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Headline
This study found that the 'weekend effect' was not caused by a lack of consultants in hospitals at weekends but was associated with factors in the community preceding hospital admission.
Abstract
Background:
NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’.
Objectives:
The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness.
Design:
This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics.
Methods:
A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision.
Results:
Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time.
Limitations:
Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time.
Conclusions:
Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care.
Future work:
Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge.
Funding:
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.
Contents
- Plain English summary
- Scientific summary
- Chapter 1. Introduction
- Chapter 2. Methodology and metric development
- Chapter 3. The magnitude and mechanisms of the weekend effect in hospital admissions: a mixed-methods systematic review
- Chapter 4. Cross-sectional and longitudinal 5-year study of weekend–weekday specialist intensity and emergency admission mortality
- Chapter 5. Case-mix differences between weekend and weekday emergency admissions to a large hospital trust
- Chapter 6. Safety and quality of weekend care in hospital: a mixed-methods evaluation
- Chapter 7. Health economics evaluation of increasing the weekend-to-weekday specialist intensity ratio in hospitals in England
- Chapter 8. Discussion
- Acknowledgements
- References
- Appendix 1. Directorate-level questionnaire
- Appendix 2. Comparison of directorate-level questionnaire and point prevalence survey data on specialist hours per 10 emergency admissions for (a) Wednesday and (b) Sunday
- Appendix 3. Characteristics of studies included in the quantitative systematic review reported
- Appendix 4. Results of meta-regressions of the weekend effect on mortality for the quantitative systematic review
- Appendix 5. Within-samples variance function
- Appendix 6. Emergency admissions weekend and weekday, all non-specialists acute trusts in England, 2007/8 to 2017/18
- Appendix 7. (Sequential) analysis of variance of Sunday-to-Wednesday intensity ratio by trust and year (n = 548)
- Appendix 8. Thirty-day post-admission crude and adjusted mortality
- Appendix 9. Risk-adjusted weekend-to-weekday mortality odds ratios
- Appendix 10. (Sequential) analysis of variance of risk-adjusted weekend-to-weekday mortality odds ratio by trust and year (n = 548)
- Appendix 11. Case characteristics: NEWS24 status, ICU24-NEWS24 status, zero length of stay and associated mortality
- Appendix 12. Characteristics in subgroups: stratified by intensive care unit and NEWS status within 24 hours post admission
- Appendix 13. Observation guide, HiSLAC qualitative research (involving interviews, and observations employing elements of an ethnographic approach): round 1
- Appendix 14. Two anonymised case study examples
- Appendix 15. The focus group interview topic guide
- Appendix 16. HiSLAC case record review data collection form
- Appendix 17. Characteristics of study population compared with background population
- Appendix 18. Mean number of errors identified per case note by reviewer
- Appendix 19. Posterior estimate and 95% credible interval of specialist intensity function for each error type by model
- Glossary
- List of abbreviations
- List of supplementary material
About the Series
Declared competing interests of authors: Yen-Fu Chen reports a grant from the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands during the conduct of the study. Michael Clancy reports grants from the NHS during the conduct of the study. Joanne Lord is a member of the National Institute for Health Research (NIHR) Evidence Synthesis Programme Advisory Group (2017–present) and was a member of the NIHR Stakeholder Advisory Group (2015–20).
Article history
The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 12/128/17. The contractual start date was in February 2014. The final report began editorial review in February 2020 and was accepted for publication in October 2020. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.
Last reviewed: February 2020; Accepted: October 2020.
- NLM CatalogRelated NLM Catalog Entries
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