“Weekend effect” for emergency general surgery has almost disappeared, study shows

The risk of death following emergency admission for general surgery has fallen significantly since 2000 and is no more likely following admission at the weekend than it is following admission midweek, a study published in the British Journal of Surgery has shown.1

Historically there has been a significantly increased risk of death from operations undertaken at the weekend, but that gap had narrowed substantially in recent years to become no longer significant, the results showed.

Researchers analysed data on general surgical admissions to NHS hospitals in the Northern Deanery in England between 2000 and 2014. There were 12 100 in-hospital deaths within 30 days of admission (3.3%), but the mortality rate fell significantly over the study period—from 5.4% in 2000-04 to 2.9% in 2010-14 (P<0.001).

Patients admitted at the weekend did not have a significantly greater risk of death compared with those admitted on a Wednesday (hazard ratio (HR) 1.00 for Saturday and 0.90 for Sunday, versus Wednesday).

Over the entire study period, mortality for operations carried out at the weekend was significantly higher (HR 1.15 for Saturday and 1.40 for Sunday; P=0.021 and P<0.001, respectively), but when the data were looked at more closely they showed that the gap had narrowed and was no longer significant (2000-04, HR 1.46 for Saturday and 1.55 for Sunday; both P<0.001; compared with 2010-14, HR 1.18 for Saturday and 1.12 for Sunday; NS).

The researchers said: “The improvements could potentially be accounted for by the changes in surgical working patterns and the improvements in provision of hospital services that have occurred over the past 15 years. Working patterns have changed following implementation of the European Working Time Directive; junior doctors now work shift patterns. This provides consistent levels of cover for surgical emergency admissions and inpatients throughout the week and weekend. Continuity of care is now provided by consultants.”

They added that it was often assumed that patients admitted at the weekend were sicker and care processes less effective, but that was not confirmed by this study. On the contrary, the data showed that patients admitted at the weekend were significantly younger, and more likely to be male.

“Younger, fitter patients may find it easier to present to health services at the weekend through the emergency department, thus avoiding a delay in presentation that may affect outcomes adversely. This is reinforced by emergency admissions being less sick than GP admissions,” they said. “The elderly were more likely to access emergency care through their GP; reduced access to general practice at the weekend results in a delay in presentation.”

John Abercrombie, consultant general surgeon and spokesperson for the Royal College of Surgeons, said: “This important study shows that the NHS has reduced the death rate from emergency general surgery over the last decade.”

He added: “Significantly, this study challenges the assumption that higher weekend mortality can, in some cases, be explained by people admitted at weekends being sicker. This study shows the opposite to be true in emergency general surgery. It also shows that the weekend effect has diminished over time for emergency general surgery patients in northern England. The NHS needs to see if there are any lessons that can be learnt from this that can be applied in other areas of medicine.”