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March 30, 2013

BehindTheMedspeak: Surgery on weekends is hazardous to your health

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All of a sudden it's news, in the New York Times even and who knows where else?

Below, excerpts from Nicholas Bakalar's article.

Emergency surgeries performed on a weekend may have poorer results than the same operation performed on a weekday, a new study concludes.

Researchers used a large database of hospitalizations nationwide to study 7,112 emergency surgeries for Crohn's disease and ulcerative colitis, all of which were performed within two days of admission.

Writing online in Alimentary Pharmacology & Therapeutics, the researchers reported no difference between weekday and weekend admissions in age or gender, the presence of other illnesses, or in-hospital deaths between the two groups. And among the Crohn's patients, there was no significant difference in any postoperative complication.

But ulcerative colitis patients admitted on the weekend were about 70 percent more likely to have complications than those admitted on weekdays. Postoperative infections were 50 percent more likely in weekend patients, pulmonary complications were twice as common, and the risk for wound complications and repeat surgery was 10 times as high.

"This doesn't mean that if you're admitted on a weekend, you should fight surgery," said the lead author, Dr. Ashwin N. Ananthakrishnan, an assistant professor of medicine at Massachusetts General Hospital. "If you need surgery, you should get it. But the question is why this happens — it's apparently not because of patient factors. Is it infrastructure, provider experience? It's important to find out what causes these disparities."

Pick up the medical insider cluephone: every doctor in the world has known since forever that weekend surgery — even and especially elective surgery — is a very bad idea, putting patients at a disadvantage in terms of of outcome compared to their weekday brethren.

The paper referred to above only brings this dark truth to light.

But alas, the authors don't seem to have reasons why.

That's why you pay me the big bucks — I do.

First, the abstract of the scientific paper bringing medicine's dirty little secret into the lay light.

Weekend hospitalizations and post-operative complications following urgent surgery for ulcerative colitis and Crohn's disease 

Background

There is increasing complexity in the management of patients with acute severe exacerbation of inflammatory bowel disease [IBD; Crohn's disease (CD), ulcerative colitis (UC)] with frequent requirement for urgent surgery.

Aim

To determine whether a weekend effect exists for IBD care in the United States.

Methods

We used data from the Nationwide Inpatient Sample (NIS) 2007, the largest all-payer hospitalisation database in the United States. Discharges with a diagnosis of CD or UC who underwent urgent intestinal surgery within 2 days of hospitalisation were identified using the appropriate ICD-9 codes. The independent effect of admission on a weekend was examined using multivariate logistic regression adjusting for potential confounders.

Results

Our study included 7,112 urgent intestinal surgeries in IBD patients, 21% of which occurred following weekend admissions. There was no difference in disease severity between weekend and weekday admissions. Post-operative complications were more common following weekend than weekday hospitalisations in UC [odds ratio (OR) 1.71, 95% confidence interval (CI) 1.01–2.90]. The most common post-operative complication was post-operative infections (Weekend 30% vs. weekday 20%, = 0.04). The most striking difference between weekend and weekday hospitalisations was noted for needing repeat laparotomy (OR 11.5), mechanical wound complications (OR 10.03) and pulmonary complications (OR 2.22). In contrast, occurrence of any post-operative complication in CD was similar between weekday and weekend admissions.

Conclusion

Patients with UC hospitalised on a weekend undergoing urgent surgery within 2 days have an increased risk for post-operative complications, in particular mechanical wound complications, need for repeat laparotomy and post-operative infections.

Where to start?

The main problem for you as a patient is that nobody — not your doctors, not the nurses, not the support personnel in the labs and x-ray and all over the hospital — wants to be there on a weekend.

Everything flows from that fact.

I feel bad that you're reading this halfway through the weekend — especially if you're doing so from a hospital bed before your scheduled Sunday case or right after Saturday surgery.

But these things happen.

Anyway.

Everyone in the O.R. on Saturday and even more on Sunday — when you don't even have a day off to look forward to, knowing you've gotta get up in the dark not that many hours from right now to start the week all over again Monday morning — just wants to get done and out of there.

So corners get cut in terms of how much time a surgeon will take to do something.

Gee, I've known attendings to not even come in on Saturdays and Sundays but instead give their chief residents a thrill by asking "Can you handle it?," knowing darned well what the answer's gonna be and thereby clearing the way to a pleasant day on the golf course or tennis court.

Meanwhile residents and medical students lick their chops, knowing they're gonna get the chance to do stuff they'll not likely be doing when dad's in the house during the week.

But it gets worse: labs and x-ray are covered from home instead of by someone in-house, which means everything takes longer to get done since people have to travel in to the hospital after being called.

And some stuff can't be done at all because special assays require hours to set up and only happen when the full work force is in place Monday through Friday.

Coverage by every service is limited to those on call, with the rest of the service not in-house doing other stuff but elsewhere out of the building, not available to lend a hand if need be.

And you're certainly not gonna call in your 3rd or 4th call person to get a case going sooner or done faster because that person will slap you right back in the face by calling you in when push comes to shove and things are reversed.

Hey, gang, guess what?

Doctors and nurses are no different — no better and no worse — than people doing jobs not involving your life.

Live — or die — with it.

March 30, 2013 at 12:01 PM | Permalink


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Comments

My sister is naturally endowed with a huge dose of common sense and perceptiveness. She avoids weekend staff for a bunch of stuff, including medical stuff. She also avoids doing business by phone on certain days and at certain hours.

Posted by: Bubbub | Apr 2, 2013 3:33:23 PM

It's good to see this study shining a light on what intuitively seems likely. We spent some time in the local ER on Easter Sunday. Even with three kids this was a rare event for us (touch wood!). I have nothing but compassion for people who are obliged to spend at least one weekend in four there.

Posted by: Kate | Apr 2, 2013 4:04:12 AM

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