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Abstract & Commentary
Synopsis: Patients with some serious conditions are more likely to die in the hospital if they are admitted on a weekend than if they are admitted on a weekday.
Source: Bell CM, Redelmeier DA. N Engl J Med. 2001;345: 663-668.
Staffing levels in acute care hospitals tend to be lower on weekends than on weekdays. In this Canadian study, Bell and Redelmeier examine whether this results in a higher death rate among patients admitted on weekends than for patients admitted on weekdays.
Bell and Redelmeier picked 3 conditions to study: abdominal aortic aneurysm, acute epiglottitis, and pulmonary embolism. They picked these conditions because they represented conditions with a high mortality rate, conditions that are treatable, and ones that receive substantial care in settings other than the emergency room and critical care units. Three control conditions—myocardial infarction, intracerebral hemorrhage, and hip fracture—were used for comparison. Myocardial infarction was selected as a control because the bulk of care is given in a critical care setting where staff fluctuations are likely to be minimal. Intracerebral hemorrhage was chosen because there is little effective treatment available. The third control, hip fracture, was chosen since it is a condition that is sometimes more promptly treated on weekends because of greater availability of operating room time on weekdays. In addition, Bell and Redelmeier examined the 100 diagnoses that caused the most deaths for differences in mortality, excluding elective admissions, urgent referrals, and elective births.
For patients with abdominal aortic aneurysm the mortality was greater for patients admitted on the weekend. For the other 2 prespecified conditions, acute epiglottitis and pulmonary embolism, the mortality rate was also higher for patients admitted on a weekend than for those admitted on a weekday. For the control conditions, there was no significant difference in mortality between weekday and weekend admissions.
The 100 conditions that Bell and Redelmeier studied accounted for 48% of all admissions and 91% of all deaths. Among these conditions, 26 were associated with a significant increase in mortality with weekend admission. No condition was associated with a significant decrease in mortality with weekend admission.
Comment by Martin Lipsky, MD
Bell and Redelmeier conclude that patients with some serious conditions are more likely to die in the hospital if they are admitted during the weekend. Anyone who has ever been on call over the weekend will not be surprised by this conclusion. As a primary care physician, I find it more difficult to access support services, get an "urgent test," and obtain a timely consult over the weekend.
Bell and Redelmeier note areas of potential bias, such as the possibility that sicker patients might be admitted over the weekend. However, they note that this would only further support the need to enhance weekend services. Another bias not commented on by Bell and Redelmeier is whether this study using Canadian data is applicable to the United States. Over the last several years, managed care has forced hospitals to expand weekend services in order to avoid lost days waiting for tests and to reduce lengths of stays. Even so, working weekends is typically unpopular in the United States and even if staffing is adequate, it often falls to the least experienced staff. It would be interesting to confirm the findings reported using United States data and also to examine whether the same weekend/weekday trend is present in Academic Health Centers, where house staff and trainees are available for in-house weekend coverage.
In the meantime, I have always told family and friends to avoid getting sick in July when all the new interns start. I will now admonish them to avoid rupturing their aortic aneurysm on Saturday or Sunday. Although not examined in this study, I will also suggest that holidays are also not a terribly good time to have an emergent medical problem.
Dr. Lipsky, Professor and Chair, Department of Family Medicine, Northwestern University Medical School, Chicago, is Associate Editor of Internal Medicine Alert.