If you must be hospitalized, choose Mondays

Most people look forward to the weekend.  But that may not be true for patients in hospital. A study in the current issue of the Journal of American College of Cardiology may make you prefer Mondays.

Researchers in Pennsylvania analyzed the outcomes of more than 151,000 patients who had cardiac arrest over a 14-year period ending in 2014. During that time, the chance of dying remained stubbornly higher for patients whose cardiac arrest took place during nights and weekends. During weekdays, the survival following a witnessed cardiac arrest or heart stoppage was 25.2 per cent. But, on nights and weekends, the survival rate dropped to 21.9 per cent. That gap of nearly 4 per cent was consistent throughout the 14-year study period.

The results come as no surprise to researchers who track this sort of thing.  It’s so well-established that they’ve dubbed it the ‘weekend effect.’ A 2015 study published in BMJ Quality & Safety looked at three million patients in several countries who had been hospitalized.  It found that the chance of dying within 30 days was significantly higher in patients who were admitted to hospital on Saturdays and Sundays. A 2016 study published in the journal Circulation found that patients admitted with stroke to hospitals in South Carolina were more likely to die if they were admitted on Saturdays.  And it’s not just adults who seem to be affected. Another study found that children admitted to hospital on weekends for urgent surgeries had a higher risk of death, surgical complications, and the need for blood transfusions.

In 2014, the Canadian Institute for Health Information (CIHI) looked at data from nine million patients admitted to Canadian hospitals. Overall, the study found a slightly higher risk of dying on the weekend. Overall, patients admitted on the weekend for urgent and unexpected conditions had a four per cent higher risk of dying compared with patients admitted during on weekdays. Those who underwent surgical procedures had seven per cent higher odds of dying on the weekend, and urgent weekend patients who did not have surgery had three per cent higher odds of dying.

The risk of death for children, as well as for patients admitted for obstetrical or mental health care, did not differ between weekdays and weekends.

Researchers aren’t completely sure about the reasons for the higher death rate on the weekends. It could be a statistical quirk, as some critics have suggested. Patients who are relatively well may not remain in hospital during the weekend. If sicker patients remain in hospital during the weekend, it stands to reason that the death rate might be higher. The other possibility is that some aspects of hospital care don’t work as quickly or as well on weekends as they do during the work week. The CIHI study found that heart attack patients waited longer for diagnostic tests, and had eight per cent higher odds of dying.  However, stroke patients also waited longer for diagnostic tests and procedures, but did not have a higher chance of dying. Another pertinent difference is that on weekends, there are fewer personnel on duty at the hospital. As well, at many hospitals, attending physicians and surgeons may be on-call and available for urgent patients but not at the hospital unless summoned. That fact alone likely contributes to delays in providing urgent care.

Researchers who study this phenomenon stress that the weekend effect is small. For instance, the CIHI study estimated that if patients admitted on weekends had the same mortality rate as patients admitted on weekdays, there would be 400 fewer deaths in hospital per year among urgent patients. That’s out of a total of 75,000 hospital deaths per year.

That is only somewhat reassuring to me. The problem with selecting death as a primary outcome measure is that it is relatively rare. Therefore, a statistically significant increase in the death rate on weekends is almost predestined to amount to a handful of extra deaths.

I strongly suspect that researchers would find far stronger indicators of a lower quality of care on weekends if they went looking for them.

As an ER physician who works nights, evenings and weekends, I’ve seen with my own eyes that important things happen faster on weekdays. I’ve never understood why the hospital should have all hands on deck on weekdays and not on weekends.

Patients who need urgent care should not hesitate to to seek medical attention on weekends.  We need to remember that people get sick at all hours on any day of the week, and the health care system should be there whenever they need it. If things run slower on weekends to the detriment of patient care, we need to find out why, and to take steps to address the bottlenecks.
By Dr. Brian Goldman
Original article at: http://www.cbc.ca/radio/whitecoat/blog/if-you-must-be-hospitalized-choose-mondays-1.4508274

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