1
|
Bion J, Aldridge C, Beet C, Boyal A, Chen YF, Clancy M, Girling A, Hofer T, Lord J, Mannion R, Rees P, Roseveare C, Rowan L, Rudge G, Sun J, Sutton E, Tarrant C, Temple M, Watson S, Willars J, Lilford R. Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background
NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’.
Objectives
The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness.
Design
This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics.
Methods
A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision.
Results
Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time.
Limitations
Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time.
Conclusions
Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care.
Future work
Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Julian Bion
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Cassie Aldridge
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Chris Beet
- Intensive Care Medicine, Royal Derby Hospital NHS Trust, Derby, UK
| | - Amunpreet Boyal
- Research & Development, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Clancy
- Emergency Medicine, University of Southampton, Southampton, UK
| | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timothy Hofer
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Joanne Lord
- Southampton Health Technology Assessments Centre, University of Southampton, Southampton, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Peter Rees
- Patient & Lay Committee, Academy of Medical Royal Colleges, London, UK
| | - Chris Roseveare
- General Internal Medicine, Southern Health NHS Foundation Trust, Southampton, UK
| | - Louise Rowan
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jianxia Sun
- Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Mark Temple
- Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sam Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Janet Willars
- Health Sciences, University of Leicester, Leicester, UK
| | - Richard Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| |
Collapse
|
2
|
Weekend Effect and in-Hospital Mortality in Elderly Patients with Acute Kidney Injury: A Retrospective Analysis of a National Hospital Database in Italy. J Clin Med 2020; 9:jcm9061815. [PMID: 32545203 PMCID: PMC7357030 DOI: 10.3390/jcm9061815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 01/05/2023] Open
Abstract
Background: The aim of this study was to relate the weekend (WE) effect and acute kidney injury (AKI) in elderly patients by using the Italian National Hospital Database (NHD). Methods: Hospitalizations with AKI of subjects aged ≥ 65 years from 2000–2015 who were identified by the ICD-9-CM were included. Admissions from Friday to Sunday were considered as WE, while all the other days were weekdays (WD). In-hospital mortality (IHM) was our outcome, and the comorbidity burden was calculated by the modified Elixhauser Index (mEI), based on ICD-9-CM codes. Results: 760,664 hospitalizations were analyzed. Mean age was 80.5 ± 7.8 years and 52.2% were males. Of the studied patients, 9% underwent dialysis treatment, 24.3% were admitted during WE, and IHM was 27.7%. Deceased patients were more frequently comorbid males, with higher age, treated with dialysis more frequently, and had higher admission during WE. WE hospitalizations were more frequent in males, and in older patients with higher mEI. IHM was independently associated with dialysis-dependent AKI (OR 2.711; 95%CI 2.667–2.755, p < 0.001), WE admission (OR 1.113; 95%CI 1.100–1.126, p < 0.001), and mEI (OR 1.056; 95% CI 1.055–1.057, p < 0.001). Discussion: Italian elderly patients admitted during WE with AKI are exposed to a higher risk of IHM, especially if they need dialysis treatment and have high comorbidity burden.
Collapse
|
3
|
Chen YF, Armoiry X, Higenbottam C, Cowley N, Basra R, Watson SI, Tarrant C, Boyal A, Sutton E, Wu CW, Aldridge CP, Gosling A, Lilford R, Bion J. Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis. BMJ Open 2019; 9:e025764. [PMID: 31164363 PMCID: PMC6561443 DOI: 10.1136/bmjopen-2018-025764] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 03/14/2019] [Accepted: 04/15/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To examine the magnitude of the weekend effect, defined as differences in patient outcomes between weekend and weekday hospital admissions, and factors influencing it. DESIGN A systematic review incorporating Bayesian meta-analyses and meta-regression. DATA SOURCES We searched seven databases including MEDLINE and EMBASE from January 2000 to April 2015, and updated the MEDLINE search up to November 2017. Eligibility criteria: primary research studies published in peer-reviewed journals of unselected admissions (not focusing on specific conditions) investigating the weekend effect on mortality, adverse events, length of hospital stay (LoS) or patient satisfaction. RESULTS For the systematic review, we included 68 studies (70 articles) covering over 640 million admissions. Of these, two-thirds were conducted in the UK (n=24) or USA (n=22). The pooled odds ratio (OR) for weekend mortality effect across admission types was 1.16 (95% credible interval 1.10 to 1.23). The weekend effect appeared greater for elective (1.70, 1.08 to 2.52) than emergency (1.11, 1.06 to 1.16) or maternity (1.06, 0.89 to 1.29) admissions. Further examination of the literature shows that these estimates are influenced by methodological, clinical and service factors: at weekends, fewer patients are admitted to hospital, those who are admitted are more severely ill and there are differences in care pathways before and after admission. Evidence regarding the weekend effect on adverse events and LoS is weak and inconsistent, and that on patient satisfaction is sparse. The overall quality of evidence for inferring weekend/weekday difference in hospital care quality from the observed weekend effect was rated as 'very low' based on the Grading of Recommendations, Assessment, Development and Evaluations framework. CONCLUSIONS The weekend effect is unlikely to have a single cause, or to be a reliable indicator of care quality at weekends. Further work should focus on underlying mechanisms and examine care processes in both hospital and community. PROSPERO REGISTRATION NUMBER CRD42016036487.
Collapse
Affiliation(s)
- Yen-Fu Chen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Xavier Armoiry
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Nicholas Cowley
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | - Ranjna Basra
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Samuel Ian Watson
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Amunpreet Boyal
- University Department of Anaesthesia & Critical Care, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Chia-Wei Wu
- National Taiwan University Hospital, Taipei, Taiwan
| | - Cassie P Aldridge
- University Department of Anaesthesia & Critical Care, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Amy Gosling
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Lilford
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Julian Bion
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- University Department of Anaesthesia & Critical Care, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
4
|
López-Soto PJ, Morales-Cané I, Smolensky MH, Manfredini R, Dios-Guerra C, Rodríguez-Borrego MA, Carmona-Torres JM. Gender, socioeconomic, medical, and environmental factors related to domestic accidents of the elderly in Spain. Findings of a national survey. Women Health 2019; 59:985-996. [PMID: 30880631 DOI: 10.1080/03630242.2019.1587665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Domestic accidents pose serious threats to the independence of the elderly. We explored associations between domestic accidents and gender, socioeconomic, medical, and environmental factors using data from the European Health Survey 2014 for elderly Spanish female and male nationals. Records of 5960 participants (mean age ± SD: 75.9 ± 7.6 years), 59.8% of whom were women, were examined. Domestic accidents occurred in 460 (7.1%) seniors, predominately in women (78.5%). Age (adjusted odds ratio [aOR]: 1.02 [95% confidence interval [CI]: 1.00-1.03, p = .003], female gender (aOR 2.04 [95% CI 1.60-2.60, p < .001]), difficulty managing 12 stairs (reference: none) (some: aOR 2.03 [95% CI 1.53-2.68, p < .001]; much: aOR 2.88 [95% CI 2.15-3.87, p < .001]; inability: aOR 3.09 [95% CI 2.14-4.45, p < .001]), and depressive symptoms severity (reference: absent) (mild: aOR 1.44 [95% CI 1.10-1.89, p = .008]; moderate: aOR 1.91 [95% CI 1.35-2.71, p < .001];. Very severe: aOR 2.53 [95% CI 1.72-3.71, p < .001]; extremely severe: aOR 2.38 [95% CI 1.45-3.93, p = .001]) were independently associated with domestic accidents. Severity of depressive symptoms was the most prominent feature for women, while inability to manage 12 stairs was the most prominent for men. Our results suggest important gender differences in factors associated with domestic accidents that are relevant to intervention and preventive programs.
Collapse
Affiliation(s)
- Pablo J López-Soto
- Department of Nursing, Maimonides Biomedical Research Institute of Cordoba (IMIBIC) , Córdoba , Spain.,Department of Nursing, University of Cordoba , Córdoba , Spain
| | - Ignacio Morales-Cané
- Department of Nursing, Maimonides Biomedical Research Institute of Cordoba (IMIBIC) , Córdoba , Spain.,Department of Nursing, University of Cordoba , Córdoba , Spain
| | - Michael H Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin , Austin , TX , USA
| | - Roberto Manfredini
- Clinica Medica, Department of Medical Sciences, University of Ferrara , Ferrara , Italy
| | - Caridad Dios-Guerra
- Department of Nursing, Maimonides Biomedical Research Institute of Cordoba (IMIBIC) , Córdoba , Spain.,Department of Nursing, University of Cordoba , Córdoba , Spain
| | - María Aurora Rodríguez-Borrego
- Department of Nursing, Maimonides Biomedical Research Institute of Cordoba (IMIBIC) , Córdoba , Spain.,Department of Nursing, University of Cordoba , Córdoba , Spain.,Department of Nursing, Reina Sofia University Hospital , Córdoba , Spain
| | - Juan Manuel Carmona-Torres
- Department of Nursing, Maimonides Biomedical Research Institute of Cordoba (IMIBIC) , Córdoba , Spain.,School of Nursing and Physiotherapy, University of Castilla-La Mancha (UCLM) , Ciudad Real , Spain
| |
Collapse
|
5
|
Manfredini R, Fabbian F. Pulmonary embolism, mortality, 'weekend effect' and gender: what do we know? Future Cardiol 2017; 14:9-13. [PMID: 29168648 DOI: 10.2217/fca-2017-0077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Roberto Manfredini
- Clinica Medica Unit, Department of Medical Sciences, Faculty of Medicine, Pharmacy & Prevention, University of Ferrara, Ferrara, Italy
| | - Fabio Fabbian
- Clinica Medica Unit, Department of Medical Sciences, Faculty of Medicine, Pharmacy & Prevention, University of Ferrara, Ferrara, Italy
| |
Collapse
|
6
|
|