title: Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study.
abstract: BACKGROUND
  Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts 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 defined specialist intensity at each trust as the self-reported 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 financial year 2013-14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile.
  
  
  RESULTS
  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 significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r -0·042; p=0·654).
  
  
  CONCLUSIONS
  This cross-sectional analysis did not detect a correlation between weekend staffing 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 effect mainly to differences in specialist staffing.
  
  
  BACKGROUND
  National Institute for Health Research Health Services and Delivery Research Programme.
authors.affiliation: University of Birmingham, Birmingham, UK.
authors.forename: Cassie
authors.initials: C
authors.lastname: Aldridge
authors.affiliation: University of Birmingham, Birmingham, UK. Electronic address: j.f.bion@bham.ac.uk.
authors.forename: Julian
authors.initials: J
authors.lastname: Bion
authors.affiliation: University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Amunpreet
authors.initials: A
authors.lastname: Boyal
authors.affiliation: University of Warwick, Coventry, UK.
authors.forename: Yen-Fu
authors.initials: YF
authors.lastname: Chen
authors.affiliation: University Hospitals Southampton NHS Foundation Trust, Southampton, UK.
authors.forename: Mike
authors.initials: M
authors.lastname: Clancy
authors.affiliation: Royal Brompton & Harefield NHS Foundation Trust, London, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: Evans
authors.affiliation: University of Birmingham, Birmingham, UK.
authors.forename: Alan
authors.initials: A
authors.lastname: Girling
authors.affiliation: University of Southampton, Southampton, UK.
authors.forename: Joanne
authors.initials: J
authors.lastname: Lord
authors.affiliation: University of Birmingham, Birmingham, UK.
authors.forename: Russell
authors.initials: R
authors.lastname: Mannion
authors.affiliation: Academy of Medical Royal Colleges Patient Liaison Group, London, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Rees
authors.affiliation: Southern Health NHS Foundation Trust, Southampton, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Roseveare
authors.affiliation: University of Birmingham, Birmingham, UK.
authors.forename: Gavin
authors.initials: G
authors.lastname: Rudge
authors.affiliation: University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Jianxia
authors.initials: J
authors.lastname: Sun
authors.affiliation: University of Leicester, Leicester, UK.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Tarrant
authors.affiliation: Heart of England NHS Foundation Trust, Birmingham, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Temple
authors.affiliation: University of Warwick, Coventry, UK.
authors.forename: Sam
authors.initials: S
authors.lastname: Watson
authors.affiliation: University of Warwick, Coventry, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Lilford
mesh_terms: D003430:Cross-Sectional Studies; D004630:Emergencies; D004739:England; D006291:Health Policy; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006761:Hospitals; D006801:Humans; D016017:Odds Ratio; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data*; D010820:Physicians / Q000600:supply & distribution*; D013038:Specialization / Q000706:statistics & numerical data*; D013222:State Medicine; D011795:Surveys and Questionnaires; D013997:Time Factors