Research and analysis

Research into 'the weekend effect' on patient outcomes and mortality

Published 30 October 2015

Applies to England

Over the last decade, an increasing number of research studies have examined the association between weekend hospital admissions and poorer patient outcomes including higher rates of mortality. There is significant evidence demonstrating this ‘weekend effect’.

A range of potential causal links for the weekend effect have been identified; one of these is the availability of staff and services at weekends. It remains unclear how many deaths are avoidable. While further evidence on the causal relationships would be of value, we do not think that this can be a justification for taking no action where there are good clinical reasons for doing so.

This government is committed to raising the quality of care for patients. So we have prioritised action on urgent and emergency care and on consultant cover as part of the move towards a 7 day NHS.

The government is seeking to reduce the deaths associated with the ‘weekend effect’ by introducing 4 priority clinical standards for hospital care, both for patients admitted in an emergency at weekends and for those already in hospital at weekends.

The most important research, papers and reviews in this area are highlighted below.

1. Freemantle et al (2015)

Freemantle et al (2015) Increased mortality associated with weekend hospital admission: a case for expanded 7 day services, BMJ

Independent research that analysed 2013 to 2014 hospital episodes statistics (HES) data found:

• although there are fewer hospital admissions at weekends, patients who are admitted on Saturday and Sunday are sicker and face an increased likelihood of death within 30 days, even when severity of illness is taken into account
• patients admitted on a Sunday have a 15% greater risk of mortality compared to those admitted on Wednesday
• patients admitted on a Saturday have a 10% greater risk of mortality compared to those admitted on a Wednesday
• there are around 11,000 excess deaths in hospitals every year among patients admitted on a Friday, Saturday, Sunday or Monday compared with other days of the week. The authors included the effect of Fridays and Mondays as ‘appropriate support services in hospitals are usually reduced from late Friday through the weekend, leading to disruption on Monday morning’
• oncology patients admitted on a Sunday have a 29% increased risk of death compared to those admitted on a Wednesday
• patients with cardiovascular disease admitted on a Sunday have a 20% increased risk of death compared to those admitted on a Wednesday

The study concluded that it is not possible to determine how many of the excess deaths were avoidable, but that the statistic is ‘not otherwise ignorable’ and ‘raises challenging questions about reduced service provision at weekends’.

2. Ruiz et al

Ruiz et al (2015) The Global Comparators Project: international comparison of 30 day in-hospital mortality by day of the week, BMJ Quality and Safety

The Global Comparators dataset collects inpatient records across 50 hospitals in 10 countries. Analysis of a sub-sample of this data (28 hospitals across England, Australia, USA and Netherlands) for emergency admissions showed:

• there is an overall 30-day crude mortality rate of 3.9%; the English hospitals had the highest crude morality rate (4.6%); crude mortality rates for the English, Dutch and USA hospitals were higher at weekends compared with weekdays
• emergency patients in the English, USA and Dutch hospitals showed a significantly higher adjusted risk of death within 30 days following admission on a Saturday or Sunday compared with admission on a Monday

This study did not show a difference in mortality within 30 days for patients admitted at weekends in Australian hospitals. However, when analysing mortality within 7 days, the Australian hospitals showed 12% higher risk of death when admitted on a Saturday compared to a Monday, and 11% higher risk of death following a Sunday admission.

3. East Midlands Clinical Senate

East Midlands Clinical Senate (2014), 7 Day Services Project: Acute Collaborative Report

Ten East Midlands acute trusts undertook a data gathering exercise to look at current provision against the 10 clinical standards for urgent and emergency care that underpin consistently high quality care 7 days a week.

The report found that:

• there is more to do for all trusts to meet the 10 clinical standards, or all of the 4 priority standards, with current performance rated as amber overall
• there is a potential need for network arrangements between trusts to ensure 7 day access to quality care, such as by developing a larger pool of clinicians in specific specialities or services
• while services will need to be redesigned to ensure the availability of workforce, a more fundamental culture shift is also needed to embrace the necessity to provide necessary services across 7 days

4. NHS services, 7 days a week

NHS services, 7 days a week forum (2013)

NHS England’s NHS Services, Seven Days a Week Forum was a clinically-led process which included an extensive review of the published literature alongside analysis of HES data to explore patient outcomes at weekends compared to during the week.

The review found that:

• there is significant variation in patient outcomes for those admitted as an emergency. This variation is seen in patient experience, mortality rates, length of hospital stay and re-admission rates
• there is a large body of evidence associating timely consultant input to patient care with improved outcomes
• radiology and endoscopy are examples of key interventions which are a time critical response to an urgent or emergency need, however, service provision is shown to be highly variable, particularly at weekends
• consultant-delivered ward rounds are a central pillar for patient care. However, reduced weekend service levels mean many hospitals do not meet national recommendations for twice daily consultant ward rounds

5. Freemantle et al (2012)

Freemantle et al (2012), Weekend hospitalisation and additional risk of death: an analysis of inpatient data, J R Soc Med

Analysis of 2009 to 2010 HES data found:

• patients admitted to hospital on a Sunday had a 16% greater risk of death within 30 days compared to those admitted on a Wednesday
• patients admitted on a Saturday had an 11% increased risk of death within 30 days compared to those admitted on a Wednesday
• day of admission was associated with increased risk of death in 7 of the 10 most common CCS groups (clinical conditions), for example:
  • patients admitted on a Sunday with acute and unspecified renal failure had a 37% increased risk of death compared with those admitted on a Wednesday
  • patients admitted on a Sunday with acute myocardial infarction had an 11% increased risk of death compared to those admitted on a Wednesday

6. AoMRC (2012)

AoMRC (2012), 7 day consultant present care

In light of evidence demonstrating less favourable patient outcomes at weekends compared to weekdays, the Academy of Medical Royal Colleges presented proposals for achieving parity for inpatient care throughout the week.

The report described:

• most hospitals and specialities already provide a non-resident consultant-led on-call rota which should ensure acutely unwell or deteriorating patients have access to consultants and timely interventions. However, in the absence of daily ‘planned’ consultant review, the remainder of the patient’s care pathway is often put into hibernation particularly over weekends, resulting in delays in diagnosis, investigation, treatment and discharge from hospital
• it is not uncommon for patients whose condition is not deteriorating to wait until the next scheduled weekday review before being seen by a consultant. For example, a patient who is admitted on a Thursday night will usually be seen by a consultant on Friday morning, but may then wait until Monday for their next scheduled consultant review
• the weekend effect is very likely attributable to deficiencies in care processes linked to the absence of skilled and empowered senior staff in a system which is not configured to provide full diagnostic and support services 7 days a week
• following discharge from acute areas to general wards the frequency of consultant review falls significantly The result is that departures from the care pathway are not uncommon, and are not detected in a timely manner
• the most effective way to improve outcomes for patients admitted to hospital at weekends is to ensure that care is delivered by adequately supported consultants and monitored during care pathways

7. Aylin et al (2010)

Aylin et al (2010), Weekend mortality for emergency admissions: a large multicentre study, BMJ Quality and Safety

This was one of the first, large scale studies of English data to explore weekend mortality rates for emergency admissions.

Using the data for financial year 2005 to 2006, the study found:

• crude mortality rates are higher for patients admitted at weekends compared to weekdays (5.2% for all weekend admissions; 4.9% for all weekday admissions; overall crude mortality rate: 5.0%)
• there is a 10% higher risk of death for patients admitted as an emergency at the weekend compared with those admitted on a weekday
• there may be a possible 3,369 excess deaths occurring at the weekend compared to weekdays (equivalent to a 7% higher risk of death)

In addition to the evidence of weekend hospital admissions resulting in poorer patient outcomes including higher rates of mortality, there is also some evidence that trainee healthcare staff are also affected by existing weekend practices. A reduction in available senior support at the weekend can lead to an ineffective use of time to support training and improve skills for the benefit of patients and staff. As discussed in the report below.

8. Professor Sir John Temple (2010)

Professor Sir John Temple (2010), Time for training

This report reviewed the impact of the European Working Time Directive (EWTD) on quality of training for doctors, dentists, healthcare scientists and pharmacists.

The report found:

• rigid, poorly designed rotas can result in trainees being unsupported and unsupervised
• splitting services into elective and emergency can enhance training, deliver EWTD-compliant rotas and improve quality of care. Elective work is relatively time driven and proactive and provides good speciality training. By contrast, emergency work is variable over 24 hours (but with predictable peaks) and can provide valuable training but is often not maximised as many trainees are unsupported and poorly supervised
• there is little support for extending hours or lengthening training programmes. This can perpetuate the situation of staff on specialty training programmes not using the hours effectively for training, which can lead to trainees providing the frontline services out of hours, unsupported and without direct supervision