Walker A Sarah, Mason Amy, Quan T Phuong, Fawcett Nicola J, Watkinson Peter, Llewelyn Martin, Stoesser Nicole, Finney John, Davies Jim, Wyllie David H, Crook Derrick W, Peto Tim E A
Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.
Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.
Lancet. 2017 Jul 1;390(10089):62-72. doi: 10.1016/S0140-6736(17)30782-1. Epub 2017 May 9.
Weekend hospital admission is associated with increased mortality, but the contributions of varying illness severity and admission time to this weekend effect remain unexplored.
We analysed unselected emergency admissions to four Oxford University National Health Service hospitals in the UK from Jan 1, 2006, to Dec 31, 2014. The primary outcome was death within 30 days of admission (in or out of hospital), analysed using Cox models measuring time from admission. The primary exposure was day of the week of admission. We adjusted for multiple confounders including demographics, comorbidities, and admission characteristics, incorporating non-linearity and interactions. Models then considered the effect of adjusting for 15 common haematology and biochemistry test results or proxies for hospital workload.
257 596 individuals underwent 503 938 emergency admissions. 18 313 (4·7%) patients admitted as weekday energency admissions and 6070 (5·1%) patients admitted as weekend emergency admissions died within 30 days (p<0·0001). 9347 individuals underwent 9707 emergency admissions on public holidays. 559 (5·8%) died within 30 days (p<0·0001 vs weekday). 15 routine haematology and biochemistry test results were highly prognostic for mortality. In 271 465 (53·9%) admissions with complete data, adjustment for test results explained 33% (95% CI 21 to 70) of the excess mortality associated with emergency admission on Saturdays compared with Wednesdays, 52% (lower 95% CI 34) on Sundays, and 87% (lower 95% CI 45) on public holidays after adjustment for standard patient characteristics. Excess mortality was predominantly restricted to admissions between 1100 h and 1500 h (p=0·04). No hospital workload measure was independently associated with mortality (all p values >0·06).
Adjustment for routine test results substantially reduced excess mortality associated with emergency admission at weekends and public holidays. Adjustment for patient-level factors not available in our study might further reduce the residual excess mortality, particularly as this clustered around midday at weekends. Hospital workload was not associated with mortality. Together, these findings suggest that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services.
NIHR Oxford Biomedical Research Centre.
周末住院与死亡率增加相关，但不同疾病严重程度和入院时间对这种周末效应的影响仍未得到探讨。
我们分析了2006年1月1日至2014年12月31日期间英国牛津大学国民保健服务体系的四家医院的非选择性急诊入院病例。主要结局是入院后30天内（无论院内还是院外）的死亡情况，采用Cox模型分析从入院开始计算的时间。主要暴露因素是入院的星期几。我们对包括人口统计学、合并症和入院特征等多个混杂因素进行了调整，纳入了非线性和相互作用因素。然后模型考虑了对15项常见血液学和生物化学检测结果或医院工作量代理指标进行调整的效果。
257596人接受了503938次急诊入院治疗。在工作日急诊入院的患者中有18313例（4.7%）在30天内死亡，在周末急诊入院的患者中有6070例（5.1%）在30天内死亡（p<0.0001）。9347人在公共假日接受了9707次急诊入院治疗。其中559例（5.8%）在30天内死亡（与工作日相比，p<0.0001）。15项常规血液学和生物化学检测结果对死亡率具有高度预后价值。在有完整数据的271465例（53.9%）入院病例中，对检测结果进行调整后，解释了与周六急诊入院相比周三急诊入院额外死亡率的33%（95%CI 21至70），周日为52%（95%CI下限34），在对标准患者特征进行调整后，公共假日为87%（95%CI下限45）。额外死亡率主要集中在11:00至15:00之间的入院病例（p=0.04）。没有医院工作量指标与死亡率独立相关（所有p值>0.06）。
对常规检测结果进行调整可大幅降低与周末和公共假日急诊入院相关的额外死亡率。对我们研究中未获取的患者层面因素进行调整可能会进一步降低残余的额外死亡率，尤其是因为这种情况在周末中午左右较为集中。医院工作量与死亡率无关。总体而言，这些发现表明周末效应源于入院时患者层面的差异，而非医院人员配备或服务的减少。
英国国家卫生研究院牛津生物医学研究中心。
