Is hospital mortality higher at weekends? If so, why?

Weekend and holiday admissions for decompensated heart failure and in-hospital mortality. A cumulative effect of "nonworking" days?

INTRODUCTION AND OBJECTIVES

The aim of this study was to analyze whether nonelective admissions in patients with heart failure (HF) on nonworking days (NWD) are associated with higher in-hospital mortality.

METHODS

We conducted a retrospective (2018-2019) observational study of episodes of nonelective admissions in patients aged 18 years and older discharged with a principal diagnosis of HF in acute general hospitals of the Spanish National Health System. NWD at admission were defined as Fridays after 14:00hours, Saturdays, Sundays, and national and regional holidays. In-hospital mortality was analyzed with logistic regression models. The length of NWD was considered as an independent continuous variable. Propensity score matching was used as a sensitivity analysis.

RESULTS

We selected 235 281 episodes of nonelective HF admissions. When the NWD periods were included in the in-hospital mortality model, the increases in in-hospital mortality compared with weekday admission were as follows: 1 NWD day (OR, 1.11; 95%CI, 1.07-1.16); 2 days (OR, 1.13; 95%CI, 1.09-1.17); 3 (OR, 1.16; 95%CI, 1.05-1.27); and ≥4 days (OR, 1.20; 95%CI, 1.09-1.32). There was a statistically significant association between a linear increase in NWD and higher risk-adjusted in-hospital mortality (chi-square trend P=.0002). After propensity score matching, patients with HF admitted on NWD had higher in-hospital mortality than those admitted on weekdays (OR, 1.11; average treatment effect, 12.2% vs 11.1%; P<.001).

CONCLUSIONS

We found an association between admissions for decompensated HF on an NWD and higher in-hospital mortality. The excess mortality is likely not explained by differences in severity. In this study, the "weekend effect" tended to increase as the NWD period became longer.

Weekend admissions and outcomes in patients with pneumonia: a systematic review and meta-analysis

Background

To document pooled evidence on the association between weekend hospital admissions and the potential risks of mortality, intensive care requirements, and readmission among patients with pneumonia.

Methods

We performed a systematic search across the PubMed, EMBASE, and Scopus databases. We collected observational studies exploring the association between weekend admissions and outcomes of interest in patients with pneumonia. To analyze the data, we used a random effects model and expressed the effect sizes as pooled odds ratios (ORs) accompanied by their respective 95% confidence intervals (CIs).

Results

The analysis comprised data from 13 retrospective studies. Compared to patients admitted on weekdays, those admitted during the weekend had a non-statistically significant marginally higher risk of in-hospital mortality (OR, 1.02; 95% CI, 1.00, 1.04) but similar 30-day mortality after admission (OR, 1.03; 95% CI, 0.97, 1.10), and similar risks of admission to intensive care unit (OR, 1.04; 95% CI, 0.98, 1.11) and re-admission (OR, 0.85; 95% CI, 0.65-1.12).

Conclusion

Our findings do not support the presence of a "weekend effect" in patients with pneumonia.

Systematic review registration

PROSPERO, identifier CRD42023425802, https://www.crd.york.ac.uk/prospero/.

Mortality and readmission differences associated with after‐hours hospital admission: A population‐based cohort study in Queensland Australia

Background and Aims

Policy makers and health system managers are seeking evidence on the risks involved for patients associated with after‐hours care. This study of approximately 1 million patients who were admitted to the 25 largest public hospitals in Queensland Australia sought to quantify mortality and readmission differences associated with after‐hours hospital admission.

Methods

Logistic regression was used to assess whether there were any differences in mortality and readmissions based on the time inpatients were admitted to hospital (after‐hours versus within hours). Patient and staffing data, including the variation in physician and nursing staff numbers and seniority were included as explicit predictors within patient outcome models.

Results

After adjusting for case‐mix confounding, statistically significant higher mortality was observed for patients admitted on weekends via the hospital's emergency department compared to within hours. This finding of elevated mortality risk after‐hours held true in sensitivity analyses which explored broader definitions of after‐hours care: an “Extended” definition comprising a weekend extending into Friday night and early Monday morning; and a “Twilight” definition comprising weekends and weeknights.

There were no significant differences in 30‐day readmissions for emergency or elective patients admitted after‐hours. Increased mortality risks for elective patients was found to be an evening/weekend effect rather than a day‐of‐week effect. Workforce metrics that played a role in observed outcome differences within hours/after‐hours were more a time of day rather than day of week effect, i.e. staffing impacts differ more between day and night than the weekday versus weekend.

Conclusion

Patients admitted after‐hours have significantly higher mortality than patients admitted within hours. This study confirms an association between mortality differences and the time patients were admitted to hospital, and identifies characteristics of patients and staffing that affect those outcomes.

Relevant vs non-relevant subspecialist for patients hospitalised in internal medicine at a local hospital: which is better? A retrospective cohort study

Background

Studies of the treatment of patients in-hospital with a specific diagnosis show that physicians with a subspecialisation relevant to this diagnosis can provide a better quality of care. However, studies including patients with a range of diagnoses show a more negligible effect of being attended by a relevant subspecialist. This project aimed to study a more extensive set of patients and diagnoses in an environment where the subspecialist present could be controlled. Thus, this study investigated whether being attended by a physician with a subspeciality relevant to the patient’s primary diagnosis was prospectively associated with readmission, in-hospital mortality, or length of stay compared to a physician with a subspeciality not relevant to the patient’s primary diagnosis.

Methods

We have conducted a retrospective register-based study of 11,059 hospital admissions across 9 years at a local hospital in south-eastern Norway, where it was possible to identify the physician attending the patients at the beginning of the stay. The outcomes studied were emergency readmissions to the same ward within 30 days, any in-hospital mortality and the total length of stay. The patients admitted were matched with the consultant(s) responsible for their treatment. Then, the admissions were divided into two groups according to their primary diagnosis. Was their diagnosis within the subspeciality of the attending consultant (relevant subspecialist) or not (non-relevant subspecialist). The two groups were then compared using bivariable and multivariable models adjusted for patient characteristics, comorbidities, diagnostic group and physician sex.

Results

A relevant subspecialist was present during the first 3 days in 8058 (73%) of the 11,059 patient cases. Patients attended to by a relevant subspecialist had an odds ratio (OR) of 0.91 (95% confidence interval 0.76 to 1.09) for being readmitted and 0.71 (0.48 to 1.04) for dying in the hospital and had a length of stay that was 0.18 (− 0.07 to 0.42) days longer than for those attended to by a non-relevant subspecialist.

Conclusions

This study found that patients attended by a relevant subspecialist did not have a significantly different outcome to those attended by a non-relevant subspecialist.

Timing errors and temporal uncertainty in clinical databases-A narrative review

A firm concept of time is essential for establishing causality in a clinical setting. Review of critical incidents and generation of study hypotheses require a robust understanding of the sequence of events but conducting such work can be problematic when timestamps are recorded by independent and unsynchronized clocks. Most clinical models implicitly assume that timestamps have been measured accurately and precisely, but this custom will need to be re-evaluated if our algorithms and models are to make meaningful use of higher frequency physiological data sources. In this narrative review we explore factors that can result in timestamps being erroneously recorded in a clinical setting, with particular focus on systems that may be present in a critical care unit. We discuss how clocks, medical devices, data storage systems, algorithmic effects, human factors, and other external systems may affect the accuracy and precision of recorded timestamps. The concept of temporal uncertainty is introduced, and a holistic approach to timing accuracy, precision, and uncertainty is proposed. This quantitative approach to modeling temporal uncertainty provides a basis to achieve enhanced model generalizability and improved analytical outcomes.

Weekday and outcomes of elective cardiac surgery in the UK: a large retrospective database analysis

OBJECTIVES

Several studies have shown worse outcomes in patients operated on later in the week. We tested this hypothesis in a large UK national audit database in elective patients undergoing adult cardiac surgery.

METHODS

We used a generalized additive model to evaluate the effect of the day of the week on the following postoperative outcomes: 30-day mortality, stroke, need for dialysis and return to theatre for bleeding. We have adjusted for the relevant European System for Cardiac Operative Risk Evaluation (EuroSCORE) II covariates, plus responsible consultant, hospital and year of operation and performed subgroup analysis for isolated coronary artery bypass grafting (CABG) procedures.

RESULTS

Out of 371 500 patients, 60 555 (16.3%) underwent AVR, 36 553 (9.8%) AVR plus CABG, 238 812 (64.3%) isolated CABG, 26 517 (7.1%) isolated mitral valve repair or replacement and 9063 (2.4%) mitral valve plus CABG. A total of 13 997 (3%) had surgery over the weekend. After covariate adjustment, we found no effect of day of surgery on mortality (P = 0.081), stroke (P = 0.137) and need for postop dialysis (P = 0.732). However, across all operations, there was evidence of a lower rate of return to theatre for bleeding/tamponade at the weekend (P = 0.039). In subgroup analysis of isolated CABG, the day of the week did not affect any outcomes.

CONCLUSIONS

We found no effect of the day of the week on risk-adjusted short-term mortality, stroke, and the requirement for postoperative dialysis after elective cardiac surgery. Overall, the patients operated on during the weekdays were less likely to return to theatre for bleeding. In isolated CABG, the day of the week did not affect any outcomes.

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

Background

Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units.

Objectives

To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations.

Design

This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data.

Setting

The setting was acute stroke services in London hyperacute stroke units.

Participants

A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours).

Intervention

Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.

Main outcome measures

Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay.

Data sources

Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period.

Results

We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions.

Limitations

We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled.

Conclusions

Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence.

Future work

Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.

The «Weekday Effect» Does Not Have an Impact on the Development of Complications or Mortality After Pulmonary Resection: Retrospective Cohort Study

OBJECTIVE

To determine whether elective anatomic pulmonary resection surgery carried out at the end of the week is associated with a higher mortality and postoperative morbidity than surgery performed at the beginning of the week.

METHOD

Historical cohort study. All patients undergoing anatomical pulmonary resection between January 2013 and November 2018 in our center were included. Patients operated at the end of the week (Thursday or Friday) were considered «not exposed» and patients operated at the beginning of the week (Monday, Tuesday or Wednesday) were considered «exposed». The likelihood of cardiorespiratory complications and operative death (30days) was compared in the two cohorts calculated using the Eurolung1 and2 risk models. 30-day mortality and the occurrence of cardiorespiratory and technical complications were studied as outcome variables. The incidence of these adverse effects was calculated for the overall series and for both cohorts, and the relative risk (RR) and its 95% confidence interval (95%CI) were determined.

RESULTS

The overall mortality of the series was 0.9% (10/1172), the incidence of cardiorespiratory complications was 10.2% (120/1172) and that of technical complications was 20.6% (242/1172). The RR calculated for cardiorespiratory, technical complications and mortality in exposed and unexposed subjects was: 0.914 (95%CI: 0.804-1.039), 0.996 (95%CI: 0.895-1.107) and 0.911 (95%CI: 0.606-1.37), respectively.

CONCLUSIONS

Patients operated at the end of the week do not present a higher risk of postoperative adverse effects.

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

OBJECTIVES

Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs).

DESIGN

Interview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al).

SETTING

Eight HASUs in London.

PARTICIPANTS

We interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week.

RESULTS

Staff were able to deliver 'front door' interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of 'front door' interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays.

CONCLUSIONS

Evidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for 'front door' interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services.

Weekend admissions and mortality for major acute disorders across England and Wales: record linkage cohort studies

Background

To establish which major disorders are susceptible to increased mortality following acute admissions on weekends, compared with week days, and how this may be explained.

Methods

Cohorts based on national administrative inpatient and mortality data for 14,168,443 hospitalised patients in England and 913,068 in Wales who were admitted for 66 disorders that were associated with at least 200 deaths within 30 days of acute admission. The main outcome measure was the weekend mortality effect (defined as the conventional mortality odds ratio for admissions on weekends compared with week days).

Results

There were large, statistically significant weekend mortality effects (> 20%) in England for 22 of the 66 conditions and in both countries for 14. These 14 were 4 of 13 cancers (oesophageal, colorectal, lung and lymphomas); 4 of 13 circulatory disorders (angina, abdominal aortic aneurysm, peripheral vascular disease and arterial embolism & thrombosis); one of 8 respiratory disorders (pleural effusion); 2 of 12 gastrointestinal disorders (alcoholic and other liver disease); 2 of 3 ageing-related disorders (Alzheimer’s disease and dementia); none of 7 trauma conditions; and one of 10 other disorders (acute renal failure). Across the disorders, 64% of the variation in weekend mortality effects in England and Wales was explained by reductions in admission rates at weekends and the medical disease category.

Conclusions

The effect of weekend admission on 30 day mortality is seen mainly for cancers, some circulatory disorders, liver disease and a few other conditions which are mainly ageing- or cancer-related. Most of the increased mortality is associated with reduced admission rates at weekends and the medical disease category.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4286-8) contains supplementary material, which is available to authorized users.

Do variations in hospital admission rates bias comparisons of standardized hospital mortality rates? A population-based cohort study

BACKGROUND

Standardized mortality rates are routinely used as measures of hospital performance and quality. Such metrics may, however, be biased if hospital admission thresholds differ and patient severity is not fully measured.

AIM

To examine whether comparisons of hospital mortality rates suffer from selection bias due to variations in hospital admission rates, using the example of variations by day of the week.

DATA

12,900,687 emergency department attendances and 3,418,446 unplanned admissions to all acute non-specialist hospitals of the National Health Service in England between 1 April 2013 and 28 February 2014.

METHODS

Population-based retrospective cohort study. Mortality within 30 days of attendance is modelled as a function of weekend or weekday attendance and hospital-level predictors of admission rates using patient-level risk-adjusted probit and bivariate Heckman selection models. Robustness is supported by the use of different hospital-level predictors.

RESULTS

When examining only the admitted population, patients admitted to hospital at weekends have a 0.206 percentage point higher risk of death within 30 days compared to patients admitted during the week. However, patients attending emergency departments at weekends have a 1.390 percentage point lower probability of being admitted to hospital. Once this selection bias is accounted for, the weekend effect in mortality is reduced by two-thirds to a 0.068 percentage point increase in the risk of death.

CONCLUSIONS

Comparisons of standardized hospital mortality rates following unplanned admissions can be biased by variations in emergency department admission rates, leading to incorrect conclusions about quality. The use of mortality as a performance measure could therefore lead to misleading comparisons if admission rates vary and illness severity is not fully controlled for. Accounting for sample selection bias and dependence between admission and mortality rates is vital if accurate comparisons of hospital performance are to be made.

Examining the weekend effect across ICU performance metrics

BACKGROUND

Known colloquially as the "weekend effect," the association between weekend admissions and increased mortality within hospital settings has become a highly contested topic over the last two decades. Drawing interest from practitioners and researchers alike, a sundry of works have emerged arguing for and against the presence of the effect across various patient cohorts. However, it has become evident that simply studying population characteristics is insufficient for understanding how the effect manifests. Rather, to truly understand the effect, investigations into its underlying factors must be considered. As such, the work presented in this manuscript serves to address this consideration by moving beyond identification of patient cohorts to examining the role of ICU performance.

METHODS

Employing a comprehensive, publicly available database of electronic medical records (EMR), we began by utilizing multiple logistic regression to identify and isolate a specific cohort in which the weekend effect was present. Next, we leveraged the highly detailed nature of the EMR to evaluate ICU performance using well-established ICU quality scorecards to assess differences in clinical factors among patients admitted to an ICU on the weekend versus weekday.

RESULTS

Our results demonstrate the weekend effect to be most prevalent among emergency surgery patients (OR 1.53; 95% CI 1.19, 1.96), specifically those diagnosed with circulatory diseases (P<.001). Differences between weekday and weekend admissions for this cohort included a variety of clinical factors such as ventilatory support and night-time discharges.

CONCLUSIONS

This work reinforces the importance of accounting for differences in clinical factors as well as patient cohorts in studies investigating the weekend effect.

Is there a "weekend effect" in emergency general surgery?

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.

Off-hours presentation is associated with short-term mortality but not with long-term mortality in patients with ST-segment elevation myocardial infarction: A meta-analysis

BACKGROUND

The association between off-hours presentation and mortality in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. We performed a meta-analysis to assess the impact of off-hours presentation on short- and long-term mortality among STEMI patients.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library from their inception to 10 July 2016. Studies were eligible if they evaluated the relationship of off-hours (weekend and/or night) presentation with short- and/or long-term mortality.

RESULTS

A total of 30 studies with 33 cohorts involving 192,658 STEMI patients were included. Off-hours presentation was associated with short-term mortality (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12, P = 0.004) but not with long-term mortality (OR 1.00, 95% CI 0.94-1.07, P = 0.979). No significant heterogeneity was observed. The outcomes remained the same after sensitivity analyses and trim and fill analyses. Subgroup analyses showed that STEMI patients undergoing primary percutaneous coronary intervention do not have a higher risk of short-term mortality (OR 1.061, 95% CI 0.993-1.151). In addition, higher mortality was observed only during hospitalization (OR 1.072, 95% CI 1.022-1.125), not at the 30-day, 1-year or long-term follow-ups.

CONCLUSIONS

Off-hours presentation was associated with an increase in short-term mortality, but not long-term mortality, among STEMI patients. Clinical approaches to decrease short-term mortality regardless of the time of presentation should be evaluated in future studies.

Elevated mortality among weekend hospital admissions is not associated with adoption of seven day clinical standards

INTRODUCTION

Patients admitted to hospital in an emergency at weekends have been found to experience higher mortality rates than those admitted during the week. The National Health Service (NHS) in England has introduced four priority clinical standards for emergency hospital care with the objective of reducing deaths associated with this 'weekend effect'. This study aimed to determine whether adoption of these clinical standards is associated with the extent to which weekend mortality is elevated.

METHODS

We used publicly available data on performance against the four priority clinical standards in 2015 and estimates of Trusts' weekend effects between 2013/2014 and 2015/2016 for 123 NHS Trusts in England. We examined whether adoption of the priority clinical standards was associated with the extent to which weekend mortality was elevated, and changes over a 3 year period in the extent to which mortality was elevated.

RESULTS

Levels of achievement of two of the four clinical standards (ongoing review and access to diagnostic services) had small positive associations with the magnitude of the weekend effect in 2015/2016. Levels of achievement of the remaining two standards (time to first consultant review and access to consultant directed interventions) had small negative associations with the magnitude of the weekend effect in 2015/2016. No association was statistically significant. The same pattern was observed in the associations between achievement of the standards and changes in the magnitudes of the weekend effect between 2013/2014 and 2015/2016.

DISCUSSION

We found no association between Trusts' performance against any of the four standards and the current magnitude of their weekend effects, or the change in their weekend effects over the past 3 years. These findings cast doubt on whether adoption of seven day clinical standards in the delivery of emergency hospital services will be successful in reducing the weekend effect.

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

Background

Patients admitted to hospital outside normal working hours suffer higher complication and mortality rates than patients admitted at times when the hospital is fully operational. This ‘weekend effect’ is well described but poorly understood. It is not clear whether or not the effect extends to other out-of-hours periods, or how far excess mortality for out-of-hours admissions reflects a different presenting population with higher severity of illness and how much is explained by poorer availability and quality of services.

Objectives

We aimed to assess (1) the costs and benefits of introducing 7-day services, (2) whether or not mortality rates are elevated during all out-of-hours periods, (3) whether or not selection of more severely ill patients for admission out of hours explains elevated mortality rates and (4) whether or not mortality rates out of hours are related to staffing levels.

Methods

We conducted a series of retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. For the national studies, we analysed emergency admissions to all 140 non-specialist acute hospital trusts in England between April 2013 and February 2014 (over 12 million accident and emergency attendances and 4.5 million emergency admissions). For the single trust, we analysed emergency admissions between April 2004 and March 2014 (240,000 admissions). Deaths within 30 days of attendance or admission were compared for normal working hours and out-of-hours periods.

Results

We found that, in addition to elevated mortality for weekend admissions, mortality rates are also elevated for patients admitted during night-time periods. Elevated mortality was reduced for stroke patients in a large acute trust when more – and more experienced – nursing staff were present during the first hour of admission. Nationally, we found that excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes when we accounted for severity of patient illness. We also found that the estimated cost of implementing 7-day services exceeds the maximum amount that the National Institute for Health and Care Excellence would recommend the NHS should spend on eradicating excess mortality at weekends.

Limitations

Our results depend on the accuracy and completeness of data recording by hospital staff. If accuracy of recording is related to time of patient admission, our results may be biased. Results based on data from a single trust should be treated as indicative.

Conclusions

In addressing variations in patient outcomes across the week, a more nuanced approach, extending services for key specialties over critical periods – rather than implementing whole-system changes – is likely to be the most cost-effective.

Future work

Future research should aim to develop and use appropriate measures of severity of illness to facilitate meaningful analysis of variations in patient outcomes, and to identify candidate specialties and critical periods for which extending services is likely to be cost-effective.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

People’s experiences of hospital care on the weekend: secondary analysis of data from two national patient surveys

Objective

To determine whether patients treated in hospital on the weekend report different experiences of care compared with those treated on weekdays.

Design

This is a secondary analysis of the 2014 National Health Service (NHS) adult inpatient survey and accident and emergency (A&E) department surveys. Differences were tested using independent samples t-tests and multiple regression, adjusting for patient age group, sex, ethnicity, proxy response, NHS trust, route of admission (for the inpatient survey) and destination on discharge (for the A&E survey).

Setting

The inpatient survey included 154 NHS hospital trusts providing overnight care; the A&E survey 142 trusts with major emergency departments.

Participants

Three cohorts were analysed: patients attending A&E, admitted to hospital and discharged from hospital. From the inpatient survey’s 59 083 responses, 10 382 were admitted and 11 542 discharged on weekends or public holidays. The A&E survey received 39 320 responses, including 11 542 (29.4%) who attended on the weekend or on public holidays. Weekday and weekend attendees’ response rates were similar once demographic characteristics were accounted for.

Main outcome measures

For the A&E survey, six composite dimensions covered waiting times, doctors and nurse, care and treatment, cleanliness, information on discharge, and overall experiences. For the inpatient survey, three questions covered admissions and two dimensions covered information about discharge and about medicines.

Results

People attending A&E on weekends were significantly more favourable about ‘doctors and nurses’ and ‘care and treatment’. Inpatients admitted via A&E on a weekend were more positive about the information given to them in A&E than others. Other dimensions showed no differences between people treated on weekdays or on weekends.

Conclusions

Patients attending emergency departments or admitted to or discharged from an inpatient episode on weekends and public holidays report similar or more positive experiences of care to other patients after adjusting for patient characteristics.

Impact of the level of sickness on higher mortality in emergency medical admissions to hospital at weekends

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.

Validation of the Child HCAHPS survey to measure pediatric inpatient experience of care in Flanders

The recently developed Child HCAHPS provides a standard to measure US hospitals' performance on pediatric inpatient experiences of care. We field-tested Child HCAHPS in Belgium to instigate international comparison. In the development stage, forward/backward translation was conducted and patients assessed content validity index as excellent. The draft Flemish Child HCAHPS included 63 items: 38 items for five topics hypothesized to be similar to those proposed in the US (communication with parent, communication with child, attention to safety and comfort, hospital environment, and global rating), 10 screeners, a 14-item demographic and descriptive section, and one open-ended item. A 6-week pilot test was subsequently performed in three pediatric wards (general ward, hematology and oncology ward, infant and toddler ward) at a JCI-accredited university hospital. An overall response rate of 90.99% (303/333) was achieved and was consistent across wards. Confirmatory factor analysis largely confirmed the configuration of the proposed composites. Composite and single-item measures related well to patients' global rating of the hospital. Interpretation of different patient experiences across types of wards merits further investigation.

CONCLUSION

Child HCAHPS provides an opportunity for systematic and cross-national assessment of pediatric inpatient experiences. Sharing and implementing international best practices are the next logical step. What is Known: • Patient experience surveys are increasingly used to reflect on the quality, safety, and centeredness of patient care. • While adult inpatient experience surveys are routinely used across countries around the world, the measurement of pediatric inpatient experiences is a young field of research that is essential to reflect on family-centered care. What is New: • We demonstrate that the US-developed Child HCAHPS provides an opportunity for international benchmarking of pediatric inpatient experiences with care through parents and guardians. • Our study findings show considerable variation in experiences for types of pediatric services. Support to share good practices and launch quality improvement initiatives can be obtained by organizing regular two-way feedback sessions with clinicians to place the findings in context.

Weekday and Survival After Cardiac Surgery-A Swedish Nationwide Cohort Study in 106 473 Patients

BACKGROUND

The purpose of this study was to investigate the association between weekday of surgery and survival following cardiac surgery.

METHODS AND RESULTS

In a nationwide cohort study, we included all patients who underwent cardiac surgery in 1999-2013 from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register. All-cause mortality until March 2014 was obtained from national registers. The association between weekday of surgery and mortality was estimated using Cox regression, and reported as hazard ratios with 95% CI. We used the restricted mean survival time difference to estimate loss of life related to weekday of surgery. Among 106 473 patients, 25 221 (24%), 24 471 (23%), 22 977 (22%), 20 189 (19%), 9251 (8.7%), and 4364 (4.1%) underwent surgery during a Monday, Tuesday, Wednesday, Thursday, Friday, and a Saturday/Sunday, respectively. More patients were operated on urgently during Friday to Sunday, and unadjusted analyses showed higher early and late mortality in those patients. The adjusted hazard ratios (95% CI) were 1.00 (0.89-1.13), 1.00 (0.88-1.12), 1.02 (0.90-1.16), 1.17 (1.01-1.37), and 1.05 (0.86-1.29) in patients who underwent surgery during a Tuesday, Wednesday, Thursday, Friday, and Saturday/Sunday compared to a Monday, after 1 year of follow-up conditional on 30-day survival. In elective surgery (n=46 146), the 1-year restricted mean survival time difference (95% CI) was -0.5 (-1.8-0.8), -0.5 (-1.9-0.8), -1.0 (-2.6-0.5), 0.02 (-2.2-2.3), and -1.2 (-6.3-3.9) days in patients who underwent surgery during a Tuesday, Wednesday, Thursday, Friday, and a Saturday/Sunday, respectively, compared to a Monday.

CONCLUSIONS

We found no evidence of a clinically relevant weekday effect in patents who underwent cardiac surgery in Sweden during a 15-year period. These data suggest that the early risk and long-term prognosis following cardiac surgery was not affected by the weekday of surgery.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02276950.

Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England

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.

The weekend effect: now you see it, now you don't

New evidence reinforces concerns about the government’s use of evidence