Weekend death rates; confusion and hype

The Today programme have said that there is  ” fresh evidence that people who are admitted to hospitals in England at weekends face a significantly increased risk of death.” 

4 days ago, the Telegraph reported that Andrew Lansley had decided to fund hospitals to work 24/7 with no weekend change to staffing, and the report cites Dr Foster’s data, which I have previously criticised for methodological failings here

The source of the latest story is this paper in the Journal of the Royal Society of Medicine, here.

It seems that Bruce Keogh has used this data to suggest that hospitals should work to a 24/7 rota rather than a weekend one – I will link to his interview on the BBC when it is available.

There are a number of flaws with this leap. First is the concept that weekend staffing is 1)related and 2)responsible.

Currently, if a consultant is on -call at the weekend, she or he is dealing primarily with the patients on the ward. There are no management meetings, outpatient clinics or educational seminars. It’s unclear whether consultant presence at weekends is any less, on the wards, than it is during the week. It’s an illusion to think that, weekdays, consultants are doing nothing but being on the ward. We have no decent comparative data. (And Dr Foster still haven’t responded to that BMJ piece criticising their methods.)

The JRSM paper is in many ways a very good paper.  They examined the 14,217,640 admissions into English hospitals in 2009/10. The researchers then looked at death rates in the following 30 days. This is what they found:

Hospital stays which included weekend days were less likely to result in death than hospital stays on midweek days.

Weekend days were associated with the lowest risk of subsequent hospital death for those admitted at the weekend.

Hospital admissions at the weekend  resulted in a higher death rate at up to 30 days later. They say “For every 100 deaths amongst patients admitted on a Wednesday,  we would expect 116 among otherwise similar patients admitted on a Sunday. However, for every 100 deaths among patients in hospital on Wednesday, we would expect to see 92 among similar patients already in hospital on a Sunday “.

Where the paper falls down is in making extrapolations to how the NHS is run at weekends. They have found some interesting things. However, we cannot explain this data. The authors also say, very interestingly:

“Our analysis was replicated on data from 254 leading US-managed care hospitals, finding increased risk of death for admission to hospital at the weekends and a reduced risk associated with hospital stays on weekend days compared to weekdays. This was despite differences in the organisation and delivery of health care between England and managed care in the US”

In otherwords, the presence of a 24/7 based hospital rota did not get rid of the finding that weekend admissions were associated with a higher death rate.

The authors of the paper then go on to say that

“Although our data does not allow a scientific analysis of the mechanisms underlying this phenomena, one could speculate that ….”

And then there are lots of speculations.

The bottom line is that this study gives us data, but is not able to explain it. There are many possible reasons for their findings, which include the issue that patients admitted at the weekend have different characteristics which places them at higher risk of death. Bruce Keogh has taken the view that staffing levels are the issue, and that we need 24/7 hospital rotas – but it would be just as possible to declare that we should stop admitting elective patients at the weekend, as this may be safer. It would also be possible to say that there is evidence that patients are better off being discharged after a weekend, rather than before it.

It’s a pity that good data has made unjustified leaps to changes in policy. It would be a disaster if vast sums were spent making non evidence based changes to working practices – and which they made no impact on death rates.



10 Responses to “Weekend death rates; confusion and hype”

  1. David Smith February 3, 2012 at 11:34 am #

    Speaking from my experience as a paramedic, could it be that the people whom we take to hospital at a weekend are actually further down the course of their illness, therefore more difficult to treat, as it’s certainly a fact that a lot of people hang on then, rather than seek help, because they have something more important to do (X Factor?)? Not being cynical, just a query based on years of experience.

  2. Margaret McCartney
    margaretmccartney February 3, 2012 at 12:56 pm #

    absolutely, because this is data collection and not a trial, there are significant uncertainties with the different types of reasons people are admitted on different days.

  3. Dave Little February 3, 2012 at 3:05 pm #

    The BBC report includes “Prof Pagano also said reduced staffing and fewer senior doctors on duty, as well as poor access to diagnostic tests at weekends, could have an effect.”
    Which is a fair speculation but one would have hoped that a senior medic would realise that the “could” is far too weak a way of saying that “there is no definite evidence that poor staffing/services at the weekend are responsible but it needs looking at”.
    Sir Bruce Keogh: said he thought the research added weight to the argument to extend NHS services through the weekend.
    “It’s about our NHS catching up with other service industries and offering a routine six- or seven-day week where people can see consultants or experts on a Saturday and maybe even a Sunday, where people can have routine operations over the weekend – more at their convenience than the convenience of the service – and also people who are worried on a Friday have access to expert advice – and that’ll put the compassion back into the NHS.”
    So not much doubt about what he thinks is wrong and can be improved with the proposed McNHS model?

  4. PJ February 3, 2012 at 9:41 pm #

    Unfortunately, my experience of acute medicine/surgery as a junior (not so much of an issue in psych fortunately) is that nights and particularly weekends are very dangerous times. Very high staff to patient ratios, few medical seniors, patients punted from acute admission units onto the wards with inadequate review, minimal support from radiology, endoscopy etc, bank nursing staff on the ward.

    No wonder people die – I’m surprised it isn’t more. I don’t know how anyone who has worked as a hospital doctor could think that staffing levels were not a problem.

  5. Sunil February 4, 2012 at 3:48 am #

    Very different case-load at the weekends.

    Weekday patients have been seen by their own GP practice, whilst weekend patients often sit at home from Friday afternoon getting sicker and sicker until they’re admitted on 48 hours later on a Sunday (yes, more anecdotal speculation – just like the discussion section of that paper!)

  6. Paul Smith February 11, 2012 at 3:57 pm #

    My own personal experience of Hospital Treatment at weekends confirms this evidence/report.
    My Mother and several relatives suffered because they were admitted at weekends, the care given was in my opinion totally different to what happened during the week, the hospital appeared like “Ghost Ship”, hardly any staff, any tests etc that needed to be done I was informed would be done once the new week commenced.

    Getting my Mother pain killers was difficult, mind you getting her something to eat that was edible was difficult.

    The whole problem with the way certain people are employed in the NHS is the problem, consultants should be on call more, the actual time they spend at the hospital instead of finishing their clinics early and then dashing off to play golf might help?

    If I had to go into hospital I would not want to go on a weekend, I’d rather take my chances and wait til monday morning…

  7. Margaret McCartney
    margaretmccartney February 11, 2012 at 6:28 pm #

    dear Pat
    sorry, but you are off the mark. My direct experience of living with a consultant, and directly of hospital medicine, is of normal 10 hour days, on calls that actually mean being in the hospital dealing with acute emergencies, an on call rota that cuts into normal family weekends and evenings, and absolutely no golf or private practice. I think 20 years ago things were different. I expect disruption, it’s what a professional signs up to, but tarring all with the same brush is neither useful nor fair.

  8. Paul Smith February 14, 2012 at 8:42 am #

    Who’s Pat by the way?

  9. steve February 14, 2012 at 8:13 pm #

    Much has been made of this recent paper in the Journal of the Royal Society of Medicine which shows a significant increased risk of dying within 30 days of admission if you are admitted on a Saturday or, particularly, a Sunday compared to being admitted on a Wednesday.
    For every 100 deaths within 30 days of admission on a Wednesday there would be 116 deaths among patients admitted on a Sunday.
    But the reality is that out of a total of 14.2 million admissions looked at the overall death rate wasjust under 285,000 which equated to about 2% of total admissions.
    If a Wednesday admission carries with it an “average” 30 day mortality rate of 2% then a Sunday admission would carry with it a risk of 2.32%.
    Or, to put it another way, if your are admitted on a Wednesday your chances of still being alive after 30 days would be 98%. But if it was a Sunday your chances of still being alive in 30 days would be 97.68%.
    When put like that it seems to me that there is little to be scared of.
    Or am I misunderstanding it all?

  10. Alec May 22, 2015 at 8:54 pm #

    I’m a GP, and today I had an 86 year old lady who collapsed with epigastric pain. I wanted her to be admitted to hospital immediately, but both she and her son were arguing against it as they thought the bank holiday weekend would mean that she would suffer more through being admitted than staying at home.
    I think this is a dangerous misconception, and a direct result of this sort of misinformation being irresponsibly reported.