Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics

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Abstract

Objectives To assess the association between mortality and the day of elective surgical procedure.

Design Retrospective analysis of national hospital administrative data.

Setting All acute and specialist English hospitals carrying out elective surgery over three financial years, from 2008-09 to 2010-11.

Participants Patients undergoing elective surgery in English public hospitals.

Main outcome measure Death in or out of hospital within 30 days of the procedure.

Results There were 27 582 deaths within 30 days after 4 133 346 inpatient admissions for elective operating room procedures (overall crude mortality rate 6.7 per 1000). The number of weekday and weekend procedures decreased over the three years (by 4.5% and 26.8%, respectively). The 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) compared with Monday.

Conclusions The study suggests a higher risk of death for patients who have elective surgical procedures carried out later in the working week and at the weekend.

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Effects of weekend admission and hospital teaching status on in-hospital mortality.

Peter Cram, Stephen L Hillis, Mitchell Barnett … (2004)

The effect of reduced hospital staffing during weekends on in-hospital mortality is not known. We compared mortality rates between patients admitted on weekends and weekdays and whether weekend-weekday variation in rates differed between patients admitted to teaching and nonteaching hospitals in California. The sample comprised patients admitted to hospitals from the emergency department with any of 50 common diagnoses (N = 641,860). Mortality between patients admitted on weekends and those admitted on weekdays (the "weekend effect") was compared. The magnitude of the weekend effect was also compared among patients admitted to major teaching, minor teaching, and nonteaching hospitals. The adjusted odds of death for patients admitted on weekends when compared with weekdays was 1.03 (95% confidence interval [CI]: 1.01 to 1.06; P = 0.0050). Three diagnoses (cancer of the ovary/uterus, duodenal ulcer, and cardiovascular symptoms) were associated with a statistically significant weekend effect. None of the 50 diagnoses demonstrated a statistically significant reduction in mortality for weekend admissions as compared with weekday admissions. Mortality was similar among patients admitted to major (odds ratio [OR] = 1.06; 95% CI: 0.94 to 1.19) and minor (OR = 1.03; 95% CI: 0.97 to 1.09) teaching hospitals, compared with nonteaching hospitals. However, the weekend effect was larger in major teaching hospitals compared with nonteaching hospitals (OR =1.13 vs. 1.03, P = 0.03) and minor teaching hospitals (OR = 1.05, P = 0.11). Patients admitted to hospitals on weekends experienced slightly higher risk-adjusted mortality than did patients admitted on weekdays. While overall mortality was similar for patients admitted to all hospital categories, the weekend effect was larger in major teaching hospitals and is cause for concern.

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Mortality after nonemergent major surgery performed on Friday versus Monday through Wednesday.

R. C. W. Henderson, Kamal Itani, Tracy Schifftner … (2007)

To determine whether nonemergent major surgery leads to higher mortality when performed on Friday versus early weekdays. Adults admitted emergently to acute-care hospitals on weekends experience higher mortality than those admitted on weekdays. Cohort study of 188,212 patients undergoing nonemergent major surgery at 124 Veterans Affairs hospitals from 2000 to 2004. Risk-adjusted 30-day mortality was compared for operations performed on Fridays versus Mondays through Wednesdays. Data were derived from the Veterans Affairs' National Surgical Quality Improvement Program database. Patients were divided into 3 groups: floor (admitted postoperatively to regular floor), ICU (admitted postoperatively to intensive care unit), and outpatient (not admitted postoperatively). A stepwise logistic regression analysis was used to test the effect of day of surgery (Friday vs. Monday-through-Wednesday) on 30-day mortality in the presence of characteristics that were significant in bivariate analysis. In the floor group (n = 89,786), operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through Wednesdays (2.94% vs. 2.18%; odds ratio, 1.36; 95% confidence interval, 1.24-1.49; P < 0.001). After adjusting for patient characteristics, odds ratio of 30-day mortality for operations on Fridays, when compared with Mondays through Wednesdays, was 1.17 (95% confidence interval, 1.05-1.26; P = 0.003). Within the ICU (n = 14,271) and outpatient (n = 84,155) groups, nonsignificant differences in 30-day mortality were observed for operations on Fridays versus Mondays through Wednesdays. For patients admitted to regular hospital floors after nonemergent major surgery, mortality is increased if surgery is performed on Friday versus Monday through Wednesday.

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Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency setting: a retrospective database study of national health service hospitals in England

Mohammed Mohammed, Khesh Sidhu, Gavin Rudge … (2012)

Background Although acute hospitals offer a twenty-four hour seven day a week service levels of staffing are lower over the weekends and some health care processes may be less readily available over the weekend. Whilst it is thought that emergency admission to hospital on the weekend is associated with an increased risk of death, the extent to which this applies to elective admissions is less well known. We investigated the risk of death in elective and elective patients admitted over the weekend versus the weekdays. Methods Retrospective statistical analysis of routinely collected acute hospital admissions in England, involving all patient discharges from all acute hospitals in England over a year (April 2008-March 2009), using a logistic regression model which adjusted for a range of patient case-mix variables, seasonality and admission over a weekend separately for elective and emergency (but excluding zero day stay emergency admissions discharged alive) admissions. Results Of the 1,535,267 elective admissions, 91.7% (1,407,705) were admitted on the weekday and 8.3% (127,562) were admitted on the weekend. The mortality following weekday admission was 0.52% (7,276/1,407,705) compared with 0.77% (986/127,562) following weekend admission. Of the 3,105,249 emergency admissions, 76.3% (2,369,316) were admitted on the weekday and 23.7% (735,933) were admitted on the weekend. The mortality following emergency weekday admission was 6.53% (154,761/2,369,316) compared to 7.06% (51,922/735,933) following weekend admission. After case-mix adjustment, weekend admissions were associated with an increased risk of death, especially in the elective setting (elective Odds Ratio: 1.32, 95% Confidence Interval 1.23 to 1.41); vs emergency Odds Ratio: 1.09, 95% Confidence Interval 1.05 to 1.13). Conclusions Weekend admission appears to be an independent risk factor for dying in hospital and this risk is more pronounced in the elective setting. Given the planned nature of elective admissions, as opposed to the unplanned nature of emergency admissions, it would seem less likely that this increased risk in the elective setting is attributable to unobserved patient risk factors. Further work to understand the relationship between weekend processes of care and mortality, especially in the elective setting, is required.

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Author and article information

Contributors

P Aylin: Role: clinical reader in epidemiology and public health

R Alexandrescu: Role: research associate

M H Jen: Role: research associate

E K Mayer: Role: Walport clinical lecturer

A Bottle: Role: senior lecturer in medical statistics

Journal

Journal ID (nlm-ta): BMJ

Journal ID (iso-abbrev): BMJ

Journal ID (publisher-id): bmj

Title: BMJ : British Medical Journal

Publisher: BMJ Publishing Group Ltd.

ISSN (Print): 0959-8138

ISSN (Electronic): 1756-1833

Publication date Collection: 2013

Publication date (Print): 2013

Publication date (Electronic): 28 May 2013

Volume: 346

Electronic Location Identifier: f2424

Affiliations

[1 ]Dr Foster Unit at Imperial College, Department of Primary Care and Public Health, School of Public Health, Imperial College, London W6 8RP, UK

[2 ]Department of Surgery and Cancer, St Mary’s Hospital, Imperial College, London W2 1NY, UK

Author notes

Correspondence to: P Aylin p.aylin@ 123456imperial.ac.uk

Article

Publisher ID: aylp008875

DOI: 10.1136/bmj.f2424

PMC ID: 3665889

PubMed ID: 23716356

SO-VID: b6323649-cf66-432e-944d-16ce32eced74

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/.

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Date accepted : 04 April 2013

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Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics

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Most cited references 14

Effects of weekend admission and hospital teaching status on in-hospital mortality.

Mortality after nonemergent major surgery performed on Friday versus Monday through Wednesday.

Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency setting: a retrospective database study of national health service hospitals in England

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