Link between weekend hospital staffing and patient deaths represents 'major oversimplification'

The ‘weekend effect’ – that patients admitted to hospital over the weekend are at an increased risk of death – overshadows a much more complex pattern of weekly changes in quality of care, which are unlikely to be addressed by simply increasing the availability of hospital doctors on Saturdays and Sundays, according a study published in The Lancet.

Studies on the weekend effect have had a major, and at times contentious, impact on health policy. Policy makers, including the UK Secretary of State and Department of Health have explicitly attributed the weekend effect to reduced availability of hospital doctors at the weekend, concluding that changes to doctors’ employment contracts will be required to deliver high quality care seven days a week. So far, however, evidence about the quality of care at the weekend compared with weekdays, or whether there is a direct link between mortality and the availability of consultants remains largely speculative.

The study, led by King’s College London and University College London, looking specifically at acute stroke care, found no weekend effect on survival, but revealed there are many variations in quality of care throughout the week, and that policies to address weekend quality of care alone represent a major oversimplification of the problem.

The study looked at how the quality of acute stroke care in particular varies by day of the week and time of day, over a whole year. The study included care data from 74307 patients admitted to 199 hospitals in England and Wales between April 2013 and March 2014, and information about patient survival 30 days post admission.

There was no difference in 30 day survival for patients admitted during the day at the weekend, compared to during the week, and only very weak evidence that survival was worse for patients admitted overnight compared to those admitted during the day.

The paper adds evidence to a report published last week suggesting that weekend mortality differences might be attributable to how sick patients are on admission, rather than the quality of their care. 

The researchers found there was wide variation in the quality of care delivered - both by days of the week and time of day. Patients who arrived in the morning were more likely to receive a brain scan within one hour (as per national stroke care guidelines) than those who arrived in the afternoon; patients admitted on a Monday had the lowest odds of being admitted to a stroke unit within four hours; and patients admitted on Thursdays and Fridays experienced the longest waits for therapy assessment.

“Much of the current discourse on reducing the weekend mortality effect has occurred in the absence of a detailed understanding of why changes in quality of care occur. Our study shows that the ‘weekend effect’ is a major oversimplification of the true extent and nature of variations in the quality of care that occur in everyday practice. Our findings apply to stroke care in particular but are likely to be reflected in many other areas of health care,” says lead author Dr Benjamin Bray, from the Royal College of Physicians’ Clinical Effectiveness and Evaluation unit and King's College London, and now at University College London. “When solutions come at such a high financial cost, it is imperative that policy makers, health-care managers and funders base their decisions on evidence. Simply transferring doctors from weekdays to weekends is highly unlikely to have the intended effect of improving quality of care.” 

Notes to editors

For more information please contact Jenny Gimpel in the King’s College London press office on +44 (0)207 848 4334, jenny.gimpel@kcl.ac.uk.

‘Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care’ by Bray et al is published in The Lancet.