Severity of illness and the weekend mortality effect: A retrospective cohort study

Abstract

Background: Weekend admission to the hospital has been found to be associated with higher in-hospital mortality rates, but the cause for this phenomenon remains controversial. US based studies have been limited in their characterization of the weekend patient population, making it difficult to draw conclusions about the implications of this effect. Methods: A retrospective cohort study, examining de-identified, patient level data from 2015 to 2017 at US academic medical centers submitting data to the Vizient database, comparing demographic and clinical risk profiles, as well as mortality, cost and length of stay, between weekend and weekday patient populations. Between-group differences in mortality were assessed using the chi-square test for categorical measures and Wilcoxon rank-sum test for continuous measures. Logistic regression models were used to test the multivariate association of weekend admission and other patient-level factors with death, LOS, etc. Results: We analyzed 10,365,605 adult inpatient encounters. Within the weekend patient population, 30.6% of patients were categorized as having either a major or extreme risk of mortality on admission, as compared to 23.7% on weekdays (p < 0.001). We found a significantly increased unadjusted mortality rate associated with weekend admission (OR 1.46; 95% CI 1.45-1.47) which was substantially attenuated after adjusting for disease severity and other demographic covariates, though remained significant (OR 1.05; 95% CI 1.04-1.06). In the subgroup of non-elective admissions, the unadjusted OR for death was 1.14 (95% CI 1.13-1.15), and the adjusted OR was 1.04 (95% CI 1.03-1.05). Weekend admission was associated with a longer median LOS (4 vs 3 days in the weekday group; p < 0.01), but a lower median cost ($8224 vs $9999 dollars in the weekday group; p < 0.01). Conclusion: The patient population admitted on weekends is proportionally higher risk than the population admitted on weekdays, and the observed weekend mortality effect is largely attributable to this risk imbalance.