Beating the 'weekend effect'

Studies have shown that patients who undergo surgery on weekends tend to experience longer hospital stays and higher mortality rates and readmissions. A new study has highlighted five things hospitals can do to improve the situation. HRMR reports.

For the first time, a study has identified five resources that can help hospitals overcome the so-called ‘weekend effect’.

The study, by researchers at Loyola University Medical Center and Loyola University Chicago was published in the October 2015 issue of the journal Annals of Surgery. A driving force behind the study was the belief that the weekend effect should not be seen as an inevitability.

“Understanding the complex health ecosystem impacting individual patient outcomes following surgery is something our group has focused much of our research on,” says Dr Anai Kothari, first author of the study, which is titled Components of hospital perioperative infrastructure can overcome the weekend effect in urgent general surgery procedures.  

“One area that was particularly interesting was the idea that the time a patient comes to a hospital could influence the quality of care he or she receives. We should not accept that weekend care can negatively impact patient outcomes. Therefore, we set out to measure the weekend effect and determine whether it could be avoided.” 

A widespread problem

Researchers from around the world are just beginning to understand the prevalence of the weekend effect, adds Kothari.

“We know that the weekend effect impacts medical and surgical patients in both the elective and the non-elective setting. The problem is not limited to the US. What our study demonstrates, which is novel, is that the weekend effect is not an inevitable consequence of caring for patients on the weekend, and that there is inter-hospital variability in its prevalence.”

Several reasons have been proposed to explain the weekend effect, including reduced staffing and resources and fewer experienced doctors and nurses working at weekends.

"Only 12.2 percent of hospitals that reported persistent weekend effect had fully adapted electronic medical records, compared with 40 percent of hospitals that overcame it."

Loyola researchers hypothesized that boosting hospital resources before, during and after surgery could overcome the effect. They tested their hypothesis in patients undergoing three types of urgent surgeries that could not be delayed until weekdays: appendectomies, hernia repairs and gall bladder removals.

The researchers examined records of 126,666 patients at 166 Florida hospitals participating in a database program sponsored by the US Agency for Healthcare Research and Quality. Florida was picked because of its large, diverse population. To determine characteristics of individual hospitals, the patient data were linked to the American Hospital Association Annual Survey database.

Researchers examined a five-year period (2007 to 2011). The weekend effect was defined as having longer length of stays on the weekend than during the week. During these five years, 21 hospitals developed a weekend effect; 41 hospitals experienced a weekend effect for all five years. Eighty-seven hospitals oscillated between having a weekend effect one year but none the next.

“We were very surprised that none of the hospitals we studied was ‘immune’ from the weekend effect for all five years we looked at,” says Kothari.

Overcoming the issue

Researchers were most interested in the 17 hospitals that were able to overcome the weekend effect. They examined 21 hospital resources, and after controlling for patient characteristics, identified five resources that helped to overcome the weekend effect:

Hospitals with increased nurse-to-bed ratios were 1.44 times more likely to overcome the weekend effect. Hospitals that overcame the weekend effect had a median nurse-to-bed ratio of 1.3, compared with a nurse-to-bed ratio of 1.1 among hospitals with a persistent weekend effect.

Hospitals with home health programs were 2.37 times more likely to overcome the weekend effect. In such programs, skilled caregivers check on patients after they are discharged, providing wound care, administering medications, etc.

Hospitals that fully adopted electronic medical records were 4.74 times more likely to overcome the weekend effect. Only 12.2 percent of hospitals that reported persistent weekend effect had fully adapted electronic medical records, compared with 40 percent of hospitals that overcame it.

Hospitals with inpatient physical rehabilitation programs were 1.03 times more likely to overcome the weekend effect. Such programs identify patients who require additional physical conditioning prior to discharge or need extra resources at home.

Hospitals with pain management programs were 1.48 times more likely to overcome the weekend effect. Seventy percent of hospitals that overcame the weekend effect had pain management programs, compared with 49.3 percent of hospitals that had persistent weekend effects.

“There is a need for recognition that temporal care disparities—such as the weekend effect—are real and supported by high level evidence, not just from our group but many others across the country and world. From a hospital standpoint, our study highlights mechanisms to mitigate or prevent these disparities and should be considered as part of surgical quality improvement efforts,” says Kothari. 

These findings are especially pertinent in light of current changes in the way hospitals are reimbursed.

“Although we did not specifically look at readmissions, the weekend effect warrants attention as more and more organizations shift to a paradigm of value-based care. Identifying cost-effective areas for quality improvement is important, and given our findings that the weekend effect is a care disparity that can be overcome, it offers a place for intervention,” says Kothari.

The study was conducted by Loyola’s predictive analytics program, which mines large datasets to predict health outcomes. In addition to the weekend effect study, researchers are studying, for example, how many rectal cancer operations a hospital needs to perform for the best results, and whether having a trauma department confers a beneficial ‘halo effect‘ on patient outcomes across the board.

Large new databases, electronic medical records and more powerful computers are enabling researchers to conduct such studies.

“We’re now able to ask and answer a broad range of questions that could significantly help improve patient care and reduce costs,” says Dr Paul Kuo, another of the study’s lead authors.

The team is working to test the wider implications of the first study.

“This study focused on a single state, Florida, because of its diverse health systems and patient population. We are now externally validating our findings on a national level to measure their generalizability,” says Kothari. 

“In addition, we are attempting to determine what electronic health record system components and vendors most strongly influence the weekend effect to help guide hospitals in efforts to overcome it.”

The team will also conduct a follow-up study of hospitals in California, which also has a large, diverse population.