November 8, 2017

expert reaction to study on seven day services and patient mortality

A new study, published in the Emergency Medicine Journal, reports that the introduction of four priority standards for emergency care in hospitals in England has not made any difference to curbing excess deaths on Saturdats and Sundays, also known as the ‘weekend effect’.

Dr Amy Mason, Applied Statistician (Research Associate), Department of Public Health and Primary Care, University of Cambridge, said:

“’Weekend effect’ studies in the UK have failed to find any clear causal link between reduced weekend services and increased weekend mortality. This study goes a step further by showing that meeting the new seven days clinical standards has not reduced excess deaths at the weekend. It adds to existing evidence that hospital staffing and services may not be the driving factor behind the weekend effect.

“The press release accurately reflects the content of the paper. They have controlled for similar confounders to the original Freemantle study that originally raised awareness of the weekend effect.  The main limitation of the study is they only have data on which hospitals met the clinical standards for a single year. It is unclear from the paper whether these the results are sufficiently robust to the possibility of an error in the data reported by a single high leverage trust. However, in personal correspondence, the authors demonstrated that even with this trust excluded from the analysis there is no evidence of a large magnitude effect on weekend outcomes associated with any of the clinical standards and that their results are robust.

“This paper raises doubt over whether continuing to improve weekend services in this way will cause any improvement in weekend mortality. These standards were designed to reduce the weekend effect, and if they cannot be demonstrated to improve outcomes at the weekend then they are not fit for purpose. These results are of particular concern as NHS hospitals will be mandated to comply with these clinical standards by 2020, and further analysis is needed to investigate their effectiveness before they become mandatory.

Dr Amitava Banerjee, Senior Clinical Lecturer in Clinical Data Science and Honorary Consultant Cardiologist, UCL, said:

“There are variations in standardised hospital mortality rates at the weekend compared with the rest of the week, but the causes are unclear, and likely to be multifactorial. Previous data have suggested that senior staffing levels do not influence the weekend effect. However, the assumption that weekend staffing levels would improve the so-called “weekend effect” led to the UK government’s “seven-day services” policy, resulting in last year’s junior doctor strike.

“This new, high-quality, national study evaluates the impact of these policies in the form of four priority clinical standards (early consultant review, access to tests, access to consultant-led decisions, and ongoing review) for emergency care on weekend mortality rates. The study’s main strength is its evaluation before and after implementation of the “seven-day services” agenda, with detailed analysis for four key indicators at individual trust level. In short, the authors conclude convincingly that compliance with these four standards was not associated with any improvement in mortality at the weekend. Before these standards become mandatory in 2020, they should be reviewed and should not be prioritised. Evidence-based policy is especially important in times of austerity, when pressures on both human and financial resources make targets even harder to meet. Resources should not be wasted on targets which do not change quality of care or patient outcomes.”

* ‘Elevated mortality among weekend hospital admissions is not associated with adoption of seven day clinical standards’ by Meacock et al. published in Emergency Medicine Journal on Wednesday 8 November.

Declared interests

Dr Amy Mason: None received

Dr Amitava Banerjee: No conflicts of interest