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Figure.  Probability of Process Measure Adherence on the Weekday vs Weekend Based on Nursing Ratio
Probability of Process Measure Adherence on the Weekday vs Weekend Based on Nursing Ratio

POD indicates postoperative day.

Table.  Differences in Process Measure Adherence Between Cases Performed on Monday Through Wednesday vs Friday
Differences in Process Measure Adherence Between Cases Performed on Monday Through Wednesday vs Friday
1.
Pauls  LA, Johnson-Paben  R, McGready  J, Murphy  JD, Pronovost  PJ, Wu  CL.  The weekend effect in hospitalized patients: a meta-analysis.   J Hosp Med. 2017;12(9):760-766. doi:10.12788/jhm.2815PubMedGoogle ScholarCrossref
2.
Smith  SA, Yamamoto  JM, Roberts  DJ,  et al.  Weekend surgical care and postoperative mortality: a systematic review and meta-analysis of cohort studies.   Med Care. 2018;56(2):121-129. doi:10.1097/MLR.0000000000000860PubMedGoogle ScholarCrossref
3.
Berian  JR, Ban  KA, Liu  JB, Ko  CY, Feldman  LS, Thacker  JK.  Adherence to enhanced recovery protocols in NSQIP and association with colectomy outcomes.   Ann Surg. 2019;269(3):486-493. doi:10.1097/SLA.0000000000002566PubMedGoogle ScholarCrossref
4.
Hoehn  RS, Go  DE, Dhar  VK,  et al.  Understanding the “weekend effect” for emergency general surgery.   J Gastrointest Surg. 2018;22(2):321-328. doi:10.1007/s11605-017-3592-xPubMedGoogle ScholarCrossref
5.
O’Leary  JD, Wunsch  H, Leo  AM, Levin  D, Siddiqui  A, Crawford  MW.  Hospital admission on weekends for patients who have surgery and 30-day mortality in Ontario, Canada: a matched cohort study.   PLoS Med. 2019;16(1):e1002731. doi:10.1371/journal.pmed.1002731PubMedGoogle Scholar
6.
Huijts  DD, van Groningen  JT, Guicherit  OR,  et al.  Weekend effect in emergency colon and rectal cancer surgery: a prospective study using data from the Dutch colorectal audit.   J Natl Compr Canc Netw. 2018;16(6):735-741. doi:10.6004/jnccn.2018.7016PubMedGoogle ScholarCrossref
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    Research Letter
    Pacific Coast Surgical Association
    August 26, 2020

    Association of Weekend Effect With Recovery After Surgery

    Author Affiliations
    • 1American College of Surgeons, Chicago, Illinois
    • 2Department of Surgery, Emory University, Atlanta, Georgia
    • 3Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Chicago, Illinois
    • 4David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles
    JAMA Surg. 2020;155(10):988-990. doi:10.1001/jamasurg.2020.2618

    Weekend effect is a phenomenon that describes worse patient outcomes for patients treated on the weekend compared with the weekday.1 Weekend effect has been described in surgical populations and is associated with worse outcomes2; however, it is unclear exactly why weekends lead to worse care. One hypothesis could be that worse processes on the weekend contribute to weekend effect, and enhanced recovery protocols are the perfect model to study this. The success of enhanced recovery protocols is particularly dependent on high adherence to process measures.3 Whether process measure adherence is affected by weekend effect remains unknown. Our objectives were to determine if there is an association between day of the week and process measure adherence and to identify hospital-level factors associated with weekend adherence.

    Methods

    Patients undergoing elective colorectal surgery at 362 hospitals in the US between January 1, 2014, and December 31, 2017, were identified using the American College of Surgeons Enhanced Recovery in National Surgical Quality Improvement Program. This study analyzed deidentified, preexisting data and was exempt from review by the Chesapeake Institutional Review Board. Adherence to 9 postoperative process measures was compared between patients undergoing surgery on Monday through Wednesday compared with Friday while risk-adjusting for procedure type and surgical complexity. American Hospital Association data were used for hospital-level factors that were modeled to determine association with adherence to process measures on the weekend. All process measures with statistical weekend effect were analyzed using clustered logistic regression models looking for significant interaction effect between hospital-level factors and weekday vs weekend groups. All analysis was performed in SAS version 9.4 (SAS Institute). Two-sided P values were statistically significant at .05. Analysis began August 2018 and ended February 2019.

    Results

    Among 27 617 patients analyzed, the mean (SD) age was 61.7 (14.4) years, and 14 126 were women (51.2%). Those who underwent surgery on Friday, compared with Monday through Wednesday, had decreased adherence to mobilization on postoperative day (POD) 1, mobilization on POD 2, and Foley catheter removal by POD 1 (Table). Hospital-level factors associated with lower weekend adherence rates included having more hospital beds, fewer nurses per bed, and fewer part-time unit staff per bed. Nonteaching hospitals were associated with lower weekend adherence rates but had better adherence rates overall compared with teaching hospitals. Physician, resident, and advanced practice clinicians to bed ratios were not associated with lower weekend adherence. Highlighting the nursing to bed ratio, we found that hospitals with fewer nurses per bed led to a decreased probability of Foley catheter removal and mobilization on POD 1 on the weekend (Figure). Additionally, fewer nurses also had decreased adherence to mobilization on POD 1 even during the weekday when compared with better-staffed hospitals.

    Discussion

    Weekend effect was found to be associated with mobilization on PODs 1 and 2 and Foley catheter removal by POD 1. This weekend effect was associated with increased bed size and decreased nurse and unit staffing ratios on a hospital-level analysis. While other studies have looked at weekend effect and surgical outcomes in the general surgery population4,5 and in the colorectal population,6 ours is the first multi-institutional study to evaluate weekend effect with process measure adherence instead, to our knowledge. The success of enhanced recovery protocols and other protocol-based quality improvement initiatives such as surgical site infection bundles rely on standardization and protocolization of care. The presence of the weekend effect in process measures suggests a target that could lead to improved surgical quality and demonstrate that hospital resources play a role in the care provided. To achieve optimal outcomes, protocol adherence is important and requires appropriately resourced patient care teams.

    Reduced adherence to mobilization and Foley catheter removal was noted during the weekend, and adherence was associated with certain organizational and unit-based factors including nurse and unit staffing ratios. These are potential targets to improve surgical quality to achieve desirable patient care.

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    Article Information

    Corresponding Author: Jessica Y. Liu, MD, MS, American College of Surgeons, 633 N St Clair St, 22nd Floor, Chicago, IL 60611 (jessica.liu@facs.org).

    Published Online: August 26, 2020. doi:10.1001/jamasurg.2020.2618

    Author Contributions: Dr Liu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Liu, Merkow, Cohen, Ko, Sweeney, Sharma.

    Acquisition, analysis, or interpretation of data: Liu, Merkow, Cohen, Bilimoria.

    Drafting of the manuscript: Liu, Merkow, Sharma.

    Critical revision of the manuscript for important intellectual content: Liu, Cohen, Bilimoria, Ko, Sweeney, Sharma.

    Statistical analysis: Liu, Merkow, Cohen.

    Supervision: Merkow, Cohen, Bilimoria, Ko, Sweeney, Sharma.

    Conflict of Interest Disclosures: Dr Bilimoria reports grants from Mallinkrdot, Agency for Healthcare Research and Quality, and Blue Cross and Blue Shield of Illinois during the conduct of the study. No other disclosures were reported.

    Meeting Presentation: This work was presented at the Pacific Coast Surgical Association 2019 Annual Meeting; February 16, 2019; Tucson, Arizona.

    Additional Contributions: We acknowledge Ryan J. Ellis, MD, MS, Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Chicago, Illinois, who assisted with the development of the analytic plan and concept development. Dr Ellis was not compensated.

    References
    1.
    Pauls  LA, Johnson-Paben  R, McGready  J, Murphy  JD, Pronovost  PJ, Wu  CL.  The weekend effect in hospitalized patients: a meta-analysis.   J Hosp Med. 2017;12(9):760-766. doi:10.12788/jhm.2815PubMedGoogle ScholarCrossref
    2.
    Smith  SA, Yamamoto  JM, Roberts  DJ,  et al.  Weekend surgical care and postoperative mortality: a systematic review and meta-analysis of cohort studies.   Med Care. 2018;56(2):121-129. doi:10.1097/MLR.0000000000000860PubMedGoogle ScholarCrossref
    3.
    Berian  JR, Ban  KA, Liu  JB, Ko  CY, Feldman  LS, Thacker  JK.  Adherence to enhanced recovery protocols in NSQIP and association with colectomy outcomes.   Ann Surg. 2019;269(3):486-493. doi:10.1097/SLA.0000000000002566PubMedGoogle ScholarCrossref
    4.
    Hoehn  RS, Go  DE, Dhar  VK,  et al.  Understanding the “weekend effect” for emergency general surgery.   J Gastrointest Surg. 2018;22(2):321-328. doi:10.1007/s11605-017-3592-xPubMedGoogle ScholarCrossref
    5.
    O’Leary  JD, Wunsch  H, Leo  AM, Levin  D, Siddiqui  A, Crawford  MW.  Hospital admission on weekends for patients who have surgery and 30-day mortality in Ontario, Canada: a matched cohort study.   PLoS Med. 2019;16(1):e1002731. doi:10.1371/journal.pmed.1002731PubMedGoogle Scholar
    6.
    Huijts  DD, van Groningen  JT, Guicherit  OR,  et al.  Weekend effect in emergency colon and rectal cancer surgery: a prospective study using data from the Dutch colorectal audit.   J Natl Compr Canc Netw. 2018;16(6):735-741. doi:10.6004/jnccn.2018.7016PubMedGoogle ScholarCrossref
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