There are plenty of reasons why patients may prefer to have surgeries on weekends. For examples, doing so could be more convenient for their family members or save them from taking sick days. However, there are two very big reasons to stick to weekdays: Appointments on a Wednesday or a Thursday could save patients money and allow them to leave their hospitals sooner.
Patients who undergo surgery on weekends routinely suffer from higher bills, higher mortality rates, higher rates of readmission and longer stays than patients who undergo the same procedures on weekdays. This long-standing phenomenon is known as the weekend effect in hospitals. Now, researchers are beginning to understand what factors cause this worrisome gap in care -- and how to stop it.
A new study to be published in a forthcoming issue of the Aesthetic Surgery Journal shows that patients who underwent a specific plastic-surgery procedure on a weekend ended up staying in the hospital for almost six days longer and paying an additional $35,481 on average than those who underwent the same procedure on a weekday.
Why the difference? Dr. Devinder Singh, a plastic surgeon at the University of Maryland and the chairman of the Maryland Board of Physicians who led the study, says that, much like other businesses, hospitals operate with skeleton staffs on weekends.
“I think the general public thinks that hospitals are just working around-the-clock. As a physician, we know that hospitals really grind to almost a halt over the weekend,” Singh says. “There are major inefficiencies -- resident coverage is thinned out, nurse coverage is thinned out, and the social workers don’t even work.”
This can lead to slower service in departments that provide support to surgeons and their patients before or after a procedure, such as processing X-rays, providing rehabilitation or monitoring pain.
Singh also says surgical teams that perform on weekdays have typically been working together on a consistent basis over a long period of time. On the weekends, these teams are frequently split up because of staffing considerations. Surgeons may be required to work with new assistants and even slight changes in personnel can cause errors or lower the standard of care that patients receive during a complex 10-hour procedure such as microvascular breast reconstruction.
“When I get an orientee who is working as a scrub tech, it can really slow the surgery down if I have to turn my head and say, ‘This is the tool I need and here’s what the tool looks like,’” Singh says.
Dr. Anai Kothari, a surgeon at Loyola University in Chicago, says the obvious short-term solution to the problem identified by Singh’s research is to avoid scheduling a surgery on the weekend if at all possible. But not every patient has the luxury of waiting for a procedure, and some will inevitably go under the knife on a Saturday or a Sunday.
So how might hospitals rid the health-care system of this problematic issue?
Kothari has found five characteristics of hospitals that appear to improve a facility’s odds of beating the weekend effect. He presented preliminary findings of this research at the American Surgical Association meeting in San Diego last month.
The surgeon teamed up with fellow researchers to study 126,666 patients at 117 hospitals in Florida through a database provided by the U.S. Agency for Healthcare Research and Quality. They examined 21 factors they believed might help or hinder a hospital’s ability to treat patients who are admitted on weekends versus those who are admitted on weekdays.
Kothari found facilities that maintained a system of electronic health records were nearly five times more likely to overcome the weekend effect than facilities that did not. Patients admitted to hospitals with comparatively high nurse-to-bed ratio or those that offered inpatient physical rehabilitation, home-health program or pain-management programs also fared far better than patients admitted to hospitals lacking these features.
The surgeon says his results support a holistic approach to health care that does not hinge solely on the skills of any single physician or nurse. “The team is so crucial in terms of not just in the operating room, but afterwards,” Kothari says. “I think this study really speaks to having a well-integrated team as really important to patient care.” For example, electronic health records connect all hospital staff members who are responsible for a patient’s care.
However, Kothari points out no hospital -- even among those equipped with all five of the features shown to improve a facility's odds of beating the weekend effect -- was able to overcome the phenomenon for all five of the years that were studied. This means that some patients in every facility were still at risk.