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Bion J, Aldridge C, Beet C, Boyal A, Chen YF, Clancy M, Girling A, Hofer T, Lord J, Mannion R, Rees P, Roseveare C, Rowan L, Rudge G, Sun J, Sutton E, Tarrant C, Temple M, Watson S, Willars J, Lilford R. Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study. Health Serv Deliv Res 2021. [DOI: 10.3310/hsdr09130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background
NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’.
Objectives
The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness.
Design
This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics.
Methods
A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision.
Results
Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time.
Limitations
Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time.
Conclusions
Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care.
Future work
Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julian Bion
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Cassie Aldridge
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Chris Beet
- Intensive Care Medicine, Royal Derby Hospital NHS Trust, Derby, UK
| | - Amunpreet Boyal
- Research & Development, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Clancy
- Emergency Medicine, University of Southampton, Southampton, UK
| | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timothy Hofer
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Joanne Lord
- Southampton Health Technology Assessments Centre, University of Southampton, Southampton, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Peter Rees
- Patient & Lay Committee, Academy of Medical Royal Colleges, London, UK
| | - Chris Roseveare
- General Internal Medicine, Southern Health NHS Foundation Trust, Southampton, UK
| | - Louise Rowan
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jianxia Sun
- Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Mark Temple
- Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sam Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Janet Willars
- Health Sciences, University of Leicester, Leicester, UK
| | - Richard Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Bion J, Aldridge C, Girling AJ, Rudge G, Sun J, Tarrant C, Sutton E, Willars J, Beet C, Boyal A, Rees P, Roseveare C, Temple M, Watson SI, Chen YF, Clancy M, Rowan L, Lord J, Mannion R, Hofer T, Lilford R. Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy. BMJ Qual Saf 2020; 30:536-546. [PMID: 33115851 PMCID: PMC8237174 DOI: 10.1136/bmjqs-2020-011165] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 10/06/2020] [Accepted: 10/11/2020] [Indexed: 12/23/2022]
Abstract
Background In 2013, the English National Health Service launched the policy of 7-day services to improve care quality and outcomes for weekend emergency admissions. Aims To determine whether the quality of care of emergency medical admissions is worse at weekends, and whether this has changed during implementation of 7-day services. Methods Using data from 20 acute hospital Trusts in England, we performed randomly selected structured case record reviews of patients admitted to hospital as emergencies at weekends and on weekdays between financial years 2012–2013 and 2016–2017. Senior doctor (‘specialist’) involvement was determined from annual point prevalence surveys. The primary outcome was the rate of clinical errors. Secondary outcomes included error-related adverse event rates, global quality of care and four indicators of good practice. Results Seventy-nine clinical reviewers reviewed 4000 admissions, 800 in duplicate. Errors, adverse events and care quality were not significantly different between weekend and weekday admissions, but all improved significantly between epochs, particularly errors most likely influenced by doctors (clinical assessment, diagnosis, treatment, prescribing and communication): error rate OR 0.78; 95% CI 0.70 to 0.87; adverse event OR 0.48, 95% CI 0.33 to 0.69; care quality OR 0.78, 95% CI 0.70 to 0.87; all adjusted for age, sex and ethnicity. Postadmission in-hospital care processes improved between epochs and were better for weekend admissions (vital signs with National Early Warning Score and timely specialist review). Preadmission processes in the community were suboptimal at weekends and deteriorated between epochs (fewer family doctor referrals, more patients with chronic disease or palliative care designation). Conclusions and implications Hospital care quality of emergency medical admissions is not worse at weekends and has improved during implementation of the 7-day services policy. Causal pathways for the weekend effect may extend into the prehospital setting.
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Affiliation(s)
- Julian Bion
- Department of Intensive Care Medicine, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - Cassie Aldridge
- Department of Intensive Care Medicine, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Alan J Girling
- Department of Intensive Care Medicine, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Gavin Rudge
- Department of Intensive Care Medicine, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Jianxia Sun
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Chris Beet
- Department of Intensive Care, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Amunpreet Boyal
- Department of Research & Development, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Rees
- Academy of Medical Royal Colleges, London, UK
| | - Chris Roseveare
- Department of Gastroenterology, Southern Health NHS Foundation Trust, Southampton, UK
| | - Mark Temple
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Samuel Ian Watson
- Division of Health Sciences, Medical School, University of Warwick, Coventry, Warwickshire, UK
| | - Yen-Fu Chen
- Division of Health Sciences, Medical School, University of Warwick, Coventry, Warwickshire, UK
| | - Mike Clancy
- Emergency Medicine, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Louise Rowan
- Department of Intensive Care Medicine, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Joanne Lord
- University of Southampton, Southampton, Hampshire, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Timothy Hofer
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Richard Lilford
- Department of Public Health, Epidemiology & Biostatistics, University of Birmingham, Birmingham, UK
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Sun J, Girling AJ, Aldridge C, Evison F, Beet C, Boyal A, Rudge G, Lilford RJ, Bion J. Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust. BMJ Qual Saf 2018; 28:223-230. [PMID: 30301873 PMCID: PMC6560459 DOI: 10.1136/bmjqs-2018-008219] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/22/2022]
Abstract
Objective To determine whether the higher weekend admission mortality risk is attributable to increased severity of illness. Design Retrospective analysis of 4 years weekend and weekday adult emergency admissions to a university teaching hospital in England. Outcome measures 30-day postadmission weekend:weekday mortality ratios adjusted for severity of illness (baseline National Early Warning Score (NEWS)), routes of admission to hospital, transfer to the intensive care unit (ICU) and demographics. Results Despite similar emergency department daily attendance rates, fewer patients were admitted on weekends (mean admission rate 91/day vs 120/day) because of fewer general practitioner referrals. Weekend admissions were sicker than weekday (mean NEWS 1.8 vs 1.7, p=0.008), more likely to undergo transfer to ICU within 24 hours (4.2% vs 3.0%), spent longer in hospital (median 3 days vs 2 days) and less likely to experience same-day discharge (17.2% vs 21.9%) (all p values <0.001). The crude 30-day postadmission mortality ratio for weekend admission (OR=1.13; 95% CI 1.08 to 1.19) was attenuated using standard adjustment (OR=1.11; 95% CI 1.05 to 1.17). In patients for whom NEWS values were available (90%), the crude OR (1.07; 95% CI 1.01 to 1.13) was not affected with standard adjustment. Adjustment using NEWS alone nullified the weekend effect (OR=1.02; 0.96–1.08). NEWS completion rates were higher on weekends (91.7%) than weekdays (89.5%). Missing NEWS was associated with direct transfer to intensive care bypassing electronic data capture. Missing NEWS in non-ICU weekend patients was associated with a higher mortality and fewer same-day discharges than weekdays. Conclusions Patients admitted to hospital on weekends are sicker than those admitted on weekdays. The cause of the weekend effect may lie in community services.
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Affiliation(s)
- Jianxia Sun
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alan J Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Cassie Aldridge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Felicity Evison
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chris Beet
- Intensive Care, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Amunpreet Boyal
- Research & Development, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Julian Bion
- Intensive Care Medicine, University of Birmingham, Birmingham, UK
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Affiliation(s)
- Chris Beet
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
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Bion J, Aldridge CP, Girling A, Rudge G, Beet C, Evans T, Temple RM, Roseveare C, Clancy M, Boyal A, Tarrant C, Sutton E, Sun J, Rees P, Mannion R, Chen YF, Watson SI, Lilford R. Two-epoch cross-sectional case record review protocol comparing quality of care of hospital emergency admissions at weekends versus weekdays. BMJ Open 2017; 7:e018747. [PMID: 29275347 PMCID: PMC5770964 DOI: 10.1136/bmjopen-2017-018747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION The mortality associated with weekend admission to hospital (the 'weekend effect') has for many years been attributed to deficiencies in quality of hospital care, often assumed to be due to suboptimal senior medical staffing at weekends. This protocol describes a case note review to determine whether there are differences in care quality for emergency admissions (EAs) to hospital at weekends compared with weekdays, and whether the difference has reduced over time as health policies have changed to promote 7-day services. METHODS AND ANALYSIS Cross-sectional two-epoch case record review of 20 acute hospital Trusts in England. Anonymised case records of 4000 EAs to hospital, 2000 at weekends and 2000 on weekdays, covering two epochs (financial years 2012-2013 and 2016-2017). Admissions will be randomly selected across the whole of each epoch from Trust electronic patient records. Following training, structured implicit case reviews will be conducted by consultants or senior registrars (senior residents) in acute medical specialities (60 case records per reviewer), and limited to the first 7 days following hospital admission. The co-primary outcomes are the weekend:weekday admission ratio of errors per case record, and a global assessment of care quality on a Likert scale. Error rates will be analysed using mixed effects logistic regression models, and care quality using ordinal regression methods. Secondary outcomes include error typology, error-related adverse events and any correlation between error rates and staffing. The data will also be used to inform a parallel health economics analysis. ETHICS AND DISSEMINATION The project has received ethics approval from the South West Wales Research Ethics Committee (REC): reference 13/WA/0372. Informed consent is not required for accessing anonymised patient case records from which patient identifiers had been removed. The findings will be disseminated through peer-reviewed publications in high-quality journals and through local High-intensity Specialist-Led Acute Care (HiSLAC) leads at the 121 hospitals that make up the HiSLAC Collaborative.
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Affiliation(s)
- Julian Bion
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Cassie P Aldridge
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chris Beet
- Critical Care Unit, University Hospitals Birmingham NHS FT, Birmingham, UK
| | | | - R Mark Temple
- Renal Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | | | - Mike Clancy
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Amunpreet Boyal
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jianxia Sun
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Peter Rees
- Member of the Academy of Medical Royal Colleges Patient Liaison Group, London, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - Richard Lilford
- Division of Health Sciences, University of Warwick, Coventry, UK
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Beet C, Sterman M. Male absenteeism and nutrition: factors affecting fertility in Matawai Bush Negro society. Nieuwe West Indische Gids 1978; 52:131-163. [PMID: 12310617 DOI: 10.1163/22134360-90002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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