Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis.

OBJECTIVE: To examine the magnitude of the weekend effect, defined as differences in patient outcomes between weekend and weekday hospital admissions, and factors influencing it. DESIGN: A systematic review incorporating Bayesian meta-analyses and meta-regression. DATA SOURCES: We searched seven databases including MEDLINE and EMBASE from January 2000 to April 2015, and updated the MEDLINE search up to November 2017. Eligibility criteria: primary research studies published in peer-reviewed journals of unselected admissions (not focusing on specific conditions) investigating the weekend effect on mortality, adverse events, length of hospital stay (LoS) or patient satisfaction. RESULTS: For the systematic review, we included 68 studies (70 articles) covering over 640 million admissions. Of these, two-thirds were conducted in the UK (n=24) or USA (n=22). The pooled odds ratio (OR) for weekend mortality effect across admission types was 1.16 (95% credible interval 1.10 to 1.23). The weekend effect appeared greater for elective (1.70, 1.08 to 2.52) than emergency (1.11, 1.06 to 1.16) or maternity (1.06, 0.89 to 1.29) admissions. Further examination of the literature shows that these estimates are influenced by methodological, clinical and service factors: at weekends, fewer patients are admitted to hospital, those who are admitted are more severely ill and there are differences in care pathways before and after admission. Evidence regarding the weekend effect on adverse events and LoS is weak and inconsistent, and that on patient satisfaction is sparse. The overall quality of evidence for inferring weekend/weekday difference in hospital care quality from the observed weekend effect was rated as 'very low' based on the Grading of Recommendations, Assessment, Development and Evaluations framework. CONCLUSIONS: The weekend effect is unlikely to have a single cause, or to be a reliable indicator of care quality at weekends. Further work should focus on underlying mechanisms and examine care processes in both hospital and community. PROSPERO REGISTRATION NUMBER: CRD42016036487.

Protocol for the health economic evaluation of increasing the weekend specialist to patient ratio in hospitals in England.

INTRODUCTION: This protocol concerns the evaluation of increased specialist staffing at weekends in hospitals in England. Seven-day health services are a key policy for the UK government and other health systems trying to improve use of infrastructure and resources. A particular motivation for the 7-day policy has been the observed increase in the risk of death associated with weekend admission, which has been attributed to fewer hospital specialists being available at weekends. However, the causes of the weekend effect have not been adequately characterised; many of the excess deaths associated with the 'weekend effect' may not be preventable, and the presumed benefits of improved specialist cover might be offset by the cost of implementation. METHODS/DESIGN: The Bayesian-founded method we propose will consist of four major steps. First, the development of a qualitative causal model. Specialist presence can affect multiple, interacting causal processes. One or more models will be developed from the results of an expert elicitation workshop and probabilities elicited for each model and relevant model parameters. Second, systematic review of the literature. The model from the first step will provide search limits for a review to identify relevant studies. Third, a statistical model for the effects of specialist presence on care quality and patient outcomes. Fourth, valuation of outcomes. The expected net benefits of different levels of specialist intensity will then be evaluated with respect to the posterior distributions of the parameters. ETHICS AND DISSEMINATION: The study was approved by the Review Subcommittee of the South West Wales REC on 11 November 2013. Informed consent was not required for accessing anonymised patient case records from which patient identifiers had been removed. The findings of this study will be published in peer-reviewed journals; the outputs from this research will also form part of the project report to the HS&DR Programme Board.

The 'weekend effect' in acute medicine: a protocol for a team-based ethnography of weekend care for medical patients in acute hospital settings.

INTRODUCTION: It is now well-recognised that patients admitted to hospital on weekends are at higher risk of death than those admitted during weekdays. However, the causes of this 'weekend effect' are poorly understood. Some contend that there is a deficit of medical staff on weekends resulting in poorer quality care, whereas others find that patients admitted to hospital on weekends are sicker and therefore at higher risk of adverse outcomes. Clarifying the causal pathway is clearly important in order to identify effective solutions. In this article we describe an ethnographic approach to evaluating the organisation and delivery of medical care on weekends compared with weekdays, with a specific focus on the role of medical staff as part of National Health Service England's plan to implement 7-day services. METHODS AND ANALYSIS: We will conduct an ethnographic study of 20 acute hospitals in England between April 2016 and March 2018 as part of the High-intensity Specialist-Led Acute Care project (www.hislac.org). Data will be collected through observations and shadowing, and interviews with staff, in 10 hospitals with higher intensity specialist (consultant) staffing on weekends and 10 with lower intensity specialist staffing. Interviews will be conducted with up to 20 patients sampled from two high-intensity and two low-intensity sites. We will coordinate, compare and contrast observations across our team of ethnographers. Analysis will be both in-depth and cross-cutting, exploring specific features within individual sites and making comparisons between them. We outline how data collection and analysis will be facilitated and organised. ETHICS AND DISSEMINATION: The project has received ethics approval from the South West Wales Research Ethics Committee: Reference 13/WA/0372. Informed consent will be obtained for all interview participants. The findings will be disseminated through peer-reviewed publications in high-quality journals and at national and international conferences.

Two-epoch cross-sectional case record review protocol comparing quality of care of hospital emergency admissions at weekends versus weekdays.

INTRODUCTION: The mortality associated with weekend admission to hospital (the 'weekend effect') has for many years been attributed to deficiencies in quality of hospital care, often assumed to be due to suboptimal senior medical staffing at weekends. This protocol describes a case note review to determine whether there are differences in care quality for emergency admissions (EAs) to hospital at weekends compared with weekdays, and whether the difference has reduced over time as health policies have changed to promote 7-day services. METHODS AND ANALYSIS: Cross-sectional two-epoch case record review of 20 acute hospital Trusts in England. Anonymised case records of 4000 EAs to hospital, 2000 at weekends and 2000 on weekdays, covering two epochs (financial years 2012-2013 and 2016-2017). Admissions will be randomly selected across the whole of each epoch from Trust electronic patient records. Following training, structured implicit case reviews will be conducted by consultants or senior registrars (senior residents) in acute medical specialities (60 case records per reviewer), and limited to the first 7 days following hospital admission. The co-primary outcomes are the weekend:weekday admission ratio of errors per case record, and a global assessment of care quality on a Likert scale. Error rates will be analysed using mixed effects logistic regression models, and care quality using ordinal regression methods. Secondary outcomes include error typology, error-related adverse events and any correlation between error rates and staffing. The data will also be used to inform a parallel health economics analysis. ETHICS AND DISSEMINATION: The project has received ethics approval from the South West Wales Research Ethics Committee (REC): reference 13/WA/0372. Informed consent is not required for accessing anonymised patient case records from which patient identifiers had been removed. The findings will be disseminated through peer-reviewed publications in high-quality journals and through local High-intensity Specialist-Led Acute Care (HiSLAC) leads at the 121 hospitals that make up the HiSLAC Collaborative.

Diffusion of a membrane protein, Tat subunit Hcf106, is highly restricted within the chloroplast thylakoid network.

The thylakoid membrane forms stacked thylakoids interconnected by 'stromal' lamellae. Little is known about the mobility of proteins within this system. We studied a stromal lamellae protein, Hcf106, by targeting an Hcf106-GFP fusion protein to the thylakoids and photobleaching. We find that even small regions fail to recover Hcf106-GFP fluorescence over periods of up to 3 min after photobleaching. The protein is thus either immobile within the thylakoid membrane, or its diffusion is tightly restricted within distinct regions. Autofluorescence from the photosystem II light-harvesting complex in the granal stacks likewise fails to recover. Integral membrane proteins within both the stromal and granal membranes are therefore highly constrained, possibly forming 'microdomains' that are sharply separated.