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Research Christmas 2018: Heart of the Matter

Death and readmissions after hospital discharge during the December holiday period: cohort study

BMJ 2018; 363 doi: (Published 10 December 2018) Cite this as: BMJ 2018;363:k4481
  1. Lauren Lapointe-Shaw, doctoral student1,
  2. Peter C Austin, professor2,
  3. Noah M Ivers, assistant professor3,
  4. Jin Luo, senior research analyst2,
  5. Donald A Redelmeier, professor2,
  6. Chaim M Bell, physician in chief4
  1. 1Toronto General Hospital, 14 EN room 216, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
  2. 2ICES, Toronto, ON, Canada
  3. 3Women’s College Hospital, Toronto, ON, Canada
  4. 4Sinai Health System, Toronto, ON, Canada
  1. Correspondence to: L Lapointe-Shaw{at}
  • Accepted 13 August 2018


Objective To determine whether patients discharged from hospital during the December holiday period have fewer outpatient follow-ups and higher rates of death or readmission than patients discharged at other times.

Design Population based retrospective cohort study.

Setting Acute care hospitals in Ontario, Canada, 1 April 2002 to 31 January 2016.

Participants 217 305 children and adults discharged home after an urgent admission, during the two week December holiday period, compared with 453 641 children and adults discharged during two control periods in late November and January.

Main outcome measures The primary outcome was death or readmission, defined as a visit to an emergency department or urgent rehospitalisation, within 30 days. Secondary outcomes were death or readmission and outpatient follow-up with a physician within seven and 14 days after discharge. Multivariable logistic regression with generalised estimating equations was used to adjust for characteristics of patients, admissions, and hospital.

Results 217 305 (32.4%) patients discharged during the holiday period and 453 641 (67.6%) discharged during control periods had similar baseline characteristics and previous healthcare utilisation. Patients who were discharged during the holiday period were less likely to have follow-up with a physician within seven days (36.3% v 47.8%, adjusted odds ratio 0.61, 95% confidence interval 0.60 to 0.62) and 14 days (59.5% v 68.7%, 0.65, 0.64 to 0.66) after discharge. Patients discharged during the holiday period were also at higher risk of 30 day death or readmission (25.9% v 24.7%, 1.09, 1.07 to 1.10). This relative increase was also seen at seven days (13.2% v 11.7%, 1.16, 1.14 to 1.18) and 14 days (18.6% v 17.0%, 1.14, 1.12 to 1.15). Per 100 000 patients, there were 2999 fewer follow-up appointments within 14 days, 26 excess deaths, 188 excess hospital admissions, and 483 excess emergency department visits attributable to hospital discharge during the holiday period.

Conclusions Patients discharged from hospital during the December holiday period are less likely to have prompt outpatient follow-up and are at higher risk of death or readmission within 30 days.


  • Contributors: All authors had full access to all of the data (including statistical reports and tables) in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. LL-S is the guarantor. LL-S, PCA, NMI, DAR, and CMB conceived and designed the study. LL-S, JL, and CMB analysed and interpreted the data. LL-S drafted the manuscript. All authors critically revised the manuscript for important intellectual content. LL-S and JL carried out the statistical analysis. CMB obtained funding. LL-S and JL provided administrative, technical, or material support. CMB supervised the study. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form and declare (with the exception of disclosures that follow): no support from any organisation for the submitted work, no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • Funding: This study was supported by a Canadian Institutes of Health Research (CIHR) and Canadian Patient Safety Institute Chair in Patient Safety and Continuity of Care (CMB). CMB also reports support from the Department of Medicine at the University of Toronto. LL-S reports support from a CIHR fellowship award (FRN 146714), and the Philipson scholar programme at the University of Toronto. PCA reports support from a mid-career investigator award from the Heart and Stroke Foundation. NMI reports support from a CIHR new investigator award and from the Department of Family and Community Medicine at the University of Toronto. DAR reports support from a Canada Research Chair in Medical Decision Science.

  • This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long term Care (MOHLTC). The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions, and statements expressed herein are those of the author, and not necessarily those of CIHI. The CIHR, ICES, the MOHLTC, and the Canadian Patient Safety Institute had no involvement in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

  • Ethical approval: This study was approved by the research ethics boards of the University of Toronto and Sunnybrook Health Sciences Centre.

  • Data sharing: Technical appendix and statistical code available from LL-S at

  • Transparency: The manuscript’s guarantor (LL-S) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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