the 'weekend effect': what is the evidence? · 2019. 9. 4. · the 'weekend...

The 'weekend effect': What is the

evidence?

Paul Aylin

Professor of Epidemiology and Public Health

[email protected] Patient

Safety

Translational

Research Centre

1st June 2016

The ‘weekend effect’

• Background

• My work

• Explanations

• Next steps

Freemantle et al.

• Update of their 2012 paper on 2009/10 admissions for 2013/14

• Compared with Wednesday

• Combines elective and emergency admissions

• Choice of disease specific analyses (Oncology and cardiovascular)

• Day of death analysis

Over 100 papers

1. Abougergi MS, Travis AC, Saltzman JR. Impact of day of admission on

mortality and other outcomes in upper GI hemorrhage: a nationwide analysis.

Gastrointest Endosc. 2014 Aug; 80(2): 228-35

http://www.ncbi.nlm.nih.gov/pubmed/24674354

2. Albright KC, Savitz SI, Raman R, Martin-Schild S, Broderick J, Ernstrom K,

Ford A, Khatri R, Kleindorfer D, Liebeskind D, Marshall R, Merino JG, Meyer

DM, Rost N, Meyer BC. Comprehensive stroke centers and the 'weekend

effect': the SPOTRIAS experience. Cerebrovasc Dis. 2012; 34(5-6): 424-9


3. Al-Lawati JA, Al-Zakwani I, Sulaiman K, Al-Habib K, Al Suwaidi J,

Panduranga P, Alsheikh-Ali AA, Almahmeed W, Al Faleh H, Al Saif S, Hersi

A, Asaad N, Al-Motarreb A, Mikhailidis DP, Amin H. Weekend versus

weekday, morning versus evening admission in relationship to mortality in

acute coronary syndrome patients in 6 middle eastern countries: results from

gulf race 2 registry. Open Cardiovasc Med J. 2012; 6: 106-12


4. Ananthakrishnan AN et al. Outcomes of Weekend Admissions for Upper

Gastrointestinal Hemorrhage: A Nationwide Analysis. Clin Gastro Hepatology

2009; 7(3): 296-302.e1 http://www.ncbi.nlm.nih.gov/pubmed/19084483

5. Arabi Y, Alshimemeri A, Taher S.. Weekend and weeknight admissions have

the same outcome of weekday admissions to an intensive care unit with

onsite intensivist coverage. Crit Care Med. 2006 Mar; 34(3): 605-11


6. Aylin P et al. Day of week of procedure and 30 day mortality for elective

surgery: retrospective analysis of hospital episode statistics.. BMJ 2013; 346:

f2424 http://www.ncbi.nlm.nih.gov/pubmed/23716356

7. Aylin P et al. Weekend mortality for emergency admissions. A large,

multicentre study. Qual Saf Health Care 2010; 19(3): 213-217


8. Barba R et al. The impact of weekends on outcome for acute exacerbations of

COPD. ERJ 2012; 39(1): 46-50


9. Barnett MJ et al. Day of the week of intensive care admission and patient

outcomes: a multisite regional evaluation. Med Care 2002; 40(6): 530-9


10. Bejanyan N, Fu AZ, Lazaryan A, Fu R, Kalaycio M, Advani A, Sobecks R,

Copelan E, Maciejewski JP, Sekeres MA. Impact of weekend admissions on

quality of care and outcomes in patients with acute myeloid leukemia Cancer.

2010 Aug 1; 116(15): 3614-20 http://www.ncbi.nlm.nih.gov/pubmed/20564070

11. Béjot Y, Aboa-Eboulé C, Jacquin A, Troisgros O, Hervieu M, Durier J, Osseby

GV, Giroud M. Eur J Neurol. Stroke care organization overcomes the

deleterious 'weekend effect' on 1-month stroke mortality: a population-based

study. 2013 Aug; 20(8): 1177-83


12. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on

weekends as compared with weekdays. N Engl J Med. 2001 Aug 30; 345(9):

663-8 http://www.ncbi.nlm.nih.gov/pubmed/11547721

13. Bell D, Lambourne A, Percival F, Laverty AA, Ward DK. Consultant input in

acute medical admissions and patient outcomes in hospitals in England: a

multivariate analysis PLoS One. 2013 Apr 17; 8(4): e61476


14. Bray B, Cloud GC, James MA, Hemmingway H, Paley L, Stewart K, Tyrrell

PJ, Wolfe CDA, Rudd AG. Weekly variation in health-care quality by day and

time of admission: a nationwide, registry-based, prospective cohort study of

acute stroke care. Lancet 2016; D

15. Bray BD, Ayis S, Campbell J, Cloud GC, James M, Hoffman A, Tyrrell PJ,

Wolfe CD, Rudd AG. Associations between stroke mortality and weekend

working by stroke specialist physicians and registered nurses: prospective

multicentre cohort study. PLoS Med. 2014 Aug 19; 11(8)

http://www.ncbi.nlm.nih.gov/pubmed/25137386?dopt=Abstract

16. Brims FJ, Asiimwe A, Andrews NP, Prytherch D, Higgins BR, Kilburn S,

Chauhan AJ. Weekend admission and mortality from acute exacerbations of

chronic obstructive pulmonary disease in winter. Clin Med. 2011 Aug; 11(4):

334-9 http://www.ncbi.nlm.nih.gov/pubmed/21853828

17. Brims FJ, Asiimwe A, Andrews NP, Prytherch D, Higgins BR, Kilburn S,

Chauhan AJ. Weekend admission and mortality from acute exacerbations of

chronic obstructive pulmonary disease in winter. Clin Med. 2011 Aug; 11(4):

Increased mortality associated with weekend hospital admission: a case for

expanded 7 day services? BMJ 2015;351 :h4596

35. Freemantle, Keogh, Pagano et al. Weekend hospitalization and additional

risk of death: An analysis of inpatient data. N J R Soc Med 2012; 105(2): 74-

84 http://www.ncbi.nlm.nih.gov/pubmed/22307037

36. Gallerani M, Imberti D, Ageno W, Dentali F, Manfredini R. Higher mortality

rate in patients hospitalised for acute pulmonary embolism during weekends.

Thromb Haemost. 2011 Jul; 106(1): 83-9


37. Gellerani M et al. Aortic rupture. Journal of Vascular Surgery. Volume 55,

Issue 5 , Pages 1247-1254, May 2012. Higher mortality in patients

hospitalized for acute aortic rupture or dissection during weekends


38. Goldacre MJ, Maisonneuve JJ. Mortality from meningococcal disease by day

of the week: English national linked database study J Public Health (Oxf).

2013 Sep; 35(3): 413-21 http://www.ncbi.nlm.nih.gov/pubmed/23378233

39. Goldstein SD, Papandria DJ, Aboagye J, Salazar JH, Van Arendonk K, Al-

Omar K, Ortega G, Sacco Casamassima MG, Abdullah F. The "weekend

effect" in pediatric surgery - increased mortality for children undergoing urgent

surgery during the weekend. J Pediatr Surg. 2014 Jul; 49(7): 1087-91.


40. Goodman EK, Reilly AF, Fisher BT, Fitzgerald J, Li Y, Seif AE, Huang YS,

Bagatell R, Aplenc R. Association of weekend admission with hospital length

of stay, time to chemotherapy, and risk for respiratory failure in pediatric

patients with newly diagnosed leukemia at freestanding US children's

hospitals. JAMA Pediatr. 2014 Oct; 168(10): 925-31


41. Groves EM, Khoshchehreh M, Le C, Malik S. Effects of weekend admission

on the outcomes and management of ruptured aortic aneurysms. J Vasc

Surg. 2014 Aug; 60(2): 318-24


42. Hamaguchi S, Kinugawa S, Tsuchihashi-Makaya M, Goto D, Tsutsui H.

Weekend versus weekday hospital admission and outcomes during

hospitalization for patients due to worsening heart failure: a report from

Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).

Heart Vessels. 2014 May; 29(3): 328-35


43. Hamilton P et al. Weekend Birth and Higher Neonatal Mortality: A Problem of

Patient Acuity or Quality of Care? Journal of Obstetric, Gynecologic, &

Neonatal Nursing 2003; 32(6): 724–733


44. Handel EH et al. Weekend admissions as an independent predictor of

mortality: an analysis of Scottish hospital admissions. BMJ Open 2012; 2:

e001789 http://www.ncbi.nlm.nih.gov/pubmed/23135542

45. Hansen KW, Hvelplund A, Abildstrøm SZ, Prescott E, Madsen M, Madsen JK,

Jensen JS, Sørensen R, Galatius S. Prognosis and treatment in patients

admitted with acute myocardial infarction on weekends and weekdays from

1997 to 2009. Int J Cardiol. 2013 Sep 30; 168(2): 1167-73


46. Hixson ED, Davis S, Morris S, Harrison AM. Do weekends or evenings matter

in a pediatric intensive care unit? Pediatr Crit Care Med. 2005 Sep; 6(5): 523-

30. http://www.ncbi.nlm.nih.gov/pubmed/16148810

47. Hoh BL, Chi YY, Waters MF, Mocco J, Barker FG. Effect of weekend

compared with weekday stroke admission on thrombolytic use, in-hospital

mortality, discharge disposition, hospital charges, and length of stay in the

Nationwide Inpatient Sample Database, 2002 to 2007. 2nd. Stroke. 2010 Oct;

41(10): 2323-8 http://www.ncbi.nlm.nih.gov/pubmed/20724715

48. Hong JS et al. Comparison of Case Fatality Rates for Acute Myocardial

Infarction in Weekday vs Weekend Admissions in South Korea. Circulation

Journal 2010; 74(3): 496-502 http://www.ncbi.nlm.nih.gov/pubmed/20075558

49. Horwich TB et al. Weekend hospital admission and discharge for heart failure:

Association with quality of care and clinical outcomes. American Heart

Journal 2009; 158(3): 451-458


50. Ibrahimou B, Salihu HM, English G, Anozie C, Lartey G, Dagne G. Twins born

over weekends: are they at risk for elevated infant mortality? Arch Gynecol

Obstet. 2012 Dec; 286(6): 1349-55

68. O'Neill DE, Southern DA, O'Neill BJ, McMurtry MS, Graham MM. Weekend

compared with weekday presentation does not affect outcomes of patients

presenting with non-ST elevation acute coronary syndrome. Eur Heart J

Acute Cardiovasc Care. 2014 Jun; 3(2): 99-104.


69. Orandi BJ, Selvarajah S, Orion KC, Lum YW, Perler BA, Abularrage CJ.

Outcomes of nonelective weekend admissions for lower extremity ischemia. J

Vasc Surg. 2014 Dec; 60(6): 1572-9


70. Orman ES, Hayashi PH, Dellon ES, Gerber DA, Barritt AS 4th. Impact of

nighttime and weekend liver transplants on graft and patient outcomes. Liver

Transpl. 2012 May; 18(5): 558-65


71. Ozdemir BA, Sinha S, Karthesalingham, Poloniecki J, Pearse RM, Grocott

MPW, Thompson MM, Holt P. Mortality of emergency general surgical

patients and associations with hospital structures and processes. British

Journal of Anaesthesia 2016;116 (1):54-62

72. Palmer W, Bottle A, Aylin P. Association between day of delivery and obstetric

outcomes: observational study. BMJ 2015;351:h5774

73. Palmer WL et al. A Retrospective Cohort Study on the Association Between

Day of Hospital Presentation and the Quality and Safety of Stroke Care. Arch

Neurol 2012; 69(10): 1296-1302


74. Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GC. Time of birth and risk

of neonatal death at term: retrospective cohort study. BMJ 2010;341:c3498.

75. Pederby MA et al. Survival From In-Hospital Cardiac Arrest During Nights

and Weekends. JAMA 2008; 299(7): 785-792


76. Powell ES, Khare RK, Courtney DM, Feinglass J. The weekend effect for

patients with sepsis presenting to the emergency department . J Emerg Med.

2013 Nov;45(5):641-8. doi: 10.1016/j.jemermed.2013.04.042. Epub 2013 Aug

30. http://www.ncbi.nlm.nih.gov/pubmed/23993937

77. Ricciardi R, Nelson J, Roberts PL, Marcello PW, Read TE, Schoetz DJ. Is the

presence of medical trainees associated with increased mortality with

weekend admission? BMC Med Educ. 2014 Jan 8;14:4. doi: 10.1186/1472-

6920-14-4 http://www.ncbi.nlm.nih.gov/pubmed/24397268

78. Robinson E, Smith G, Power S, Harrison D, Nolan J, Soar J, Spearpoint K,

Gwinnutt C, Rowan K. Risk-adjusted survival for adults following in-hospital

cardiac arrest by day of week and time of day: observational cohort study.

BMJ Qual Saf 2015. http://dx.d

79. Ruiz M, Bottle A, Aylin P. The Global Comparators Project: international

comparison of 30 day in-hospital mortality by day of the week. BMJ Quality

and Safety 2015;0:1-13 doi:10.1136/bmjqs-2014-003467

80. Sakhuja A et al. Outcomes of Patients Receiving Maintenance Dialysis

Admitted Over Weekends. Ankit Sakhuja. AJKD 2013; 62(4): 763-770


81. Salihu HM, Ibrahimou B, August EM, Dagne G. Risk of infant mortality with

weekend versus weekday births: a population-based study. J Obstet

Gynaecol Res. 2012 Jul; 38(7): 973-9


82. Saposnik G, Baibergenova A, Bayer N, Hachinski V. Weekends: a dangerous

time for having a stroke? Stroke. 2007 Apr; 38(4): 1211-5


83. Schmid M, Ghani KR, Choueiri TK, Sood A, Kapoor V, Abdollah F, Chun FK,

Leow JJ, Olugbade K Jr, Sammon JD, Menon M, Kibel AS, Fisch M, Nguyen

PL, Trinh QD. An evaluation of the 'weekend effect' in patients admitted with

metastatic prostate cancer. BJU Int. 2014 Aug 7. doi: 10.1111/bju.12891.

[Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/25099032

84. Schmulewitz L, Proudfoot A, Bell D. The impact of weekends on outcome for

emergency patients. Clin Med 2005;5:621e5

85. Schneider EB et al. Beating the weekend trend: Increased mortality in older

adult traumatic brain injury (TBI) patients admitted on weekends. J Surg Res

2012; 177(2): 295-300 http://www.ncbi.nlm.nih.gov/pubmed/22795343

86. Shaheen AA, Kaplan GG, Myers RP. Clin Gastroenterol Hepatol . Weekend

versus weekday admission and mortality from gastrointestinal hemorrhage

caused by peptic ulcer disease. 2009 Mar; 7(3): 303-10

Bell et al. NEJM 2001

• Mortality among patients admitted to hospital on weekends as

compared with weekdays Canadian study, acute care from ER

departments in Ontario, Canada.

• 3.8 million admissions

• Looked at specific conditions (AAA, acute epiglottis, PE, AMI,

Stroke and #NOF) plus the 100 conditions that were the most

common causes of death.

• Significant weekend effect for AAA (OR 1.28), epiglottis (OR

5.47) and PE (OR 1.19), plus 23 out of the 100 leading causes

of death.

• No conditions associated with significantly lower mortality rates

at the weekend.

Bell CM, Redelmeier DA. Mortality among patients admitted to hospital on weekends as

compared with weekdays. N Engl J Med 2001;345:663e8.

Kostis et al. 2007

• Weekend versus weekday admission and mortality from

myocardial infarction

• Acute Myocardial Infarction, all admissions in New Jersey 1987-

2002

• 231,164 admissions

• In the interval from 1999 to 2002 (59,786 admissions), mortality

at 30 days was significantly higher for patients admitted on

weekends (12.9% vs. 12.0%, P = 0.006).

• Persisted at 1 year (1% absolute difference in mortality).

• Associated with lower rate of invasive procedures

Kostis WJ, Demissie K, Marcella SW, et al. Weekend versus weekday admission and mortality

from myocardial infarction. N Engl J Med 2007;356:1099e109

Barba et al. 2006

• Mortality among adult patients admitted to the hospital on

weekends

• All acute admissions to tertiary acute care hospital in Spain

(1999-2003)

• 35,993 hospital admissions

• All in-hospital deaths OR = 1.1, but not significant. Deaths

within 48 hours OR=1.4

Barba R, Losa JE, Velasco M, et al. Mortality among adult patients admitted to the hospital on

weekends. Eur J Intern Med 2006;17:322e4

Imperial Patient

Safety Translational

Research Centre

Other studies

• Hamilton et al found higher weekend neonatal

mortality (OR= 1.42) in Texas 1999-2000.

• Schmulewitz et al found no weekend effect in a single

Scottish hospital

• Wunsch et al used ICNARC to examine 75,621

admissions to 102 ICUs across England, Wales and

NI and found admissions on weekend days (Friday,

Saturday, Sunday) or in the evening/night were

associated with higher odds of crude hospital death,

but this was accounted for by case mix.

Hamilton P, Resttrepo E. Weekend birth and higher neonatal mortality: a problem of patient acuity or quality? J Obstet Gynecol Neonatal Nurs

2003;32:724e33.

Schmulewitz L, Proudfoot A, Bell D. The impact of weekends on outcome for emergency patients. Clin Med 2005;5:621e5.

Wunsch H, Mapstone J, Brady T, et al. Hospital mortality associated with day and time of admission to intensive care units. Intensive Care

Med 2004;30:895e901.

Literature

• Studies finding no effect tend to be smaller, single

hospital studies or based in intensive care

Mikulich et al

• St. James Hospital, Dublin

• 49,337 episodes of inpatient care

• 30 day in-hospital mortality at the weekend

(9.99% vs. 9.0%)

• Wide confidence intervals (small sample)

• Unadjusted OR 1.11 (CI 0.99-1.23)

• Adjusted OR 1.05 (CI 0.88-1.24)

• Entirely consistent with other papers showing

weekend effects

Weekend mortality for emergency admissions

• All emergency admissions in England for 2005/6

• Examined top 50 diagnoses leading to death and all

cause admissions.

• Adjusted for age, sex, socioeconomic deprivation,

comorbidity and diagnosis

• Odds of death were calculated for admissions at the

weekend compared to admissions during the week

Imperial Patient

Safety

Translational

Research Centre

Weekend mortality for emergency admissions

• 4,317,866 admissions with 215,054 in-hospital

deaths

• Crude mortality

• 5.2% for weekend admissions

• 4.9% for weekday admissions

• 17 out of 50 diagnosis groups associated with

significantly higher odds of death (p<0.001) including

stroke (OR 1.13), AMI (OR1.08)

• Overall adjusted odds of death was 10% higher

(OR=1.10, 95% CI 1.08-1.11) in those patients

admitted at the weekend compared with patients

admitted during a weekday (p<0.001)

Results

Limitations

• Multiple statistical tests

• No out of hospital deaths

• Fewer admissions at weekend, so casemix

might be different

Methods

• All acute and specialist English hospitals carrying out

elective surgery over three financial years, from 2008-09 to

2010-11

• Planned operating room planned procedures based on

AHRQ patient safety indicator1

• Exclude day cases

• 30 day post op deaths (including out of hospital deaths

linked to ONS death data)

• Adjusted for age, sex, ethnic group, socio-economic

deprivation, co-morbidities, number of emergency

admissions in the last 12 months, year and procedure risk

quintile

1 Bottle A, Aylin P, 2009, Application of AHRQ patient safety indicators to English hospital data, Quality & Safety in Health

Care, Vol:18, ISSN:1475-3898, Pages:303-308

Results

• 27,582 deaths within 30 days following 4,133,346

inpatient admissions for elective operating room

procedures (6.7 per 1000).

• Compared with Monday, adjusted odds of death

were 44% and 82% higher, respectively, if the

procedures were carried out on Friday (odds ratio

1.44, 95% confidence interval 1.39 to 1.50) or a

weekend (1.82, 1.71 to 1.94)

1 Bottle A, Aylin P, 2009, Application of AHRQ patient safety indicators to English hospital data, Quality & Safety in Health

Care, Vol:18, ISSN:1475-3898, Pages:303-308

Adjusted odds of death and 95% confidence intervals by day of procedure in English

hospitals for 2008-9 to 2010-11. (Crude rate 0.67%)

Aylin P, Alexandrescu R, Jen MH, et al., 2013, Day of week of procedure and 30 day mortality for elective surgery:

retrospective analysis of hospital episode statistics, British Medical Journal, Vol:346, ISSN:1756-1833,

Pages:f2424-f2424

©2013 by British Medical Journal Publishing Group

(exc. day cases and

deliveries)

Discussion

• Not able to use more recent data

• Mortality low for elective procedures (6.7 per 1000)

• Monday benchmark

• Hypothesis that post-op care may have contributed to

mortality• Same picture in 2 day mortality

• Fall in Sunday mortality

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

Mon Tues Wed Thu Fri Sat Sun

OR

an

d 95%

CI

Days of week

Adjusted odds of death and 95% confidence intervals by day of procedure in English hospitals for 2008-9 to 2010-11.

(exc. day cases and deliveries)

Discussion

• Not able to use more recent data

• Mortality low for elective procedures (6.7 per 1000)

• Monday benchmark

• Hypothesis that post-op care may have contributed

to mortality• Same picture in 2 day mortality

• Fall in Sunday mortality

• Are junior consultants more likely to operate on a

Friday?

Proportions of procedures carried out by consultant experience

by day of procedure in English hospitals for 2008-9 to 2010-11.

12 11.7 12.3 12.2 15.5 13.3 12.1

45.5 44.6 45 4546.1 48.5 45.5

42.5 43.7 42.7 42.8 38.4 38.2 42.4

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

0-2 yrs 3-10 yrs ≥ 11 yrs

Ruiz M, Bottle A, Aylin PP, 2015, Exploring the impact of consultants' experience on hospital mortality by day of the week: a retrospective analysis of hospital episode statistics. 2015 BMJ Qual Saf. Published Online First: doi:10.1136/bmjqs-2015-004105

Additional adjustment by consultant experience

• Adjustment makes little difference.

• Friday effect increases from OR = 1.44

to 1.48

Interpretation

• Key is higher mortality on Friday with no

apparent difference in casemix

• 48 hours following surgery

• Frailer patients, with a high burden of

co-morbidity are at higher risk of

mortality at the weekend.

Rapid Response

“…….The biggest increase in mortality in those

operated on over Friday through to Sunday

may perhaps be due to the seemingly

ubiquitous practice of drastically reducing the

number of doctors, in particular junior doctors,

working out of hours and at weekends. A single

foundation year 1 (FY1) doctor may cover a

number of wards, as many as 60-100 patients.

Their immediate senior, the SHO may cover

twice that number or more, and so on up the

ladder.”

Methods

• English patients admitted to hospital with a stroke

(ICD I60-I64) from April 2009 to March 2010

• Look at 6 process and outcome indicators• Brain scan on day of admission

• Thrombolysis treatment

• Aspiration pneumonia

• Seven-day in-hospital mortality

• Discharge to usual place of residence within 56 days

• Thirty day emergency readmission (all cause)

• Adjusted for age, sex, socio-economic deprivation,

previous emergency admissions, co-morbidities,

ethnic group, source of admissions and stroke type.

Results

• 93,621 stroke admissions

• 9.3% died within 7 days, and 17.1% died within

30 days

• 46.5% had same day brain scan

• 2.6% received thrombolysis

• 5.2% had aspiration pneumonia

• 72.6% were discharged to their normal place of

residence

• 11% readmitted within 30 days

Adjusted odds of stroke indicators and 95% CIs weekend

versus weekday, England 2009/10

0.60

0.70

0.80

0.90

1.00

1.10

1.20

1.30

Same dayscanning

Thrombolysis Aspirationpneumonia

7-day in-hospitalmortality

Discharge tousual place of

admissionwithin 56 days

30-dayemergency

readmissionswithin

OR

an

d 9

5%

CI

Association between weekday/weekend delivery and indicators of

quality and safety of care – England 1st April 2010 and 31st March 2012

0.80

0.85

0.90

0.95

1.00

1.05

1.10

1.15

1.20

Perineal tear Puerperalinfection

3-daymaternal

readmission

In-hospitalperinatalmortality

Injury toneonate

Selectedneonatalinfections

3-dayneonatal

rradmissions

Od

ds R

ati

o (9

5%

CI)

Daily trends

Summary

• Babies born at the weekend have an

increased risk of being still born or dying in

hospital within the first 7 days.

• Increased complication rates at weekends,

with higher rates of puerperal infection, injury

to neonate and 3-day neonatal emergency

readmissions

• “No consistent association between outcomes

and staffing was identified”

Indicator Adjusted OR (95%

CI) – original paper Excluding elective caesareans

Adjusting for induction labour

Excluding antenatal stillbirths

Perineal tear 1.00

(0.98 to 1.03)

- 1.00

(0.98 to 1.02)

-

Puerperal infection 1.06

(1.01 to 1.11)

1.05

(1.00 to 1.09)

1.07

(1.02 to 1.12)

-

3-day maternal readmissions

0.93

(0.84 to 1.02)

0.92

(0.83 to 1.02)

0.93

(0.84 to 1.03)

-

In-hospital perinatal mortality

1.07

(1.02 to 1.13)

1.07

(1.02 to 1.12)

- 1.09

(1.02 to 1.16)

Injury to neonate 1.06

(1.02 to 1.09)

1.05

(1.02 to 1.08)

- -

Selected neonatal infections

1.01

(0.98 to 1.04)

1.00

(0.97 to 1.03)

- -

3-day neonatal readmissions

1.04

(1.00 to 1.08)

1.03

(0.99 to 1.07)

- -

Re-analysis following comments

After excluding elective caesareans

Odds of death if born at the weekend compared with weekdays OR = 1.3 (1.0-1.7)

Odds of dying from anoxia at weekend compared with weekdays OR = 1.5 (1.1-2.1)

“About one in four deaths from intrapartum anoxia at term could be prevented if all women attempting vaginal birth had the same risk of this event as women delivering during the normal working week”

What’s the explanation?

• Conflicting evidence?

4,317,866

14,217,640 14,818,374

5,271,327

4,133,346

93,621

1,349,599

49,337 29498758

6,92336,734

1,578

0.8

1

1.2

1.4

1.6

1.8

2

weekend (

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Su

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weekend (

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Weeke

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Friday (

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Weeke

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Str

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Weeke

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Birth

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weekend (

Em

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Weeke

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Aylin 2010(England)

Freemantle 2010(England)


Handel(Scotland)

Aylin 2013 (England) Palmer2012

Palmer2015

Mikulich2010

(Dublin)

Byun 2012(Korea)

Kazley2010 (US)

Kevin 2010(Canada)

Myers2009 (US)

Turin 2008(Japan)

Od

ds/H

azard

/Rate

Rati

o

UK studiesStudies cited for no weekend

effect (all non-UK)

What’s the explanation?

• Conflicting evidence?

• Coding?

• Statistical artefact?

Imperial Patient

Safety

Translational

Research Centre

“His team studied 1,693 stroke hospital admissions and found 638 (38%) were

lower-level incidents that had been put in the wrong category.”

“The new research based on the Oxford Vascular Study - which has been

sent to the British Medical Journal but not published - comes as the BMA

union starts five days of fresh talks over the junior doctors' contract”

Rothwell et al. Administrative classification

Classification

• Hospital admissions

• Elective admissions

• Subdural/extradural haemorrhage

• Inpatient events after emergency

admission

• Inpatient events after elective

admission

• Transfers from hospital

• Episodes?

• Spells?

• Superspells?

Apparent “incorrect coding”

• Only admitted patients

• Elective admissions (293)

• Subdural/extradural haemorrhage (55)

• Inpatient events after emergency

admission (9)

• Inpatient events after elective

admission (39)

• Transfers from hospital (34)

• Admission date wrong (24)

• GP information wrong (20)

• Unknown (12)

• Cancelled admission (15)

4,317,866

14,217,640 14,818,374

5,271,327

4,133,346

93,621

1,349,59949,337 294

987586,923

36,7341,578

1,292

3,715,727

0.6

0.8

1

1.2

1.4

1.6

1.8

2

wee

ken

d (

Emer

gen

cy)

Satu

rday

(A

ll ad

mis

sio

ns)

Sun

day

(A

ll ad

mis

sio

ns)

Satu

rday

(A

ll ad

mis

sio

ns)

Sun

day

(A

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mis

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ns)

wee

ken

d (

Emer

gen

cy)

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ken

d (

Elec

tive

)

Frid

ay (

Ele

ctiv

e)

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d (

Stro

ke)

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d (

Bir

ths)

wee

ken

d (

Emer

gen

cy)

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ken

d (

EVH

)

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ken

d (

Stro

ke)

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ken

d (

Infe

ctio

n)

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ken

d (

EVH

)

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ken

d (

Stro

ke)

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ken

d (

Stro

ke)

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ken

d (

via

A&

E)

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ken

d (

Dir

ect

adm

issi

on

s)

Aylin 2010(England)



Handel(Scotland)

Aylin 2013 (England) Palmer2012

Palmer2015

Mikulich2010

(Dublin)

Byun2012

(Korea)

Kazley2010 (US)

Kevin2010

(Canada)

Myers2009 (US)

Turin2008

(Japan)

Rothwell2016 (UK)

Meacock 2016 (UK)

Od

ds/

Haz

ard

/Rat

e R

atio

UK studies Studies cited for noweekend effect

940,859

Meacock et al.

• Examined A&E attendances as well as admitted

patients.

• “There are fewer deaths following hospital admission

at weekends. “

• “Higher mortality rates at weekends are found only

amongst the subset of patients who are admitted.”

• “Fewer and sicker patients are admitted at weekends

than during the week.”

Imperial Patient

Safety

Translational

Research Centre

Meacock et al.

• Paper shows a higher mortality rate for patients

admitted at the weekend

• True for both admissions via A & E and direct

admissions from the community. In line with previous

work.

• “Fewer and sicker patients are admitted at weekends

than during the week.

• Their own figures suggest patients admitted at

weekend not sicker - younger, fewer co-morbidities

etc.

• A&E attendances - a questionable choice of

denominatorImperial Patient

Safety

Translational

Research Centre

What other explanations are there?

Nursing and outcomes

• “An increase in a nurses' workload by one patient increased the

likelihood of an inpatient dying within 30 days of admission by 7% (odds

ratio 1·068, 95% CI 1·031–1·106), and every 10% increase in

bachelor's degree nurses was associated with a decrease in this

likelihood by 7% (0·929, 0·886–0·973).”

• “These associations imply that patients in hospitals in which 60% of

nurses had bachelor's degrees and nurses cared for an average of six

patients would have almost 30% lower mortality than patients in

hospitals in which only 30% of nurses had bachelor's degrees and

nurses cared for an average of eight patients.”

Conclusions

• “Mortality outcomes after stroke are

associated with the intensity of weekend

staffing by registered nurses but not 7-d/wk

ward rounds by stroke specialist physicians”

• “The findings have implications for quality

improvement and resource allocation in

stroke care”

Summary

• Lots of literature supporting the weekend effect (using

variety of clinical and administrative data)

• Not explained away by casemix or data quality

• Clinical datasets

• Relationships with other factors

• Pattern not just in mortality

• Differences in patterns of care

• Mechanism still unclear

• Failure to rescue?

• Further work required on staffing levels (difficult to

do), and other contributing factors.

• Interventions Imperial Patient

Safety

Translational

Research Centre

• National Cardiac Arrest Audit (NCAA)

• 27,700 in-hospital cardiac arrest

• Odds of survival weekend daytime vs. weekday daytime = 0.72 (0.68-76)

Stroke mortality England 2008-2014

Acknowledgements

Dr Alex Bottle

Prof Derek Bell

Dr Roxana Alexandrescu

Dr William Palmer

Dr Min Hua Jen

Dr Milagros Ruiz

Prof Azeem Majeed

the 'weekend effect': what is the evidence? · 2019. 9. 4. · the 'weekend...

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