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Excess Mortality Associated with Junior Doctor Treatment at the Weekend: An Analysis of Electronic Medical Records in the UK
32 Pages Posted: 21 Sep 2018More...
Background: Admission to hospital over a weekend is associated with increased mortality but the underlying causes are ill understood. We explore to what extent differences in emergency department admission and discharge processes, severity of illness, and the seniority of the treating physician explain the weekend effect.
Methods: We analyzed linked emergency department attendances to hospital admissions to Cambridge University Hospitals NHS Foundation Trust, UK over a seven-year period from January 1, 2007 to December 31, 2013 with 30-day in-hospital death as the primary outcome and discharge as a competing risk. The primary exposure was day of the week of arrival. Cox proportional hazards and sub-distribution hazards models controlled for multiple confounders including sociodemographic characteristics, diagnosis group, triage, hospital staffing, and seasonality.
Findings: 229,401 patients made 424,845 emergency department attendances, of which 158,396 (37·3%) were admitted to the hospital. 3,947 (3·3%) patients admitted on a weekday to hospital and 1,454 (3·7%) patients admitted at a weekend died within 30 days. In the adjusted Cox model, the hazard ratio of death within 30 days of attendance was 16·0% higher (95% CI 9·2%, 23·3%) for weekend arrivals. The weekend effect for patients treated by junior doctors (aHR 1·19 [1·10, 1·29]) was significant and suggestive for patients treated by senior doctors (aHR 1·09 [0·99, 1·21]). The "Monday effect" was as large as the weekend effect in all statistical models (p<0·001). There was no excess mortality risk for weekend arrivals between 2000h and 0759h (p>0·05 for all triage categories).
Interpretation: Our findings suggest that the seniority of the physician is an important factor in the weekend effect, which persists for patients treated by junior doctors during working hours. Changes to NHS policy that emphasize consultant-led emergency services at weekends may decrease the weekend effect.
Funding Statement: This work was supported by the Bill and Melinda Gates Foundation through a Gates Cambridge Scholarship. The views expressed are those of the authors and not necessarily those of the NHS, Department of Health, or Public Health England.
Declaration of Interests: The authors declare "none."
Ethics Approval Statement: The authors obtained Research Ethics Committee and Health Research Authority approval from Cambridge University Hospitals NHS Foundation Trust.
Keywords: Emergency Department; Junior Doctor; Mortality; Subdistribution Hazard; Weekend Effect
Suggested Citation: Suggested Citation