Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis

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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.

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CRD42016036487

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Most cited references 71

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

P Aylin, R Alexandrescu, M. Jen … (2013)

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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Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis

Atsushi Sorita, Adil Ahmed, Stephanie Starr … (2014)

Objective To assess the association between off-hour (weekends and nights) presentation, door to balloon times, and mortality in patients with acute myocardial infarction. Data sources Medline in-process and other non-indexed citations, Medline, Embase, Cochrane Database of Systematic Reviews, and Scopus through April 2013. Study selection Any study that evaluated the association between time of presentation to a healthcare facility and mortality or door to balloon times among patients with acute myocardial infarction was included. Data extraction Studies’ characteristics and outcomes data were extracted. Quality of studies was assessed with the Newcastle-Ottawa scale. A random effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I2. Results 48 studies with fair quality, enrolling 1 896 859 patients, were included in the meta-analysis. 36 studies reported mortality outcomes for 1 892 424 patients with acute myocardial infarction, and 30 studies reported door to balloon times for 70 534 patients with ST elevation myocardial infarction (STEMI). Off-hour presentation for patients with acute myocardial infarction was associated with higher short term mortality (odds ratio 1.06, 95% confidence interval 1.04 to 1.09). Patients with STEMI presenting during off-hours were less likely to receive percutaneous coronary intervention within 90 minutes (odds ratio 0.40, 0.35 to 0.45) and had longer door to balloon time by 14.8 (95% confidence interval 10.7 to 19.0) minutes. A diagnosis of STEMI and countries outside North America were associated with larger increase in mortality during off-hours. Differences in mortality between off-hours and regular hours have increased in recent years. Analyses were associated with statistical heterogeneity. Conclusion This systematic review suggests that patients with acute myocardial infarction presenting during off-hours have higher mortality, and patients with STEMI have longer door to balloon times. Clinical performance measures may need to account for differences arising from time of presentation to a healthcare facility.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2019

Publication date (Electronic): 4 June 2019

Volume: 9

Issue: 6

Electronic Location Identifier: e025764

Affiliations

[1 ] departmentDivision of Health Sciences, Warwick Medical School , University of Warwick , Coventry, UK

[2 ] University Hospitals Birmingham NHS Foundation Trust , Birmingham, UK

[3 ] Worcestershire Acute Hospitals NHS Trust , Worcester, Worcestershire, UK

[4 ] University Hospitals of North Midlands NHS Trust , Stoke-on-Trent, Staffordshire, UK

[5 ] departmentDepartment of Health Sciences , University of Leicester , Leicester, UK

[6 ] departmentUniversity Department of Anaesthesia & Critical Care, Institute of Clinical Sciences , University of Birmingham , Birmingham, UK

[7 ] National Taiwan University Hospital , Taipei, Taiwan

Author notes

[Correspondence to ] Dr Yen-Fu Chen; y-f.chen@ 123456warwick.ac.uk

Article

Publisher ID: bmjopen-2018-025764

DOI: 10.1136/bmjopen-2018-025764

PMC ID: 6561443

PubMed ID: 31164363

SO-VID: c20fae4d-efab-4100-8ff6-9f40a1945f53

License:

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

History

Date received : 08 August 2018

Date revision received : 14 March 2019

Date accepted : 15 April 2019

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ScienceOpen disciplines: Medicine

Keywords: weekend effect,mortality,adverse events,systematic review,bayesian meta-analysis,healthcare databases

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ScienceOpen disciplines: Medicine

Keywords: weekend effect, mortality, adverse events, systematic review, bayesian meta-analysis, healthcare databases

Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis

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SDG 3: Good Health and Well-Being

Most cited references 71

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

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

Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis

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