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Magnitude and Modifiers of the Weekend Effect in Hospital Admissions: a Systematic Review and Meta-Analysis

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Magnitude and Modifiers of the Weekend Effect in Hospital Admissions: a Systematic Review and Meta-Analysis Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-025764 on 4 June 2019. Downloaded from Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis Yen-Fu Chen,1 Xavier Armoiry,1 Caroline Higenbottam,2 Nicholas Cowley,3 Ranjna Basra,4 Samuel Ian Watson,1 Carolyn Tarrant,5 Amunpreet Boyal,6 Elizabeth Sutton,5 Chia-Wei Wu,7 Cassie P Aldridge,6 Amy Gosling,2 Richard Lilford,1 Julian Bion2,6 To cite: Chen Y-F, Armoiry X, ABSTRACT Strengths and limitations of this study Higenbottam C, et al. Magnitude Objective To examine the magnitude of the weekend effect, and modifiers of the weekend defined as differences in patient outcomes between weekend ► This systematic review provides a comprehensive effect in hospital admissions: and weekday hospital admissions, and factors influencing it. a systematic review and summary and appraisal of the international litera- Design A systematic review incorporating Bayesian meta- meta-analysis. BMJ Open ture published up to November 2017 on the week- analyses and meta-regression. 2019;9:e025764. doi:10.1136/ end effect associated with mortality, adverse events, Data sources We searched seven databases including bmjopen-2018-025764 hospital length of stay and patient satisfaction. MEDLINE and EMBASE from January 2000 to April 2015, ► The Bayesian meta-analyses take into account vari- ► Prepublication history and and updated the MEDLINE search up to November 2017. ations both within and between studies. additional material for this Eligibility criteria: primary research studies published in paper are available online. To ► The review examines different modifiers of the peer-reviewed journals of unselected admissions (not view these files, please visit weekend effect using both subgroup analyses of focusing on specific conditions) investigating the weekend the journal online (http:// dx. doi. study-level data and subgroup analyses reported effect on mortality, adverse events, length of hospital stay org/ 10. 1136/ bmjopen- 2018- within individual studies. 025764). (LoS) or patient satisfaction. ► The review focuses only on hospital-wide sample of Results For the systematic review, we included 68 studies admissions and does not include condition-specific Received 8 August 2018 (70 articles) covering over 640 million admissions. Of these, admissions. Revised 14 March 2019 two-thirds were conducted in the UK (n=24) or USA (n=22). Accepted 15 April 2019 ► Quantitation of the weekend effect does not explain The pooled odds ratio (OR) for weekend mortality effect http://bmjopen.bmj.com/ underlying mechanisms. across admission types was 1.16 (95% credible interval 1.10 to 1.23). The weekend effect appeared greater for elective (1.70, 1.08 to 2.52) than emergency (1.11, 1.06 to so-called weekend effect has motivated poli- 1.16) or maternity (1.06, 0.89 to 1.29) admissions. Further cies to strengthen 7-day services in the UK examination of the literature shows that these estimates are but has also triggered a heated debate about influenced by methodological, clinical and service factors: at 1–4 weekends, fewer patients are admitted to hospital, those who how to interpret the evidence. Hundreds are admitted are more severely ill and there are differences of studies examining the weekend effect in in care pathways before and after admission. Evidence different clinical areas from around the world on September 29, 2021 by guest. Protected copyright. regarding the weekend effect on adverse events and LoS have now been published, some focusing on is weak and inconsistent, and that on patient satisfaction is unselected emergency admissions, others sparse. The overall quality of evidence for inferring weekend/ on elective admissions, and exploring weekday difference in hospital care quality from the observed outcomes for specific diagnostic groups.5–11 weekend effect was rated as ‘very low’ based on the Grading More recently, several systematic reviews and of Recommendations, Assessment, Development and meta-analyses have attempted to summarise Evaluations framework. these studies.12–14 However, the published Conclusions The weekend effect is unlikely to have a single reviews have been limited to describing the cause, or to be a reliable indicator of care quality at weekends. Further work should focus on underlying mechanisms and presence or absence, and estimating the magnitude, of the weekend effect. Few had © Author(s) (or their examine care processes in both hospital and community. employer(s)) 2019. Re-use Prospero registration number CRD42016036487 gone beyond describing the quantitative permitted under CC BY. estimates to explore possible mechanisms Published by BMJ. behind this apparently ubiquitous phenom- For numbered affiliations see enon. In those reviews that attempted to do end of article. INTRODUCTION so, conclusions were drawn from subgroup Correspondence to Increased mortality rates among patients meta-analyses and meta-regressions of a small Dr Yen-Fu Chen; admitted to hospital during weekends have number of variables without paying sufficient y- f. chen@ warwick. ac. uk received substantial public attention. This attention to potential confounding factors Chen Y-F, et al. BMJ Open 2019;9:e025764. doi:10.1136/bmjopen-2018-025764 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-025764 on 4 June 2019. Downloaded from in study-level data and nuanced analyses reported within Records were imported into EndNote (Thomson individual studies.13 Understanding causation is of crucial Reuters) and de-duplicated. The initial search in April importance for healthcare providers, policy makers and 2015 was updated with a MEDLINE search in May 2016 patients in order to take actions that are based on an and again in November 2017 as our screening of the accurate interpretation of the scientific evidence. We have initial search identified few (1/28) relevant publications therefore performed a comprehensive mixed methods uniquely in other databases. We used reference chaining review of the quantitative and qualitative literature. Here, for completeness. Additional searches were undertaken we report our analysis of the quantitative literature to specifically for framework synthesis, described in the characterise the magnitude of the weekend effect and companion paper. explore potential modifiers of the effect. Study selection and eligibility criteria Records were initially screened by one reviewer. Poten- METHODS tially relevant records were discussed in plenary meet- Structure of the review ings by both teams to refine study eligibility criteria, and This paper is part of a mixed methods review incor- subsequently coded according to the following grouping: porating a systematic review of the magnitude of the 1. Observational studies comparing weekday and week- weekend effect and a framework synthesis that examines end admissions with quantitative data on processes the underlying mechanisms of the effect. The protocol and/or outcomes. providing details of the overall study design and meth- 2. Studies in which changes in service delivery and organ- odological approaches has been previously reported.15 isation at weekends were introduced and the impacts Briefly, the review aims to answer the following overar- were evaluated quantitatively. ching question: 3. Studies providing qualitative evidence that could shed What is the magnitude of the weekend effect associ- light on the mechanisms of the weekend effect. ated with hospital admission, and what are the likely 4. Studies describing differences in case-mix between mechanisms through which differences in structures weekday and weekend admissions without looking into and processes of care between weekdays and weekends process of care or patient outcomes. contribute to this effect? Studies that fell under (1) above are the focus of this We define the weekend effect as the difference in systematic review; studies that were classified into groups patient outcomes between weekend and weekday hospital (2) to (4) were routed to framework synthesis for further admissions, using the definitions of ‘weekend’ as those consideration. given in the various publications. The research question is A study needed to have met the following criteria to be addressed through (1) examination of studies providing included in the systematic review: http://bmjopen.bmj.com/ quantitative estimates of the weekend effect and its ► Have evaluated undifferentiated admissions to acute possible modifiers and (2) interrogation of diverse (both hospitals, that is, admissions across different condi- quantitative and qualitative, primary and secondary) tions or specialties, rather than being limited solely evidence that sheds light on the underlying mecha- to those related to specific conditions or specialties. nisms of the weekend effect. The former is reported as Undifferentiated admissions included emergency a systematic review in this paper, whereas the latter will and elective adult, paediatric, medical, surgical and be described in a companion paper in the form of a obstetric admissions. For studies that reported both framework synthesis. The two components of the mixed aggregated and condition-specific weekend effects, on September 29, 2021 by guest. Protected copyright. methods review shared the same initial comprehensive only the aggregated data were used in the quantitative literature search and study screening process (described analyses of the systematic review. We chose to focus on below), and were then
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