New evidence of worse outcomes for weekend patients reignites call for seven day hospital services

Patients admitted to hospital at the weekend are significantly more likely to die within 30 days than those admitted during the week, concludes a study that has led to renewed calls for the NHS to provide true seven day access.

The comprehensive study, published in the Journal of the Royal Society of Medicine, analysed all 14.2 million admissions to NHS hospitals in England between April 2009 and March 2010, during which time there were 187 337 in-hospital deaths within 30 days of admission (doi:10.1258/jrsm.2012.120009). A supportive analysis found a total of 284 852 deaths within 30 days, whether in or out of hospital.

The study took into account diagnosis, comorbidities, admission history, age, sex, ethnicity, deprivation, seasonality, day of admission, and hospital trust.

For every 100 deaths within 30 days of patients admitted to hospital on a Wednesday, the study found that there would be 116 deaths of patients admitted on a Sunday (95% confidence interval 114 to 118; P<0.0001). However, the study also found that the likelihood of patients dying in hospital is less at the weekend than during the week. For every 100 deaths of patients in hospital on a Wednesday, 92 deaths would occur among similar patients already in hospital on a Sunday (95% confidence interval 91 to 94; P<0.0001). The study findings were consistent for emergency and for elective admissions. The authors also found that the findings were consistent with data from 254 academic and not for profit hospitals in the United States.

The study confirms previous reports concerning specific clinical conditions and a recent survey of outcomes published in the Dr Foster 2011 hospital guide (BMJ 2011;343:d7791, doi:10.1136/bmj.d7791).

Its lead researcher, Domenico Pagano, of the quality and outcomes research unit of the University Hospitals Birmingham NHS Foundation Trust, said, “Previous reports, however, have not accounted for differences in patient characteristics associated with admissions on different days.”

Professor Pagano said that a number of factors might be associated with the greater risk of death for patients admitted at weekends. Patients admitted during the weekend will include those patients who would otherwise, had they been less ill, have had their admissions postponed until a weekday. At the weekend there may be reduced or altered staffing and skill mix, with fewer senior staff to review cases and respond to emergencies. Another possibility is that a coding bias may affect weekend admissions, with less information on comorbidity being collected.

The study also showed a greater risk of death over the 30 days of follow-up among patients who were admitted electively at weekends than among similar patients admitted during the week.

Professor Pagano said, “This could be because patients [who are] planned to have higher risk elective procedures at the beginning of the week are admitted over the previous weekend. Consequently the risk profile of elective patients admitted at weekends may be different and possibly higher from those admitted during the week.”

The study analysed all deaths within 30 days of admission, whether it took place in or out of hospital. Among patients admitted as emergency cases the ratio of in-hospital to out of hospital deaths was around 2:1 and was similar for admissions at weekends and during weekdays. Among elective patients the ratio is 2:1 among those admitted at weekends but is almost reversed to 1:2 among those admitted during the week. This may indicate that high risk elective patients are admitted at weekends for operations early in the week.

The researchers observed lower rates of in-hospital and out of hospital deaths during the weekend than during the week. Professor Pagano said, “This phenomenon must be due to the way services are organised since, all things being equal, we would expect a similar number of deaths on each day of the week.”

Responding to the new research, the Royal College of Physicians reissued its call for any hospital that admits acutely ill patients to have a consultant physician on site for at least 12 hours a day, seven days a week, who should have no other duties scheduled during this time.

Andrew Goddard, director of medical workforce at the college, said, “This study is further evidence that patients admitted at weekends are more likely to die following admission than patients admitted to hospital during the week. There are many reasons for this, but the two most important are that the patients are more ill and there are fewer doctors available.”

England’s health secretary, Andrew Lansley, said, “It is unacceptable that patients admitted to hospital on a Saturday or Sunday stay longer and have worse results. By opening some services seven days a week, more patients will get the care and treatment that they need when they need it. In some parts of the NHS this is already happening. On Saturdays and sometimes Sundays some services have scanners open to provide tests, are doing operations, and have more senior staff around.” He added: “We will work with all the professional associations to encourage progress on this across the NHS. By increasing the number of consultants who are on duty at the weekends, we will both strengthen the training of junior doctors and improve quality of care for patients.”

David Stout, deputy chief executive of the NHS Confederation, which represents most NHS organisations, said, “We support the government taking proactive steps to help the NHS reduce variations in care and look at getting the right levels of round the clock senior support for patients and staff.” But he added that reorganisation of some services was also necessary. “We have seen examples of this in London, where stroke care has been drastically improved by concentrating care on a smaller number of specialist sites.”