Health Economics Volume 24, Issue 8, pages 907–912, August 2015
- Using data from Health Episode Statistics health economists from the University of Manchester have estimated that:
- the crude 30-day mortality rate for weekday emergency admissions was 3.70% and 4.05% for weekend admissions, while excess weekend death rate equates to 4355 (risk adjusted 5353) additional deaths each year.
- the health gain of avoiding these deaths would be 29 727–36 539 quality-adjusted life years per year.
- They also consider the cost of implementing 7 day services.
- "There is as yet no clear evidence: that 7-day working will, in isolation, reduce the weekend death rate; that lower weekend mortality rates can be achieved without increasing weekday death rates; or that such reorganisation is cost-effective."
The English National Health Service is moving towards providing comprehensive 7-day hospital services in response to higher death rates for emergency weekend admissions. Using Hospital Episode Statistics between 1st April 2010 and 31st March 2011 linked to all-cause mortality within 30 days of admission, we estimate the number of excess deaths and the loss in quality-adjusted life years associated with emergency weekend admissions. The crude 30-day mortality rate was 3.70% for weekday admissions and 4.05% for weekend admissions. The excess weekend death rate equates to 4355 (risk adjusted 5353) additional deaths each year. The health gain of avoiding these deaths would be 29 727–36 539 quality-adjusted life years per year. The estimated cost of implementing 7-day services is £1.07–£1.43 bn, which exceeds by £339–£831 m the maximum spend based on the National Institute for Health and Care Excellence threshold of £595 m–£731 m. There is as yet no clear evidence that 7-day services will reduce weekend deaths or can be achieved without increasing weekday deaths. The planned cost of implementing 7-day services greatly exceeds the maximum amount that the National Health Service should spend on eradicating the weekend effect based on current evidence. Policy makers and service providers should focus on identifying specific service extensions for which cost-effectiveness can be demonstrated. Copyright © 2015 John Wiley & Sons, Ltd.
Conslusions:
Recent initiatives to extend normal hours of hospital operation and to provide more comprehensive 7- day services have been implemented in response to alarming statistics on the gap in mortality rates between patients admitted at the weekend compared with those admitted on weekdays. These statistics, however, are insufficient by themselves to justify a policy change towards extending normal hours of operation into the weekend. There is as yet no clear evidence: that 7-day working will, in isolation, reduce the weekend death rate; that lower weekend mortality rates can be achieved without increasing weekday death rates; or that such reorganisation is cost-effective.
Our analysis indicates that the estimated cost of implementing 7-day services exceeds the maximum amount that NICE would recommend the NHS should be prepared to spend on eradicating the observed weekend effect. A comprehensive roll-out of 7-day services across the NHS is therefore unlikely to be a cost-effective use of resources, particularly as our estimates of potential health benefit represent the upper limit of what is achievable. Given the lack of evidence supporting the impact of service extension on patient outcomes, the benefits actually realised would likely to be much lower. Furthermore, the consequences for patients admitted during the week also need to be considered, as care for these patients may deteriorate if resources are redistributed.
More – and more nuanced – evidence is required before a policy of providing full 7-day services can be supported. For example, our analysis only considered mortality and associated QALYs as an outcome, which are increasingly recognised as limited measures of outcomes (Coast,2004). There may be other detrimental effects on quality and outcomes for patients admitted at the weekend that improved weekend services could address. Whilst the policy debate to date has focused on the excess mortality rates observed for patients admitted in an emergency to hospitals during the weekend, there are likely to be wider consequences, such as the impact on elective activity currently undertaken during the week, and the impact on primary and community services that are also limited at weekends. It is possible that selected service extensions – for specific specialties and at certain times of day – could prove to be cost-effective, but substantial commitments of NHS resources should not be made until these can be identified and robust evidence provided.
Conslusions:
Recent initiatives to extend normal hours of hospital operation and to provide more comprehensive 7- day services have been implemented in response to alarming statistics on the gap in mortality rates between patients admitted at the weekend compared with those admitted on weekdays. These statistics, however, are insufficient by themselves to justify a policy change towards extending normal hours of operation into the weekend. There is as yet no clear evidence: that 7-day working will, in isolation, reduce the weekend death rate; that lower weekend mortality rates can be achieved without increasing weekday death rates; or that such reorganisation is cost-effective.
Our analysis indicates that the estimated cost of implementing 7-day services exceeds the maximum amount that NICE would recommend the NHS should be prepared to spend on eradicating the observed weekend effect. A comprehensive roll-out of 7-day services across the NHS is therefore unlikely to be a cost-effective use of resources, particularly as our estimates of potential health benefit represent the upper limit of what is achievable. Given the lack of evidence supporting the impact of service extension on patient outcomes, the benefits actually realised would likely to be much lower. Furthermore, the consequences for patients admitted during the week also need to be considered, as care for these patients may deteriorate if resources are redistributed.
More – and more nuanced – evidence is required before a policy of providing full 7-day services can be supported. For example, our analysis only considered mortality and associated QALYs as an outcome, which are increasingly recognised as limited measures of outcomes (Coast,2004). There may be other detrimental effects on quality and outcomes for patients admitted at the weekend that improved weekend services could address. Whilst the policy debate to date has focused on the excess mortality rates observed for patients admitted in an emergency to hospitals during the weekend, there are likely to be wider consequences, such as the impact on elective activity currently undertaken during the week, and the impact on primary and community services that are also limited at weekends. It is possible that selected service extensions – for specific specialties and at certain times of day – could prove to be cost-effective, but substantial commitments of NHS resources should not be made until these can be identified and robust evidence provided.
