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Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study

Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study
Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study
Background: Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service.

Methods: Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defined specialist intensity at each trust as the self-reported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for financial year 2013–14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile.

Findings: 127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34?350 clinicians surveyed, 15?537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 [11%]) than on Wednesday (6105 [42%]). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5·74 h [SD 3·39] vs 3·97 h [3·31]); however, the median specialist intensity on Sunday was only 48% (IQR 40–58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0·7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1·10, 95% CI 1·08–1·11; p<0·0001). There was no significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r ?0·042; p=0·654).

Interpretation: This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing.

Funding: National Institute for Health Research Health Services and Delivery Research Programme.
0140-6736
178-186
Aldridge, Cassie
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Bion, Julian
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Boyal, Amunpreet
52349e3f-efb1-4f29-b620-95e23379acc2
Chen, Yen-Fu
2cdacb26-d432-4ba5-acfd-e0d88879a7d9
Clancy, Mike
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Evans, Tim
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Girling, Alan
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Lord, Joanne
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Mannion, Russell
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Rees, Peter
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Roseveare, Chris
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Rudge, Gavin
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Sun, Jianxia
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Tarrant, Carolyn
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Temple, Mark
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Watson, Sam
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Lilford, Richard
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Aldridge, Cassie
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Bion, Julian
57c7fc1a-5a87-48d1-b4dd-748a9d8c76e7
Boyal, Amunpreet
52349e3f-efb1-4f29-b620-95e23379acc2
Chen, Yen-Fu
2cdacb26-d432-4ba5-acfd-e0d88879a7d9
Clancy, Mike
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Evans, Tim
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Girling, Alan
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Lord, Joanne
fd3b2bf0-9403-466a-8184-9303bdc80a9a
Mannion, Russell
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Rees, Peter
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Roseveare, Chris
0538c527-d647-409e-ae74-533e4ef48188
Rudge, Gavin
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Sun, Jianxia
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Tarrant, Carolyn
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Temple, Mark
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Watson, Sam
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Lilford, Richard
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Aldridge, Cassie, Bion, Julian, Boyal, Amunpreet, Chen, Yen-Fu, Clancy, Mike, Evans, Tim, Girling, Alan, Lord, Joanne, Mannion, Russell, Rees, Peter, Roseveare, Chris, Rudge, Gavin, Sun, Jianxia, Tarrant, Carolyn, Temple, Mark, Watson, Sam and Lilford, Richard (2016) Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. The Lancet, 388 (10040), 178-186. (doi:10.1016/S0140-6736(16)30442-1).

Record type: Article

Abstract

Background: Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service.

Methods: Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defined specialist intensity at each trust as the self-reported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for financial year 2013–14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile.

Findings: 127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34?350 clinicians surveyed, 15?537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 [11%]) than on Wednesday (6105 [42%]). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5·74 h [SD 3·39] vs 3·97 h [3·31]); however, the median specialist intensity on Sunday was only 48% (IQR 40–58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0·7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1·10, 95% CI 1·08–1·11; p<0·0001). There was no significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r ?0·042; p=0·654).

Interpretation: This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing.

Funding: National Institute for Health Research Health Services and Delivery Research Programme.

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e-pub ahead of print date: 10 May 2016
Published date: 9 July 2016
Organisations: Faculty of Medicine

Identifiers

Local EPrints ID: 402786
URI: https://eprints.soton.ac.uk/id/eprint/402786
ISSN: 0140-6736
PURE UUID: a6be5ee4-5948-4a6c-ab1d-60be793f656d
ORCID for Joanne Lord: ORCID iD orcid.org/0000-0003-1086-1624

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Date deposited: 15 Nov 2016 14:29
Last modified: 19 Jul 2019 00:34

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Contributors

Author: Cassie Aldridge
Author: Julian Bion
Author: Amunpreet Boyal
Author: Yen-Fu Chen
Author: Mike Clancy
Author: Tim Evans
Author: Alan Girling
Author: Joanne Lord ORCID iD
Author: Russell Mannion
Author: Peter Rees
Author: Chris Roseveare
Author: Gavin Rudge
Author: Jianxia Sun
Author: Carolyn Tarrant
Author: Mark Temple
Author: Sam Watson
Author: Richard Lilford

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