Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics

Abstract

Objectives To assess the association between mortality and the day of elective surgical procedure.Design Retrospective analysis of national hospital administrative data.Setting All acute and specialist English hospitals carrying out elective surgery over three financial years, from 2008-09 to 2010-11.Participants Patients undergoing elective surgery in English public hospitals.Main outcome measure Death in or out of hospital within 30 days of the procedure.Results There were 27 582 deaths within 30 days after 4 133 346 inpatient admissions for elective operating room procedures (overall crude mortality rate 6.7 per 1000). The number of weekday and weekend procedures decreased over the three years (by 4.5% and 26.8%, respectively). The adjusted odds of death were 44% and 82% higher, respectively, if the procedures were carried out on Friday (odds ratio 1.44, 95% confidence interval 1.39 to 1.50) or a weekend (1.82, 1.71 to 1.94) compared with Monday.Conclusions The study suggests a higher risk of death for patients who have elective surgical procedures carried out later in the working week and at the weekend. IntroductionA substantial number of patients die as a result of unsafe medical practices and care during their admission to hospital.1 Previous research carried out with English hospital data has suggested a significantly higher risk of death if patients are admitted as an emergency at the weekend compared with a weekday. 2 Other papers have described the "weekend effect"-that is, a worse outcome for patients admitted at weekends compared with weekdays in terms of (in and out of hospital) mortality or length of stay in hospital. [3][4][5] Other studies, however, have found no such effect. 6 Most previous work has focused on acute admissions. A study looking at Veteran Affairs' hospitals in the United State found an increased 30 day mortality (deaths in hospital and after discharge) after non-emergency surgery on Fridays versus early weekdays in patients admitted to regular hospital wards (that is, excluding intensive care units). 7 A recent Australian study reported that after hours and weekend admissions to intensive care units are associated with increased hospital mortality, with the results attributed mainly to patients with planned admissions after elective surgery. 8 A recent English study found an increased risk of hospital death in the elective setting for weekend admissions but, critically (like most previous studies), focused on the day of admission, rather than day of procedure and did not include out of hospital deaths, a potential source of bias. 9There are at least two potential explanations for finding worse outcomes in patients in hospital at the weekend. The first is that these differences reflect poorer quality of care at the weekend, and the second is that patients admitted or operated on at the weekend are more severely ill than those admitted during the week. Some research has proposed reduced staffing levels or less senior and less experienced staff at the weekends as an explana...

Impact of ambulatory surgery day of the week on postoperative outcomes: a population-based cohort study

“…In the United Kingdom, each day following Monday was associated with an independent increase in the odds of 30-day mortality, with a marked relative increase (compared with Monday) of 44% on Friday and 82% on weekend days. 18 In the United States, patients whose operations occurred on Friday were more likely to die after surgery than those whose operations occurred on Monday, Tuesday, or Wednesday. 19 Although any causal factors underlying this relationship have not been fully elucidated, they are hypothesized to be related to gaps in the healthcare system which are potentially due to low staffing levels and physician cross-coverage of patients occurring during the weekend after surgery.…”

“…19 Although any causal factors underlying this relationship have not been fully elucidated, they are hypothesized to be related to gaps in the healthcare system which are potentially due to low staffing levels and physician cross-coverage of patients occurring during the weekend after surgery. 10,18,[23][24][25] Unplanned admissions or returns to the hospital or ED for surgical complications are considered to be important quality indicators in ambulatory surgery programs 1,26,27 ; however, investigations are lacking on the impact of the day of the week on outcomes after ambulatory surgery. In this study, we hypothesized that the day of the week on which ambulatory surgery was performed would impact postoperative outcomes, primarily because patients having surgery late in the week may have limited access to care in a surgeon or family physician's office over the subsequent weekend.…”

“…7 Beyond the impact of discharge day, evidence from a variety of areas of clinical medicine suggests that the day of the week on which medical care is provided may have a significant impact on health outcomes. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] For patients undergoing elective inpatient surgery, there is evidence that the risk of mortality differs between days of the work week. In the United Kingdom, each day following Monday was associated with an independent increase in the odds of 30-day mortality, with a marked relative increase (compared with Monday) of 44% on Friday and 82% on weekend days.…”

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14

“…3,[32][33][34][35] However, much of the evidence on the effect of weekend admission has been limited in key respects. First, it tends to be cross-sectional and there is therefore limited information on the trends in disparities over time.…”

The “Friday effect”: Can epidemiology tell us when to operate?

“…1,2 Indeed, more recent work addressing the effect of the day of the week as a factor in surgical outcomes has suggested that the odds of death are higher following elective surgery on a Friday compared with other days of the week. 3 This ''Friday effect'' and the accompanying concerns over reduced staffing levels on weekends have been suggested as the main explanation for the differences in outcomes and have led to calls for increased weekend staffing. For example, in the United Kingdom (UK), the clinical director of the National Health Service has called this need for more staffing his numberone priority.…”