CONCLUSIONS There was no weekend effect for hip fracture patients in our study. These results indicate an adequate level of perioperative care outside weekday office hours within our health care system.
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Affiliation(s)
| | - Julian Karres
- Department of Surgery, OLVG Hospital, Amsterdam, The Netherlands; Department of Orthopaedic Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
| | - Anouk E Simons
- Department of Surgery, OLVG Hospital, Amsterdam, The Netherlands
| | - Jan M Ultee
- Department of Surgery, OLVG Hospital, Amsterdam, The Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Walker AS, Mason A, Quan TP, Fawcett NJ, Watkinson P, Llewelyn M, Stoesser N, Finney J, Davies J, Wyllie DH, Crook DW, Peto TEA. Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records. Lancet 2017; 390:62-72. [PMID: 28499548 PMCID: PMC5494289 DOI: 10.1016/s0140-6736(17)30782-1] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 01/07/2017] [Accepted: 02/07/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Weekend hospital admission is associated with increased mortality, but the contributions of varying illness severity and admission time to this weekend effect remain unexplored. METHODS We analysed unselected emergency admissions to four Oxford University National Health Service hospitals in the UK from Jan 1, 2006, to Dec 31, 2014. The primary outcome was death within 30 days of admission (in or out of hospital), analysed using Cox models measuring time from admission. The primary exposure was day of the week of admission. We adjusted for multiple confounders including demographics, comorbidities, and admission characteristics, incorporating non-linearity and interactions. Models then considered the effect of adjusting for 15 common haematology and biochemistry test results or proxies for hospital workload. FINDINGS 257 596 individuals underwent 503 938 emergency admissions. 18 313 (4·7%) patients admitted as weekday energency admissions and 6070 (5·1%) patients admitted as weekend emergency admissions died within 30 days (p<0·0001). 9347 individuals underwent 9707 emergency admissions on public holidays. 559 (5·8%) died within 30 days (p<0·0001 vs weekday). 15 routine haematology and biochemistry test results were highly prognostic for mortality. In 271 465 (53·9%) admissions with complete data, adjustment for test results explained 33% (95% CI 21 to 70) of the excess mortality associated with emergency admission on Saturdays compared with Wednesdays, 52% (lower 95% CI 34) on Sundays, and 87% (lower 95% CI 45) on public holidays after adjustment for standard patient characteristics. Excess mortality was predominantly restricted to admissions between 1100 h and 1500 h (pinteraction=0·04). No hospital workload measure was independently associated with mortality (all p values >0·06). INTERPRETATION Adjustment for routine test results substantially reduced excess mortality associated with emergency admission at weekends and public holidays. Adjustment for patient-level factors not available in our study might further reduce the residual excess mortality, particularly as this clustered around midday at weekends. Hospital workload was not associated with mortality. Together, these findings suggest that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services. FUNDING NIHR Oxford Biomedical Research Centre.
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Affiliation(s)
- A Sarah Walker
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.
| | - Amy Mason
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - T Phuong Quan
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Nicola J Fawcett
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Peter Watkinson
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Martin Llewelyn
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - Nicole Stoesser
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - John Finney
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Jim Davies
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Department of Computer Science, University of Oxford, Oxford, UK
| | - David H Wyllie
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; National Infection Service, Public Health England, Colindale, London, UK
| | - Derrick W Crook
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK; National Infection Service, Public Health England, Colindale, London, UK
| | - Tim E A Peto
- Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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O'Brien L, Mitchell D, Skinner EH, Haas R, Ghaly M, McDermott F, May K, Haines T. What makes weekend allied health services effective and cost-effective (or not) in acute medical and surgical wards? Perceptions of medical, nursing, and allied health workers. BMC Health Serv Res 2017; 17:345. [PMID: 28494806 PMCID: PMC5427575 DOI: 10.1186/s12913-017-2279-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/27/2017] [Indexed: 12/11/2022] Open
Abstract
Background There is strong public support for acute hospital services to move to genuine 7-day models, including access to multidisciplinary team assessment. This study aimed to identify factors that might enable an effective and cost-effective weekend allied health services on acute hospital wards. Methods This qualitative study included 22 focus groups within acute wards with a weekend allied health service and 11 telephone interviews with weekend service providers. Data were collected from 210 hospital team members, including 17 medical, 97 nursing, and 96 allied health professionals from two Australian tertiary public hospitals. All were recorded and imported into nVivo 10 for analysis. Thematic analysis methods were used to develop a coding framework from the data and to identify emerging themes. Results Key themes identified were separated into issues perceived as being enablers or barriers to the effective or cost-effective delivery of weekend allied health services. Perceived enablers of effectiveness and cost-effectiveness included prioritizing interventions that prevent decline, the right person delivering the right service, improved access to the patient’s family, and ability to impact patient flow. Perceived barriers were employment of inexperienced weekend staff, insufficient investment to see tangible benefit, inefficiencies related to double-handling, unnecessary interventions and/or inappropriate referrals, and difficulty recruiting and retaining skilled staff. Conclusions Suggestions for ensuring effective and cost effective weekend allied health care models include minimization of task duplication and targeting interventions so that the right patients receive the right interventions at the right time. Further research into the effectiveness and cost effectiveness of these services should factor in hidden costs, including those associated with managing the service.
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Affiliation(s)
- Lisa O'Brien
- Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University - Peninsula Campus, PO Box 527, Frankston, VIC, 3199, Australia.
| | - Deb Mitchell
- Allied Health Workforce, Innovation, Strategy, Education and Research Unit, Monash Health, Moorabbin, Australia
| | | | - Romi Haas
- Allied Health Research Unit Kingston Centre, Monash Health, Melbourne, Australia
| | - Marcelle Ghaly
- Western Centre for Health Research and Education, Melbourne, Australia
| | - Fiona McDermott
- Department of Social Work, Monash University, Melbourne, Australia
| | | | - Terry Haines
- Allied Health Research Unit Kingston Centre, Melbourne, Australia
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Conway R, Cournane S, Byrne D, O’Riordan D, Silke B. Improved mortality outcomes over time for weekend emergency medical admissions. Ir J Med Sci 2017; 187:5-11. [DOI: 10.1007/s11845-017-1627-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/27/2017] [Indexed: 01/12/2023]
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Tarrant C, Sutton E, Angell E, Aldridge CP, Boyal A, Bion J. The 'weekend effect' in acute medicine: a protocol for a team-based ethnography of weekend care for medical patients in acute hospital settings. BMJ Open 2017; 7:e016755. [PMID: 28385913 PMCID: PMC5719649 DOI: 10.1136/bmjopen-2017-016755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION It is now well-recognised that patients admitted to hospital on weekends are at higher risk of death than those admitted during weekdays. However, the causes of this 'weekend effect' are poorly understood. Some contend that there is a deficit of medical staff on weekends resulting in poorer quality care, whereas others find that patients admitted to hospital on weekends are sicker and therefore at higher risk of adverse outcomes. Clarifying the causal pathway is clearly important in order to identify effective solutions. In this article we describe an ethnographic approach to evaluating the organisation and delivery of medical care on weekends compared with weekdays, with a specific focus on the role of medical staff as part of National Health Service England's plan to implement 7-day services. METHODS AND ANALYSIS We will conduct an ethnographic study of 20 acute hospitals in England between April 2016 and March 2018 as part of the High-intensity Specialist-Led Acute Care project (www.hislac.org). Data will be collected through observations and shadowing, and interviews with staff, in 10 hospitals with higher intensity specialist (consultant) staffing on weekends and 10 with lower intensity specialist staffing. Interviews will be conducted with up to 20 patients sampled from two high-intensity and two low-intensity sites. We will coordinate, compare and contrast observations across our team of ethnographers. Analysis will be both in-depth and cross-cutting, exploring specific features within individual sites and making comparisons between them. We outline how data collection and analysis will be facilitated and organised. ETHICS AND DISSEMINATION The project has received ethics approval from the South West Wales Research Ethics Committee: Reference 13/WA/0372. Informed consent will be obtained for all interview participants. The findings will be disseminated through peer-reviewed publications in high-quality journals and at national and international conferences.
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Affiliation(s)
- Carolyn Tarrant
- University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK
| | - Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Angell
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Amunpreet Boyal
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
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Patella M, Papagiannopoulos K, Milton R, Chaudhuri N, Kefaloyannis E, Brunelli A. Operating room scheduling is not associated with early outcome following elective anatomic lung resections: a propensity score case-matched analysis. Eur J Cardiothorac Surg 2017; 51:660-666. [PMID: 28007872 DOI: 10.1093/ejcts/ezw371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/10/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives To investigate the effect of operating room scheduling on the outcome of patients undergoing elective lung resection. Methods In total, 420 patients submitted to anatomical pulmonary resections (363 lobectomies, 35 pneumonectomies, 22 segmentectomies) (April 2014-November 2015) were analysed. Ninety-two patients (22%) were operated on during weekends (Friday or Saturday) and 161 patients (38%) in the afternoon. Propensity score matching was performed to account for possible selection bias between the groups. The matched groups (weekdays versus weekends; morning versus afternoon) were compared in terms of cardiopulmonary complications, in-hospital mortality and length of stay (LOS). Results In total, 102 (24%) patients developed cardiopulmonary complications and 56 (13%) patients developed major complications. In-hospital mortality was 3.1% (13 patients). The case-matched comparison between patients operated on during the week versus those operated on during weekends (92 pairs) showed no differences of cardiopulmonary morbidity (22 vs 24, P = 0.8), major complications (14 in both groups), mortality (2 vs 4, P = 0.7) and LOS (7 vs 7.5 days, P = 0.6). The case-matched comparison between patients operated on in the morning versus those operated on in the afternoon (161 pairs) showed no differences of cardiopulmonary morbidity (32 vs 33, P = 0.9), major morbidity (17 vs 19, P = 1), mortality (7 vs 4, P = 0.5) and LOS (7.2 vs 5.9 days, P = 0.2). Conclusions In our setting, operating room scheduling did not affect early outcome following elective lung resections, confirming the appropriate structural and procedural characteristics of a dedicated Thoracic Unit.
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Affiliation(s)
- Miriam Patella
- Department of Thoracic Surgery, St James's University Hospital, Leeds, UK
| | | | - Richard Milton
- Department of Thoracic Surgery, St James's University Hospital, Leeds, UK
| | | | - Emmanuel Kefaloyannis
- Department of Thoracic Surgery, St James's University Hospital, Leeds, UK,Department of Thoracic Surgery, Leeds Teaching Hospitals, Leeds, UK
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94
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Chana P, Joy M, Casey N, Chang D, Burns EM, Arora S, Darzi AW, Faiz OD, Peden CJ. Cohort analysis of outcomes in 69 490 emergency general surgical admissions across an international benchmarking collaborative. BMJ Open 2017; 7:e014484. [PMID: 28274969 PMCID: PMC5353261 DOI: 10.1136/bmjopen-2016-014484] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE This study aims to use the Dr Foster Global Comparators Network (GC) database to examine differences in outcomes following high-risk emergency general surgery (EGS) admissions in participating centres across 3 countries and to determine whether hospital infrastructure factors can be linked to the delivery of high-quality care. DESIGN A retrospective cohort analysis of high-risk EGS admissions using GC's international administrative data set. SETTING 23 large hospitals in Australia, England and the USA. METHODS Discharge data for a cohort of high-risk EGS patients were collated. Multilevel hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals. RESULTS 69 490 patients, admitted to 23 centres across Australia, England and the USA from 2007 to 2012, were identified. For all patients within this cohort, outcomes defined as: 7-day and 30-day inhospital mortality, readmission and length of stay appeared to be superior in US centres. A subgroup of 19 082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at 7 days in this subgroup. 30-day mortality (OR=1.47, p<0.01) readmission (OR=1.42, p<0.01) and length of stay (OR=1.98, p<0.01) were worse in English units. Patient factors (age, pathology, comorbidity) were significantly associated with worse outcome as were structural factors, including low intensive care unit bed ratios, high volume and interhospital transfers. Having dedicated EGS teams cleared of elective commitments with formalised handovers was associated with shorter length of stay. CONCLUSIONS Key factors that influence outcomes were identified. For patients who underwent surgery, outcomes were similar at 7 days but not at 30 days. This may be attributable to better infrastructure and resource allocation towards EGS in the US and Australian centres.
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Affiliation(s)
- Prem Chana
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
- The Global Comparators Unit, Dr Foster Intelligence, London, UK
- Department of Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Imperial College London, London, UK
| | - Mark Joy
- The Global Comparators Unit, Dr Foster Intelligence, London, UK
- School of Health Sciences, University of Surrey, Surrey, UK
| | - Neil Casey
- The Global Comparators Unit, Dr Foster Intelligence, London, UK
| | - David Chang
- Codman Centre, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elaine M Burns
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Sonal Arora
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Ara W Darzi
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Omar D Faiz
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
- Department of Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Imperial College London, London, UK
| | - Carol J Peden
- Centre for Health Systems Innovation, University of Southern California, Los Angeles, California, USA
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95
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Abstract
OBJECTIVES Excess mortality following weekend hospital admission has been observed but not explained. As readmissions have greater age, comorbidity and social deprivation, outcomes following emergency index admission and readmission were examined for temporal and demographic associations to confirm whether weekend readmissions contribute towards excess mortality. DESIGN A retrospective observational study. Individual patient Hospital Episode Statistics were linked and 2 categories created: index admissions (not within 60 days of discharge from an emergency hospitalisation) and readmissions (within 60 days of discharge from an emergency hospitalisation). Logistic regression examined associations between admission category, weekend and weekday mortality, age, gender, season, comorbidity and social deprivation. SETTING A single acute National Health Service (NHS) trust serving a population of 550 000 via 3 emergency departments. PARTICIPANTS Emergency admissions between 1 January 2010 and 31 March 2015. OUTCOME MEASURE All-cause 30-day mortality. RESULTS Over 5 years there were 128 966 index admissions (74.7% weekday/25.3% weekend) and 20 030 readmissions (74.9% weekday/25.1% weekend). Adjusted 30-day death rates for weekday/weekend admissions were 6.93%/7.04% for index cases and 12.26%/13.27% for readmissions. Weekend readmissions had a higher mortality risk relative to weekday readmissions (OR 1.10 (95% CI 1.01 to 1.20)) without differences in comorbidity or deprivation. Weekend index admissions did not have a significantly increased mortality risk (OR 1.04 (95% CI 0.98 to 1.11)) but deaths which did occur were associated with lower deprivation (OR 1.24 (95% CI 1.11 to 1.38)) and an absence of comorbidities (OR 1.17 (1.02 to 1.34)). CONCLUSIONS Associations with emergency hospitalisation were not identical for index admissions and readmissions. Further research is needed to confirm what factors are responsible for the 'weekend effect'.
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Affiliation(s)
- Ivy Shiue
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Christopher Price
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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96
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Hancock L, Sagar P. Why rolling out routine seven-day surgical services would threaten emergency care. ACTA ACUST UNITED AC 2017. [DOI: 10.1308/rcsbull.2017.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Scheduling of elective weekend operations is entirely within our control and deaths are therefore preventable.
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Affiliation(s)
- L Hancock
- University Hospital of South Manchester
| | - P Sagar
- St James’ University Hospital, Leeds
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97
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Noad R, Stevenson M, Herity NA. Analysis of weekend effect on 30-day mortality among patients with acute myocardial infarction. Open Heart 2017; 4:e000504. [PMID: 28409006 PMCID: PMC5384461 DOI: 10.1136/openhrt-2016-000504] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/13/2016] [Accepted: 09/20/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Several publications have demonstrated increased 30-day mortality in patients admitted on Saturdays or Sundays compared with weekdays. We sought to determine whether this was true for two different cohorts of patients admitted with acute myocardial infarction (MI). METHODS AND RESULTS Thirty-day mortality data were obtained for 3757 patients who had been admitted to the Belfast Health and Social Care Trust with acute MI between 2009 and 2015. They were subdivided into those presenting with ST elevation MI (n=2240) and non-ST elevation MI (n= 1517). We observed no excess 30-day mortality in those admitted over weekends. CONCLUSION Excess mortality in patients admitted at weekends is not a universal finding. This may mean that that there are patient subgroups with proportionately greater weekend hazard and points to the need for more detailed understanding of the weekend effect.
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Affiliation(s)
- Rebecca Noad
- Department of Cardiology, Belfast HSC Trust, Belfast, Northern Ireland
| | - Michael Stevenson
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Niall A Herity
- Department of Cardiology, Belfast HSC Trust, Belfast, Northern Ireland
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98
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Affiliation(s)
- Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
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99
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Barer D. Do studies of the weekend effect really allow for differences in illness severity? An analysis of 14 years of stroke admissions. Age Ageing 2017; 46:138-142. [PMID: 28181628 DOI: 10.1093/ageing/afw173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 08/24/2016] [Indexed: 11/14/2022] Open
Abstract
Background An increased mortality rate among patients admitted to hospital at weekends has been found in many studies, and this ‘weekend effect’ has been used to justify major health service reorganisation. Most studies have used routine administrative data to adjust for potential confounding factors, and are unable to measure differences in illness severity due to the tendency of patients with milder symptoms to stay home at weekends. We set out to estimate the importance of such unmeasured ‘confounding by severity’, using data from a hospital stroke register. Methods All suspected acute stroke admissions in Gateshead were prospectively registered over a period of 14.3 years, including information on premorbid factors, measures of stroke severity and survival to hospital discharge. We examined whether each factor differed between weekday and weekend admissions, then used logistic regression to estimate the main contributors to variation in mortality rates. Results Stroke severity, measured by the Scandinavian Stroke Scale (SSS), was significantly greater among weekend admissions and strongly associated with mortality, and after adjustment for SSS score in logistic regression, the weekend effect completely disappeared. By contrast, most indicators of pre-stroke function, comorbidity or stroke type did not differ between weekday and weekend admissions, although some of them had prognostic significance. Conclusions The sorts of factors measurable in administrative databases only account for a small part of the prognostically important differences in case-mix between weekday and weekend stroke admissions. While increasing weekend staffing might improve adherence to care standards, evidence that it could save lives is unreliable.
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Affiliation(s)
- David Barer
- Stroke Unit, Sunderland Royal Hospital , Sunderland SR4 7TP, UK
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100
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Anselmi L, Meacock R, Kristensen SR, Doran T, Sutton M. Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England. BMJ Qual Saf 2016; 26:613-621. [PMID: 27756827 PMCID: PMC5537532 DOI: 10.1136/bmjqs-2016-005680] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 09/02/2016] [Accepted: 09/03/2016] [Indexed: 11/29/2022]
Abstract
Background Studies finding higher mortality rates for patients admitted to hospital at weekends rely on routine administrative data to adjust for risk of death, but these data may not adequately capture severity of illness. We examined how rates of patient arrival at accident and emergency (A&E) departments by ambulance—a marker of illness severity—were associated with in-hospital mortality by day and time of attendance. Methods Retrospective observational study of 3 027 946 admissions to 140 non-specialist hospital trusts in England between April 2013 and February 2014. Patient admissions were linked with A&E records containing mode of arrival and date and time of attendance. We classified arrival times by day of the week and daytime (07:00 to 18:59) versus night (19:00 to 06:59 the following day). We examined the association with in-hospital mortality within 30 days using multivariate logistic regression. Results Over the week, 20.9% of daytime arrivals were in the highest risk quintile compared with 18.5% for night arrivals. Daytime arrivals on Sundays contained the highest proportion of patients in the highest risk quintile at 21.6%. Proportions of admitted patients brought in by ambulance were substantially higher at night and higher on Saturday (61.1%) and Sunday (60.1%) daytimes compared with other daytimes in the week (57.0%). Without adjusting for arrival by ambulance, risk-adjusted mortality for patients arriving at night was higher than for daytime attendances on Wednesday (0.16 percentage points). Compared with Wednesday daytime, risk-adjusted mortality was also higher on Thursday night (0.15 percentage points) and increased throughout the weekend from Saturday daytime (0.16 percentage points) to Sunday night (0.26 percentage points). After adjusting for arrival by ambulance, the raised mortality only reached statistical significance for patients arriving at A&E on Sunday daytime (0.17 percentage points). Conclusion Using conventional risk-adjustment methods, there appears to be a higher risk of mortality following emergency admission to hospital at nights and at weekends. After accounting for mode of arrival at hospital, this pattern changes substantially, with no increased risk of mortality following admission at night or for any period of the weekend apart from Sunday daytime. This suggests that risk-adjustment based on inpatient administrative data does not adequately account for illness severity and that elevated mortality at weekends and at night reflects a higher proportion of more severely ill patients arriving by ambulance at these times.
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Affiliation(s)
- Laura Anselmi
- Centre for Health Economics, University of Manchester, Manchester, UK
| | - Rachel Meacock
- Centre for Health Economics, University of Manchester, Manchester, UK
| | | | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Matt Sutton
- Centre for Health Economics, University of Manchester, Manchester, UK
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