Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study

Background Increased mortality rates associated with weekend hospital admission (the so-called weekend eff ect) have been attributed to suboptimum staffi ng levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist defi cit remains unquantifi ed. This uncertainty could hamper eff orts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service. Methods Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defi ned specialist intensity at each trust as the selfreported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for fi nancial year 2013-14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratifi ed trusts by size quintile. Findings 127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34 350 clinicians surveyed, 15 537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 [11%]) than on Wednesday (6105 [42%]). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5 . 74 h [SD 3 . 39] vs 3 . 97 h [3 . 31]); however, the median specialist intensity on Sunday was only 48% (IQR 40-58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0 . 7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1 . 10, 95% CI 1 . 08-1 . 11; p<0 . 0001). There was no signifi cant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r -0 . 042; p= 0 . 654). Interpretation This cross-sectional analysis did not detect a correlation between weekend staffi ng of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend eff ect mainly to diff erences in specialist staffi ng.