Effect of Weekend Admission on Mortality Associated With Severe Acute Kidney Injury in England: a Propensity Score Matched, Population-based Study

Increased in-hospital mortality associated with weekend admission has been reported for many acute conditions, but no study has investigated "weekend effect" for acute kidney injury requiring dialysis (AKI-D). In this study, the investigators compared mortality in AKI-D patients admitted on weekday versus weekend and assessed factors associated with increased mortality.

Study Overview

• Status: Completed
• Conditions: Acute Kidney Injury; Outcome, Fatal

Detailed Description

Several studies have reported an unwanted adverse effect of weekend admission on mortality in certain acute medical conditions. Though the reason for this variation could be illness severity, some studies have hypothesized that this could be due to variation in care provided over weekends when services are a minimum. The increased mortality over weekends for certain conditions in the National Health Service (NHS) in England has led to an intense debate on reconfiguring the health service. Little is known about the impact of the weekend effect on severe acute kidney requiring dialysis (AKI-D) in England, the incidence of which has increased more than 12-foldover the past 15 years. Most nephrology departments in England provide continuous consultant cover over weekends and have the capacity to perform emergency dialysis as needed over weekends suggesting that a weekend effect is less likely to occur. Patients admitted over the weekend may present in three ways - with severe AKI requiring dialysis over the weekend, with AKI and requiring dialysis on a subsequent weekday or with no AKI, but develop AKI-D during the in-patient stay over next few days. Some studies have reported that patients starting dialysis on Sunday or a diagnosis of severe AKI over weekend, does not affect mortality, while others have reported increased mortality for AKI in all sizes of hospital over weekend. One explanation for this observation is that necessary dialysis therapy may not be initiated on a weekend as a result of limitations in physician or nurse staffing or device availability. However, bias can be created by single center studies as it is well recognized that the epidemiology of AKI-D shows considerable regional variation and this may be true for all days of the week. It can also be speculated that patients admitted on weekends may not receive optimal care resulting in development of new AKI or progression of AKI to AKI-D resulting in excess mortality.

With this background, the investigators wanted to investigate whether a weekend effect on mortality exists for AKI-D patients in England. The investigators hypothesized that patients admitted over weekend would have increased mortality irrespective of demographic features and clinical characteristics. They also hypothesized that the effect on mortality would be more pronounced in centers with no on-site nephrology services.

• Study Type: Observational
• Enrollment (Actual): 53878

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: No older than 120 years (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

2003-2015 data from the Hospital Episode Statistics (HES) database containing details of all admissions at National Health Service (NHS) hospitals in England will be used to extract all AKI-D patients

Description

Inclusion Criteria:

1. AKI cases identified by using validated International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes of N17 in any diagnoses codes.
2. AKI cases requiring dialysis (AKI-D) were identified by OPCS code of X40.3 for hemodialysis or X40.4 for hemofiltration in any of the 24 procedures.

Exclusion Criteria:

1. Patients' with ICD10 codes N18.5 and N18.6 for chronic kidney disease stage five (CKD-5) and end stage renal disease (ESRD) respectively will be excluded.
2. Patients with OPCS-4 codes for arteriovenous fistula (L74.2) or arteriovenous shunt (L74.3) during the inpatient admission will be excluded.

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Acute kidney injury patients admitted on weekday; All patients with acute kidney injury requiring dialysis admitted on week day (Monday to Friday) between 1st April 2003 and 31st March 2015
Acute kidney injury patients admitted on weekend; All patients with acute kidney injury requiring dialysis admitted on weekend (Saturday or Sunday) between 1st April 2003 and 31st March 2015

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
in-hospital mortality for weekend and weekday AKI-D admissions	60-day

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Effect of in-center nephrology services on weekdays and weekend mortality of AKI-D admissions		60-day
Effect of deprivation on weekdays and weekend mortality of AKI-D admissions	The Index of Multiple Deprivation is the official measure of relative deprivation (for neighborhoods) in England. The Index of Multiple Deprivation ranks every small area in England from one (most deprived area) to 32,844 (least deprived area) and deciles are calculated dividing the ranking into 10 equal groups	60-day

Collaborators and Investigators

• Sponsor: University Hospitals of Derby and Burton NHS Foundation Trust
• Investigators: Principal Investigator: Nitin V Kolhe, MD, Derby Hospital NHS Foundation Trust

Study record dates

Study Major Dates

• Study Start: January 1, 2016
• Primary Completion (Actual): April 1, 2016
• Study Completion (Actual): April 1, 2016

Study Registration Dates

• First Submitted: October 26, 2016
• First Submitted That Met QC Criteria: October 27, 2016
• First Posted (Estimate): October 28, 2016

Study Record Updates

• Last Update Posted (Estimate): October 28, 2016
• Last Update Submitted That Met QC Criteria: October 27, 2016
• Last Verified: October 1, 2016

More Information

Terms related to this study

• Keywords: acute kidney injury; mortality; weekend admission
• Additional Relevant MeSH Terms: Kidney Diseases; Urologic Diseases; Renal Insufficiency; Wounds and Injuries; Acute Kidney Injury
• Other Study ID Numbers: 1.4

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: The data is anonymised and freely available from HSCIC