The impact of weekends on outcome for acute exacerbations of COPD

Abstract

Differences in hospital staffing may influence outcomes for patients with acute conditions, including acute exacerbations of chronic obstructive pulmonary disease (COPD), depending on which day of the week the patients are admitted. This study was conducted to determine whether weekend admission increases the risk of dying in hospital.We analysed the clinical data of 289,077 adults with acute exacerbations of COPD admitted to the hospital at any public centre in Spain, during 2006 and 2007. We analysed the following factors for their association with death rate: day of admission, demographics, medical history and comorbidity.During the study period, there were 35,544 (12.4%) deaths during admission in COPD patients. Weekend admissions were associated with a significantly higher in-hospital mortality (12.9%) than weekday admissions (12.1%) among COPD patients (OR 1.07 (95% CI 1.04-1.10)). The differences in mortality persisted after adjustment for age, sex and coexisting disorders (OR 1.05 (95% CI 1.02-1.08)). Analyses of deaths within 2 days after admission showed larger relative differences in mortality between the weekend and weekday admissions (OR 1.17 (95% CI 1.11-1.23)).We conclude that patients with acute exacerbations of COPD are more likely to die in the hospital if they are admitted on a weekend compared with a weekday.KEYWORDS: Chronic obstructive pulmonary disease, mortality, weekend effect A cute exacerbations of chronic obstructive pulmonary disease (COPD) are among the leading causes of morbidity and mortality in industrialised countries [1,2]. ,10% of all hospitalisations are either directly or indirectly attributable to COPD [3], and internal medicine [4] and respiratory wards care for many patients with this disease. Acute exacerbations of COPD requiring hospital treatment are a severe strain on health services and are responsible for at least two-thirds of the total cost of treating respiratory diseases in both Europe and the USA [5]. The acute exacerbation phase entails a substantial rate of hospital mortality [6]. The recognition of risk factors for mortality among patients hospitalised for COPD can be of crucial importance for curtailing cost and reducing mortality.Several studies [7][8][9][10][11][12] concluded that weekend hospitalisation is associated with worse health outcomes. These studies are supported by the work of others [13,14], which find a positive correlation across hospitals between annual average staff-to-patients ratios and quality of care. While the burden of disease and demand on health services is similar from one day to the next, at the weekend, there are staff shortages and reduced availability of services. Unfortunately, this might not be compensated for by increased care on subsequent days.The weekend effect on COPD has been specifically studied in a recent Australian study [15] by a retrospective analysis of administrative data from public hospitals, analysing the 30-day inhospital mortality in 30,000 patients; no significant weekend effect was detected. Ho...

Higher mortality for weekend admissions: quality of care or selection bias?

“…This could well explain why the observed variations in the denominators exactly paralleled and dwarfed the marginal differences (a few per cent) in mortality rates (higher during Saturday and Sunday, but with no difference between Friday and other weekdays). Similar variations in the denominators were also present and apparently unaddressed in two other studies cited above [3,4]. Closer examination of the relevant denominators might well be called for in future studies.…”

“…The authors retrospectively looked at all hospitalisations for chronic obstructive pulmonary disease (COPD) exacerbation or pneumonia during the period 1990-2007 from the healthcare databases of Quebec, Canada, and found higher mortality for weekend, but not Friday, admissions, relative to Monday-Thursday admissions. Similar weekend effects were observed for multiple medical conditions across different settings [2][3][4]. The increased mortality for weekend acute admissions is often attributed to lower quality of care during the weekend even though it could be equally plausible that sicker people came into hospital at weekends [2].…”

“…Closer examination of the relevant denominators might well be called for in future studies. None of the above three studies [1,3,4] specifically examined variations in access to specialised procedures or sophisticated care across the week, which might otherwise have allowed attribution of the higher mortality of weekend admissions to poorer quality of care on Saturdays and Sundays. While it may be difficult to highlight any particular specialised procedures that could substantially impact mortality in the first-line care of COPD exacerbation and pneumonia, early endoscopy may be a candidate for cases of upper gastrointestinal bleeding.…”

Friday and weekend hospital stays: effects on mortality

“…Similarly, a 1% absolute excess in mortality was reported for weekend admissions for a first myocardial infarction, which was partially explained by the lower rate of invasive procedures carried out on the weekend [8]. An excess has been previously reported for patients admitted for COPD exacerbations with a greater excess for deaths occurring in the first 48 h [15].…”

Something better for the weekend?

“…Worryingly, the excess mortality at the weekend was at least as great when patients were admitted electively as in those presenting as emergencies [7]. More recently, BARBA et al [8] noted that mortality among chronic obstructive pulmonary disease (COPD) patients was greater in the 48 h after admission for an exacerbation when it occurred at the weekend. However, to date, we have much less data about how significant the day of hospitalisation is for our respiratory patients.…”