Multiple studies have demonstrated that patients admitted on weekends have worse outcomes, higher costs, and less efficient care compared to those admitted during the week. This “weekend effect” has been documented across diagnoses and healthcare systems, indicating that hospitals tend not to function as well on weekends when staffing is typically at lower levels with less experienced providers and other resources such as specialized imaging and surgery may not be available. Given that spine trauma occurs 24 hours a day, 7 days a week, the authors decided to evaluate the “weekend effect” in cervical spine trauma patients using the National Inpatient Sample over a 10 year period. They identified over 34,000 cervical spine trauma patients who underwent surgical treatment for their injury and classified them as weekend (Saturday or Sunday) or weekday (Monday through Friday) admissions and performed subgroup analyses for those treated with anterior, posterior, and anterior-posterior fusion. Weekend patients were significantly younger, more likely to be male, and had more comorbidities. There were also trends towards the weekend patients being slightly less likely to be Caucasian. Consistent with prior “weekend effect” studies, this study showed that weekend patients had an increased length of stay by two to four days, increased costs by over $10,000, and an increased risk of infection. Inpatient mortality was increased by approximately 50% in the anterior and posterior fusion groups, with these differences bordering on statistical significance.
The less efficient and more expensive care leading to worse outcomes in patients admitted over the weekend does not come as a surprise to anyone who takes care of spine trauma patients. The questions raised by this and other “weekend effect” studies, are 1) Why are the differences observed? and 2)What can be done to improve weekend care processes? Observational studies such as this one demonstrate correlation, but in the absence of randomization, it is generally not possible to show causation. While less experienced providers, delays in care, fewer resources, and other process factors likely contributed to the weekend effect, it is possible that patients injured on the weekend suffered higher energy trauma, were more likely to have a neurological deficit, more likely to have other injuries, and were more likely to have psychosocial problems affecting their care and outcomes. As such, it is not possible to determine how much hospital, provider, and patient factors contributed to the “weekend effect” observed in this study, though all three likely played a role. While it is going to be challenging to determine the causes of the observed differences, making process changes to improve weekend care may be even more vexing. This study does not provide much in the way of answers, but it certainly highlights a problem about which those involved in spine trauma have always been aware. Hopefully future studies can elucidate what is driving the disparities in care and identify process changes to reduce them.
Please read Dr. Singh’s article on this topic in the December 1 issue. Does this article change how you view spine trauma care provided on the weekend? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor