Weekend health care

Yesterday's New York Times warns us not to have a heart attack over the weekend. While that's good advice in general, for any day of the week, it seems the prospects are most grim on Saturdays and Sundays:

A study of nearly all heart attack patients in New Jersey finds that those who arrived at a hospital on a weekend were less likely to get aggressive treatment and were slightly more likely to die than those who arrived during the week, researchers are reporting.

The study, based on an analysis of 231,164 heart attack patients admitted to New Jersey hospitals from 1987 to 2002, found a gap of almost a percentage point in heart attack death rates over a three-year span: 12.9 percent for weekend patients versus 12 percent for weekday patients. (The deaths occurred within a month of admission.)

In that period, 1999 to 2002, 10 percent of weekday heart attack patients had angioplasty to open blocked arteries on the day they were admitted, compared with just 6.7 percent of weekend patients. Angioplasty performed within a few hours of the start of heart attacks can interrupt the attacks and save lives.

The researchers' report was published today in the peer-reviewed New England Journal of Medicine (and here's the PDF version). They say this in the introductory paragraph:

Although most service industries operate on a daily basis, many hospitals provide routine care on weekdays and only emergency or urgent care on weekends. Hospital staffing is reduced on weekends, both numerically and in terms of available expertise on site. This difference in staffing may result in different outcomes for patients with acute conditions such as myocardial infarction, depending on whether they are admitted on weekends or weekdays. [...] Even small differences in mortality between weekday and weekend admissions of patients with acute myocardial infarction can translate to substantial numbers of additional deaths in the population because of the high incidence and case fatality rate associated with this condition.

Canadian physicians Donald A. Redelmeier and Chaim M. Bell provide an editorial to go along with the report, which starts with this seat-of-the-pants observation:

Clinicians strive to provide care to patients every day of the week. Doing so entails effort, and people who work in hospitals (unlike those in many other lines of work) are not always compensated for taking the weekend shift. Casual observations of hospital parking lots suggest that staffing shortfalls may prevail, indicating that the intensity of medical care on weekends does not match that provided on other days of the week.

They point out that the difference can't be made up for on Monday morning. That obviously true if the patient has already died by then, but even if not, the eventual outcome is often, particulatly in conditions such as heart attacks, dependent upon the first steps of care when the patient arrives at the hospital.

Now that we have another study showing this: what do we do about it? In the editorial the doctors suggest increasing Medicare reimbursement for weekend care, and they cite experience with this in Canada. But they soberly recommend patient awareness of the situation:

First, patients who feel unwell during the week should not wait to see whether they feel better during the weekend. Second, if they are unsure of how sick they may be, they should contact their doctor by Friday, when staff are more available. Third, if patients are hit by an emergency on the weekend, they should go to the hospital; patients who sustain a heart attack, for example, are far safer receiving weekend hospital care than staying at home.