The “weekend effect” is a term used to refer to an increase in untoward events or suboptimal outcomes occurring in patients admitted to hospitals over the weekend. In some cases we use the term “after hours effect” since some of the same issues occur in patients admitted at night. We’ve discussed the numerous factors that may contribute to the “weekend effect” in our previous columns:
Now 3 more studies add to the growing list of undesirable outcomes on patients admitted on weekends. One study done in the UK (Palmer 2012) affirmed what has been previously reported in the US and elsewhere: patients admitted with strokes on weekends have higher mortality rates. The adjusted 7-day mortality rate was almost 20% higher in those admitted over the weekend. While the authors cannot exclude the possibility that patients admitted over the weekend might have confounding factors to explain the disparity (eg. they might have more severe strokes), they did identify process measures that indicated probable inferior care on weekends. For example, the rate of patients receiving prompt imaging studies was almost 20% lower in those admitted over the weekend and almost 20% fewer patients received thrombolytic therapy when admitted over the weekend. There was also a trend toward higher rates of aspiration pneumonia in those admitted over the weekend. And the number of patients being discharged to places other than home was higher in those admitted over the weekend. The potential cost implications related to this phenomenon are large.
The second study (Deshmukh 2012) demonstrated patients admitted on weekends with atrial fibrillation (AF) were 24% more likely to die in hospital than those admitted on weekdays. They were substantially less likely to receive cardioversion. Those who were cardioverted had longer lengths to the cardioversion procedure. They also had longer lengths of stay. After adjustment for other factors, the cardioversion issues may have been responsible for both the increased mortality and longer lengths of stay. Interestingly, costs were lower in those admitted on weekends, most likely because of the lower rates of cardioversion. The authors discuss potential contributing factors, including staffing issues, physician cross-coverage issues, and availability of ancillary studies and procedures. They suggest that perhaps an organized model, such as those regionalized programs established for trauma or acute MI, might be developed for patients in atrial fibrillation.
The third study (Worni 2012) looked at outcomes for patients operated upon for diverticulosis on weekends compared to weekdays. Those having the surgery on weekends were less likely to get a primary anastamosis, had increased rates of postsurgical complications, higher likelihood of nonroutine discharge, longer lengths of stay and higher average hospital costs.
Our healthcare systems clearly do not deliver uniform care 24x7. With reduced hospital margins leading to staffing cuts and fewer physicians being “on-call” for patients with whom they are familiar it is unlikely that the “weekend effect” will disappear any time soon. Perhaps the time has come to consider models where patients get selectively directed to true full-service hospitals on weekends. But ensuring that even those hospitals remain truly full-service is likely to be challenging.
Update: Make that 4 articles! Another recent article (Johns Hopkins Medicine 2012) showed that older patients admitted with head trauma on weekends had higher mortality rates (14% higher) than those admitted on weekdays, even when severity of head injury and comorbidities were less. The authors used the HCUP database to identify cases. However, they were unable to determine which type of facility these patients were admitted to. Prior studies have shown that the weekend effect does not usually apply to patients at Level I trauma centers. Many of these patients may have been at facilities with lower levels of trauma care or community hospitals.
Palmer WL, Bottle A, Davie C, et al. Dying for the Weekend. A Retrospective Cohort Study on the Association Between Day of Hospital Presentation and the Quality and Safety of Stroke Care. Arch Neurol 2012; (): 1-7 published online July 9, 2012
Deshmukh A, Pant S, Kumar G, et al. Comparison of Outcomes of Weekend Versus Weekday Admissions for Atrial Fibrillation. Am J Cardiol 2012; 110(2): 208-211
Worni M, Schudel IM, Řstbye T, et al. Worse Outcomes in Patients Undergoing Urgent Surgery for Left-Sided Diverticulitis Admitted on Weekends vs WeekdaysA Population-Based Study of 31 832 Patients. Arch Surg. 2012; 147(7): 649-655
Johns Hopkins Medicine. Weekend Hospital Stays Prove More Deadly Than Other Times for Older People with Head Trauma. Press Release 8/6/2012