Los Angeles, CA - The day of the week on which a patient is admitted to the hospital for heart failure or discharged has no bearing on their clinical outcome, new registry data show [1]. Dr Gregg C Fonarow (University of California, Los Angeles) and colleagues report their findings in the inaugural, May 1, 2008 issue of Circulation: Heart Failure.

"Prior studies have shown that in acute MI and other medical conditions, the day of the week that a patient is admitted influences clinical outcomes, with some results showing that those presenting on weekends are less likely to make it out of the hospital," Fonarow told heartwire. "To our knowledge, this has not been studied well in heart failure, which is one of the biggest causes of hospital admission. Unlike acute MI, we did not find that the day of the week on which a patient was admitted was predictive of clinical outcomes."

His team did find, however, that the day of admission influenced the length of stay (LOS) in the hospital, with those admitted on a Thursday or a Friday having prolonged LOS compared with those admitted on other days, even after risk adjustment. And discharges were substantially more likely than expected on a Friday and substantially lower than expected on a Sunday.

"Clearly, the day of the week on which a patient is admitted is a strong determinant of LOS, and this has cost implications," Fonarow noted. "Understanding the factors responsible for the increased LOS and making potential adjustments in staffing to facilitate weekend discharges may improve the efficiency of heart-failure hospital care." He estimates that for a hospital with 1000 HF admissions annually, changing staffing models to ensure that discharges can take place regardless of the day of the week could translate into cost savings of $330 000 per year, without a difference in clinical outcomes.

Fonarow et al used the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, in which a total of 259 US hospitals submitted data on 48 612 patients with HF. They analyzed day of admission and discharge, demographics, medical history, medication use, and laboratory and in-hospital procedure data for their association with hospital LOS and death rate. They also prospectively collected 60- to 90-day postdischarge follow-up data in a prespecified 10% sample.

Patient characteristics were similar for weekday and weekend presentation. LOS was a median of 4.0 days and a mean of 5.7 days; in-hospital death was 3.8%. In-hospital and postdischarge mortality were similar for each day of the week admitted, but LOS was significantly influenced by day of admission, even after adjustment for other LOS risk factors. The shortest LOS by admission day of the week was Tuesday (5.39 days) and the longest was Friday (5.88 days; p<0.001).

Fonarow told heartwire that previous studies have shown that hospital staffing is reduced on Saturdays and Sundays in terms of both the number of staff and level of experience. In addition, the level of physician coverage differs on weekends in most hospital settings, he says.

Although this study suggests there is adequate medical care and staffing to ensure there are few treatment differences in HF on a weekend—evidenced by the similar clinical outcomes seen—it does suggest preferential discharge on certain days, with Friday being most common, he notes.

This finding is not new—a 2002 Canadian study of 2.4 million medical and surgical hospitalizations found that Friday was the most frequent day of discharge, occurring in 19% of hospitalizations compared with 8% of discharges occurring on a Sunday. Among the 141 687 HF hospitalizations in that study, in-hospital death rate did not differ by weekday compared with weekends, either (10.8% vs 11.0%, adjusted hazard ratio 1.0).

"Together, these studies may suggest that physicians and perhaps nursing staff, patients, and their families prefer weekday discharge," say the researchers. "This may raise the possibility that a certain portion of HF patients discharged on Fridays could be leaving the hospital before they are fully stabilized. However, we found no evidence that different days of the week for HF admission or discharges were associated with differences in postdischarge clinical outcomes."

Nevertheless, the findings could have cost implications, they stress. "The knowledge provided by the current study may help guide clinicians and hospital administrators in implementing more effective staffing and management strategies for hospitalized HF patients. Approximately $360 million in direct costs could be eliminated each year without patients being exposed to higher risk of early death or rehospitalization," they predict.

"Future studies should be designed to prospectively test whether different weekend staffing models and other interventions to facilitate weekend hospital discharges can favorably impact hospital LOS without exposing patients to lower quality of care or higher risk of postdischarge death/rehospitalization," they conclude.