Abstract
Purpose:
Limited operating room availability constrains hospital scheduling capacity for elective surgical cases. Leveraging weekends for elective surgical cases could increase operative capacity but must be balanced with practical considerations. Our study aimed to characterize trends and outcomes for elective pediatric surgeries performed during weekends.
Methods:
This retrospective cohort study used the Pediatric Health Information System database from 2016 to 2019 to identify surgeries in children <18 years of age from 38 hospitals. Six elective surgeries, commonly performed on the weekend, were selected for analysis. Trends in elective surgeries during weekends (Saturday or Sunday) were evaluated using the Mann-Kendall trend test. Multivariable regression models were used to compare complications and costs between weekend and weekday surgeries.
Results:
Of the 233,266 elective surgeries evaluated, 357 (0.15%) were performed during weekend hours. The proportion of surgeries performed on weekends was stable over time (p=0.65). Following adjustment for clinicodemographic and hospital-level factors, no differences were observed when comparing weekend to weekday surgeries in terms of surgical complications [adjusted Odds Ratio: 1.59; 95% Confidence Interval (CI): 0.65-3.90; p=0.32] or mortality (n=1 in cohort). Weekend surgeries were associated a small additional cost compared to weekday surgeries (β-coefficient $312; 95% CI: $152 to $473; p<0.01).
Conclusion:
Elective pediatric surgeries performed during weekends were uncommon, stable in occurrence, and not associated with substantial increases in complications or costs compared to weekday surgeries. Increasing surgical capacity by extending into weekend scheduling merits further assessment of patient and provider satisfaction, unexpected human resource costs, and thoughtful case selection to ensure patient safety.
Level of Evidence:
III
Keywords: Elective weekend surgery, Weekend effect, Trends, Operating capacity
1. Introduction
Pediatric surgery is frequently performed in high volumes at specialized contemporary tertiary children’s hospitals.1–3 The regionalization of children’s surgery within the United States has accelerated this process.4–7 Changes in referral patterns have resulted in both low-volume, complex pediatric/neonatal procedures as well as more common surgical procedures being performed more frequently at dedicated children’s hospitals.7,8 Closure of pediatric units around the country have also contributed to increased referral to tertiary centers.2,9,10
Important questions remain about how children’s hospitals can appropriately respond to increasing clinical demands by optimizing and maintaining surgical operating capacity. To meet the challenges of increased surgical volumes, pediatric hospitals may be pressured by economic factors to perform more elective surgeries outside of established weekday hours. Pediatric and adult literature suggests that adverse outcomes, such as increased risk of mortality and procedural complications, can result when procedures are performed during the weekend.11–14 The majority of the studied weekend effect are operations performed for urgent/emergent indications.11 There is a dearth of knowledge on the safety profile of pediatric surgeries performed for nonurgent purposes on the weekend and whether the “weekend” effect can be avoided in elective cases. Moreover, elective weekend surgeries may require alternative workflows outside normal business, which could potentially affect resource utilization and/or hospital costs.15
In this current study, we aimed to characterize trends in the performance of representative elective pediatric surgeries during weekends as opposed to established weekday hours, determine whether elective weekend surgeries lead to greater chances of morbidity and mortality, and assess the economic implications of performing more elective weekend surgeries by comparing overall adjusted estimated costs of a hospital visit.15,16 We hypothesized an increasing trend in the number of elective surgeries performed on the weekend as children’s hospitals have sought to offload increased clinical volume by performing more elective surgeries during weekends. Moreover, we postulate elective weekend surgeries may prove more costly when compared to those performed during normal business hours due to increases in surgical complications and mortality.
2. Methods
2.1. Study Design and Population
A multi-center, retrospective cohort data analysis was performed using the Pediatric Health Information System (PHIS) database spanning January 1, 2016 to December 31, 2019. Data was extracted on all procedures performed in an operative room on children <18 years old with the exception of patients that were admitted through the emergency department. PHIS hospitals (n=38) that reported all patient encounter types (e.g., ambulatory surgery, inpatient, and observation) throughout the study period were included. Only procedures that were classified as “Elective” based on priority of admission and identified with “Principal Operative Flag,” which is an indicator of an operative procedure recognized by the Center for Medicare & Medicaid Services (CMS) Diagnostic Related Group (DRG) algorithm, were considered. Among these procedures, six of the most common elective surgeries performed on the weekend were selected for analysis including: myringotomy with or without ear tubes, tonsillectomy-adenoidectomy, orchiopexy, inguinal hernia repair, circumcision, and strabismus repair. These selected surgeries were verified by their Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Edition (ICD-10) codes (Supplemental Table 1). This study was approved by the Institutional Review Board (IRB #2023-6411) at Ann and Robert H. Lurie Children’s Hospital of Chicago and followed the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
2.2. Data Source
PHIS is a secondary administrative database maintained by the Children’s Hospital Association with data from more than 50 children’s hospitals on over 20 million patient encounters. PHIS contains encounter types from the Emergency Department (ED), inpatient, observation, and ambulatory surgery settings. Data elements include unique patient identifiers within hospitals but are de-identified across hospitals. Data elements include information about diagnoses, procedures, utilization, costs, and charges. The database allows for longitudinal studies and its clinical and economic variables allows for a wide variety of studies to be conducted about pediatric health services.17
2.3. Primary Predictor and Outcomes of Interest
The primary exposure is pediatric patients undergoing elective surgery on the weekend. Weekend surgeries were defined as operative procedures occurring any time on Saturday or Sunday, in contrast to weekday surgeries occurring Monday through Friday, based on if the date of service occurred on a weekend date. The primary outcome was the trend in the overall rate of weekend surgical procedures measured per quarter. Secondary outcomes were the odds of surgical complications or post-operative mortality and the difference in adjusted estimated hospital costs for operations performed on the weekend versus the weekday. Surgical complications were defined as a binary variable based on the absence or presence of one or more of clinical diagnosis codes (995 ICD-10 diagnosis codes validated by PHIS database) representing common post-operative complications occurring within the hospital stay. Mortality was defined as a binary variable. The total adjusted estimated hospital cost was defined by PHIS as the total patient hospital charges adjusted by CMS wage/price index for the hospital’s location multiplied by a cost to charge ratio for each encounter based on hospital and discharge year. The cost to charge ratio for each hospital is created based on certified cost reports submitted to CMS every year.
2.4. Covariates
Covariates included age, race, sex, ethnicity, geographical region, insurance payer status, urban status, encounter type, complex chronic condition (CCC), median household income, length of stay, and number of procedures. Age was defined as a continuous variable for children < 18 years of age. Sex was a binary variable based on gender assigned at birth. Race was defined as categorical variable in four sub-groups: White, Black, Asian, and Other. Ethnicity was defined as categorical variable in three sub-groups: Hispanic or Latino, not Hispanic or Latino, or Unknown. Geographical region was defined as a categorical variable in 4 sub-groups: West, Midwest, South, and Northeast. Insurance payer status was defined as a categorical variable defined by four sub-groups: Public, Private, Self-Pay, and Other (including unknown, charity, not billed for service). Urban status was defined as a binary variable based being urban versus non-urban according to 2010 U.S. national census data. CCC was defined as present or absent with a binary variable.18 Median household income was defined as continuous variable based on zip code from 2010 U.S. national census data. Length of stay was defined as a continuous variable as counts of day from admission to discharge. Number of procedures is a continuous variable defined as the total number of procedures within a single hospital encounter.
2.5. Statistical Plan
Demographic and clinical characteristics were compared by surgeries performed on the weekend versus weekday. Categorical data were described using counts and percentages. Continuous data were described using median as measure of central tendency. Comparison of demographic and clinical characteristics were performed using Pearson chi-squared tests for categorial variables and Mann-Whitney U tests for continuous variables.
A Mann-Kendall trend test was performed to analyze trends in number of operative procedures performed on the weekend versus weekday over time from 2016 to 2019. A multivariable quantile linear regression model was fit to evaluate the association between weekend surgeries and estimated adjusted hospital costs after adjusting for age, race, sex, ethnicity, geographical region, urban status, insurance payer status, CCC, number of procedures, length of stay, and median household income. A multivariable logistic regression model was fit to evaluate the association between weekend surgeries and the likelihood of surgical complications after adjusting for age, race, sex, ethnicity, geographical region, urban status, insurance payer status, number of procedures, and CCC. A p-value of <0.05 was used to define statistical significance. All tests were two-sided. Statistical analyses were done using Stata v17.0 (Stata Corp LLC, College Station, TX, USA).
3. Results
3.1. Bivariate Analysis
The cohort consisted of 233,266 selected surgical procedures undergone by 213,845 pediatric patients. Of these 357 (0.15%) were performed on the weekend (Figure 2). Compared to the remainder of the cohort, a higher proportion of weekend surgeries were performed in infants (35.85% v. 32.48%, p<0.01), in Hispanic children (19.61% v. 13.63%, p<0.01), in the Midwest (37.25% v. 27.17%, p<0.01), in rural areas (14.85% v. 9.48%, p<0.01) and those admitted under observation status (18.49% v. 10.94%, p<0.01) (Table 1). Higher rates of surgical complications were observed after weekend procedures compared to those performed during weekday (1.68% v. 0.79%, p=0.06), but this difference was not statistically significant. There was no observed mortality among patients with any of the selected surgeries performed during weekend hours within the study period and one mortality identified during weekday hours. Children who had weekend surgeries had a statistically significant longer median length of stay compared to weekday operations (median: 1d v. 1d, p<0.01). Additionally, the average adjusted estimated cost for weekend surgeries was greater than the cost for weekday surgery (median: $3,102 v. $2,991, p<0.01) (Table 1).
Figure 2.
Trends in children’s surgical procedures performed in children <18 years old on the weekend versus weekday from 2016 to 2019 at 38 tertiary children’s hospitals.
Table 1.
Cohort demographic and clinical preoperative risk factors by performance of surgery on the weekend versus weekday.
| Characteristics | Weekend | Weekday | Total | p-value |
|---|---|---|---|---|
| N (%) | 357 (0.15) | 232,909 (99.85) | 233,266 | |
| Gender | 0.53 | |||
| Female (%) | 134 (37.54) | 91,177 (39.15) | 91,311 (39.14) | |
| Male (%) | 223 (62.46) | 141,732 (60.85) | 141,955 (60.86) | |
| Ethnicity | <0.01 | |||
| Hispanic (%) | 70 (19.61) | 31,727 (13.62) | 31,797 (13.63) | |
| Non-Hispanic (%) | 279 (78.15) | 192,171 (82.51) | 192,450 (82.50) | |
| Unknown (%) | 8 (2.24) | 9,011 (3.87) | 9,019 (3.87) | |
| Race | 0.34 | |||
| White (%) | 269 (75.35) | 169,655 (72.84) | 169,924 (72.85) | |
| Black (%) | 44 (12.32) | 35,721 (15.34) | 35,765 (15.33) | |
| Asian (%) | 8 (2.24) | 6,646 (2.85) | 6,654 (2.85) | |
| Other (%) | 36 (10.08) | 20,887 (8.97) | 20,923 (8.97) | |
| Census Region | <0.01 | |||
| Midwest (%) | 133 (37.25) | 63,242 (27.15) | 63,375 (27.17) | |
| Northeast (%) | 58 (16.25) | 45,584 (19.57) | 45,642 (19.57) | |
| South (%) | 164 (45.94) | 116,098 (49.85) | 116,262 (49.84) | |
| West (%) | 2 (0.56) | 7,985 (3.43) | 7,987 (3.42) | |
| Urban Status | <0.01 | |||
| Yes (%) | 304 (85.15) | 210,844 (90.53) | 211,148 (90.52) | |
| No (%) | 53 (14.85) | 22,065 (9.47) | 22,118 (9.48) | |
| Insurance | 0.26 | |||
| Public (%) | 160 (44.82) | 97,639 (41.92) | 97,799 (41.93) | |
| Private (%) | 197 (55.18) | 134,240 (57.64) | 134,437 (57.63) | |
| Other (%) | 0 (0.00) | 1,030 (0.44) | 1,030 (0.44) | |
| Complex Chronic Condition | 0.41 | |||
| Yes (%) | 23 (6.44) | 17,685 (7.59) | 17,708 (7.59) | |
| No (%) | 334 (93.56) | 215,224 (92.41) | 215,558 (92.41) | |
| Admission Type | <0.01 | |||
| Inpatient (%) | 8 (2.24) | 577 (0.25) | 585 (0.25) | |
| Ambulatory Surgery (%) | 283 (79.27) | 206,878 (88.82) | 207,161 (88.81) | |
| Observation Status (%) | 66 (18.49) | 25,454 (10.93) | 25,520 (10.94) | |
| APR-DRG Severity | 0.63 | |||
| Minor (%) | 316 (88.52) | 207,165 (88.95) | 207,481 (88.95) | |
| Moderate (%) | 35 (9.80) | 22,592 (9.70) | 22,627 (9.70) | |
| Major (%) | 5 (1.40) | 2,960 (1.27) | 2,965 (1.27) | |
| Extreme (%) | 1 (0.28) | 192 (0.08) | 193 (0.08) | |
| Surgical Complications | 0.06 | |||
| Yes (%) | 6 (1.68) | 1,838 (0.79) | 1,844 (0.79) | |
| No (%) | 351 (98.32) | 213,071 (99.21) | 231,422 (99.21) | |
| Mortality | 0.97 | |||
| Yes (%) | 0 (0.00) | 1 (0.00) | 1 (0.00) | |
| No (%) | 357 (100.0) | 232,908 (100.00) | 233,265 (100.00) | |
| Age, median (IQR) | 2 (1-6) | 3 (1-6) | 3 (1-6) | 0.06 |
| Median Household Income, median (IQR) | $44,822 ($35,734-$61,535) | $48,172 ($37,356-$61,393) | $48,172 ($37,356-$61,393) | 0.25 |
| Adjusted Estimated Hospital Cost, median (IQR) | $3,102 ($2,723-$4,175) | $2,991 ($1,706-$4,371) | $2,990 ($1,704-$4,372) | <0.01 |
| Length of Stay, median (IQR) | 1 (1-1) | 1 (1-1) | 1 (1-1) | <0.01 |
Cells represent number and percentage derived from row totals for categorical variables. Cells represent median and interquartile range (IQR) for continuous variables.
3.2. Primary Outcome
The quarterly rate of weekend surgeries ranged from 0.04% to 0.32% during the study period from 01/01/2016-12/31/2019 with the peak occurring during the third quarter of 2016. The proportion of weekend surgeries remained stable from 2016 to 2019 (p=0.65) (Figure 2). Stability in the number of weekend surgeries performed was observed for each respective type of selected surgery: myringotomy (p=0.16), tonsillectomy-adenoidectomy (p=0.17), orchiopexy (p=0.64), inguinal hernia repair (p=0.12), circumcision (p=0.09), and strabismus repair (p=0.53). Overall, there was a significant downward trend in the total number of selected surgeries performed at any time (weekday and weekend) during the study period from a peak of 19,769 surgeries performed in the first quarter of 2016 decreased to a low of 12,831 in the last quarter of 2019 (p=0.02).
3.3. Secondary Outcomes
Multivariable logistic regression modeling odds of a surgical complication showed no difference in the odds of a surgical complication for those who had surgery during weekend compared to weekday hours while accounting for age, race, sex, ethnicity, geographical region, urban status, insurance payer status, number of procedures, and CCC [adjusted OR (aOR): 1.59; 95%CI: 0.65-3.90] (Table 2). Covariates by performance of surgery on the weekend compared to weekdays that were independently associated with a higher likelihood of surgical complications included female gender (aOR: 1.13; 95%CI: 1.03-1.25), non-urban location (aOR: 1.39; 95% CI: 1.21-1.59), presence of a CCC (aOR: 4.55; 95% CI: 3.80-5.43), admission status (inpatient aOR: 5.06; 95%CI: 3.63-7.04 and observation aOR: 1.43; 95%CI: 1.26-1.63), higher APR-DRG case severity (Major severity aOR: 1.89; 95%CI: 1.49-2.40 and Extreme severity aOR: 5.55; 95%CI: 3.49-8.85), and a higher number of procedures within an encounter (aOR: 1.45; 95%CI: 39-1.53) (Table 2). Following adjustment for age, race, sex, ethnicity, geographical region, urban status, insurance payer status, CCC, number of procedures, length of stay, and median household income, weekend surgical procedures were associated with $312 increase in total adjusted estimated hospital costs (95%CI: $152 to $473) (Table 3) compared to procedures performed on weekdays.
Table 2.
Multivariable logistic model of the association of surgical complications with performance of surgery on the weekend
| Surgical Complications | Odds Ratio (OR) | 95% Confidence Interval (CI) | p-value |
|---|---|---|---|
| Weekend Status | |||
| No | Reference | ||
| Yes | 1.59 | 0.65-3.90 | 0.32 |
| Gender | |||
| Male | Reference | ||
| Female | 1.13 | 1.03-1.25 | <0.01 |
| Ethnicity | |||
| Non-Hispanic | Reference | ||
| Hispanic | 0.82 | 0.70-0.97 | 0.02 |
| Unknown | 4.58 | 4.00-5.26 | <0.01 |
| Race | |||
| White | Reference | ||
| Black | 0.91 | 0.79-1.03 | 0.16 |
| Asian | 0.78 | 0.57-1.07 | 0.13 |
| Other | 0.74 | 0.61-0.90 | <0.01 |
| Census Region | |||
| South | Reference | ||
| Midwest | 0.87 | 0.77-0.98 | 0.02 |
| Northeast | 0.86 | 0.75-0.99 | 0.03 |
| West | 1.21 | 0.93-1.57 | 0.15 |
| Urban Status | |||
| Yes | Reference | ||
| No | 1.39 | 1.21-1.59 | <0.01 |
| Insurance | |||
| Private | Reference | ||
| Public | 1.08 | 0.97-1.19 | 0.16 |
| Other | 0.91 | 0.40-2.07 | 0.83 |
| Complex Chronic Condition | |||
| No | Reference | ||
| Yes | 4.55 | 3.80-5.43 | <0.01 |
| Admission Type | |||
| Ambulatory Surgery | Reference | ||
| Inpatient | 5.06 | 3.63-7.04 | <0.01 |
| Observation Status | 1.43 | 1.26-1.63 | <0.01 |
| APR-DRG Severity | |||
| Minor | Reference | ||
| Moderate | 1.15 | 0.95-1.38 | 0.15 |
| Major | 1.89 | 1.49-2.40 | <0.01 |
| Extreme | 5.55 | 3.49-8.85 | <0.01 |
| Age | 1.01 | 1.00-1.02 | 0.09 |
| Procedure Number | 1.45 | 1.39-1.53 | <0.01 |
| Year of Operation | 0.93 | 0.90-0.97 | <0.01 |
aOR=adjusted odds ratio, 95% CI=95% confidence interval
Table 3.
Multivariable quantile linear regression model of the association of adjusted estimated hospital costs with performance of surgery on the weekend
| Adjusted Estimated Cost | Beta Coefficient in Dollars | 95% Confidence Interval (CI) | P-value |
|---|---|---|---|
| Weekend Status | |||
| Yes | 312 | 152, 473 | <0.01 |
| No | Reference | ||
| Age | |||
| Neonate, <30 days | 684 | −179, 1,549 | 0.12 |
| Infant, <2 years | −533 | −549, −516 | <0.01 |
| Child, 2-12 years | Reference | ||
| Adolescent, 12-18 years | 485 | 455, 515 | <0.01 |
| Gender | |||
| Female | −173 | −187, −159 | <0.01 |
| Male | Reference | ||
| Ethnicity | |||
| Hispanic | 1,451 | 1,425, 1,477 | <0.01 |
| Non-Hispanic | Reference | ||
| Unknown | 342 | 293, 391 | <0.01 |
| Race | |||
| White | Reference | ||
| Black | 179 | 155, 203 | <0.01 |
| Asian | 452 | 372, 532 | <0.01 |
| Other | −42 | −71, −13 | <0.01 |
| Census Region | |||
| Midwest | 720 | 702, 738 | <0.01 |
| Northeast | 1,821 | 1,789, 1,853 | <0.01 |
| South | Reference | ||
| West | 1,985 | 1,941, 2,029 | <0.01 |
| Urban Status | |||
| Yes | Reference | ||
| No | −117 | −145, −89 | <0.01 |
| Insurance | |||
| Public | 118 | 97, 139 | <0.01 |
| Private | Reference | ||
| Other | −231 | −302, −160 | <0.01 |
| Complex Chronic Condition | |||
| Yes | 439 | 392,486 | <0.01 |
| No | Reference | ||
| Admission Type | |||
| Inpatient | 4,210 | 3,598, 4,822 | <0.01 |
| Ambulatory Surgery | Reference | ||
| Observation Status | 1,839 | 1,808, 1,870 | <0.01 |
| APR-DRG Severity | |||
| Minor | Reference | ||
| Moderate | 259 | 223, 294 | <0.01 |
| Major | 871 | 764, 979 | <0.01 |
| Extreme | 2,575 | 1,806, 3,343 | <0.01 |
| Procedure Number | 83 | 74, 92 | <0.01 |
| Year of Service | 447 | 439, 455 | <0.01 |
| Median Household Income | 0 | 0 | <0.01 |
| Length of Stay | 1,879 | 1,376, 2,383 | <0.01 |
Cells represents costs measured in US dollars.
4. Discussion
This multi-center, retrospective cross-sectional analysis of six elective surgical procedures performed on children <18 years of age from 2016 to 2019 during weekend versus weekday hours indicates that performance of elective surgeries on weekends was infrequent, but stable in occurrence. Overall surgical volumes for the six selected surgeries significantly decreased over the study period. These findings contradict our initial hypothesis that surgical volumes on weekends were increasing based on perceived limitations in limited operating room availability during weekdays. Our findings also show that weekend elective surgical cases are not associated with substantially increased costs or compromise in patient safety in terms of surgical morbidity and mortality. Patients with high-risk profiles such as chronic complex conditions or higher case severity had increased odds of suffering a surgical complication on weekends, indicating appropriate patient selection for performance on the weekend is warranted. Moreover, our results suggest the well documented “weekend effect,” whereby patients undergoing surgery during weekend hours experience increased morbidity and mortality, can be avoided with the careful selection of low-risk elective surgical procedures.12–14,19
While we expected to observe an increase in surgical volume over time at specialized children’s hospitals due to regionalization, the rate of the six selected elective weekend surgeries remained stable and the overall surgical volume decreased over the study time period. Based on the literature, the rate of pediatric surgery performed in the U.S. from 2005 to 2018 has remained relatively stable over time.20 According to data from the 2016 Kid Inpatient Database, regionalization of pediatric surgical care was already underway at the start of our study with only 8.7% of U.S. hospitals admitting children responsible for 90.1% of pediatric surgeries3 and approximately one half of these hospitals with pediatric surgical volume of less than 10 patients per year.6 We likely observed a significant downtrend of surgical volume as a possible consequence of limiting our cohort to the most common six elective surgeries performed on the weekend. Overall, our results show elective weekend surgery was performed at a low, steady rate over time and has not been utilized to increase operative capacity.
Multiple arguments could be made for considering scheduling elective surgeries during weekend hours. Ample evidence examining ambulatory surgery and same day discharge after routine surgeries (e.g., appendectomies) highlight patient and family preferences to minimize time in the hospital and recover at home after surgery.16,21,22 Notably, all of the most commonly performed elective weekend surgeries sampled for analysis are routine same-day discharge surgeries (e.g., myringotomy with or without Eustachian tubes, tonsillectomy-adenoidectomy, orchiopexy, inguinal hernia repair, circumcision, and strabismus repair). Elective weekend surgeries could have special appeal to families by offering broader scheduling options for same-day discharge procedures. Moreover, the economic impact of pediatric surgical care on families could be decreased by minimizing direct non-medical costs such as avoiding lost wages from missing work or allowing for more flexible travel plans or child care coverage for siblings at home outside typical weekday business hours.16,21–23
Provider preferences should also be taken into account. Surgeons may embrace the opportunity to operate on routine elective cases during the weekend in order to preserve weekday block time for clinically complex scheduled or inpatient cases and to leave room for potential urgent/emergent cases. In contrast, surgeons and operative support staff may regard the promotion of elective weekend surgery as an intrusion or threat on their discretionary free time, leading to decreases in staff satisfaction. Ultimately, careful consideration of surgeon and staff perspectives is imperative to obtain buy-in and feedback on how to optimize access to elective weekend surgery while preventing staff burnout and balancing patient/family satisfaction.24
From a system perspective, disruptions in normal hospital processes, resources, and staffing, such as those experienced during the coronavirus disease of 2019 (COVID-2019) pandemic, may result in surgical backlogs and delays.25 Surgeons and administrators must work collaboratively to proactively consider system wide capacity management.26 Shifting elective surgeries to weekend hours may be one potential strategy.25 Our study findings show that markedly increased costs and concerns for patient safety were not significant barriers to implementing elective weekend surgeries. Additional hospital costs for elective weekend surgeries, however, could arise if dedicated surgical staff (e.g., registration, anesthesia, nursing for post-anesthesia care unit) were required to effectively complete a higher volume of weekend cases than the low case rates evaluated in this study.15 Significant resource allocation in the form of premium pay to surgical staff for overtime or on-call scheduling may be necessary to optimize surgical workflow outside typical business hours and organize an efficient weekend call team. Implementing elective weekend surgeries may incur additional expenses to the hospital and draw away resources from other clinical priorities even if those expenses do not translate into direct costs charged to patients. Therefore, operative physicians, staff, and administrators should proceed cautiously by weighing the benefits and risks of performing elective weekend surgeries and assess if it is appropriate based on their current financial and clinical environment.
Limitations of this study include the typical restrictions of using administrative databases such as limited data sources and issues with data quality. PHIS only includes data from specialized, high-volume children’s hospitals and thus, the data may not accurately describe trends in non-children’s hospitals that may perform pediatric surgical procedures and have different institutional care patterns affecting outcomes and costs. Confounders included emergency surgeries that need immediate operative management regardless of timing and could bias the analysis of scheduled procedures on the weekend. Although difficult, we tried to avoid misclassification bias within our cohort by ensuring encounters with an ED charge were excluded a priori from the cohort to minimize the number of surgeries performed in urgent or emergent settings. Additionally, within PHIS, a significant proportion of surgeries were miscoded as “elective” on priority of admission, but had urgent/emergent clinical indications (i.e., Extracorporeal Membrane Oxygenation). Directly comparing the outcomes of elective weekend and weekday surgeries is already highly susceptible to selection bias as the risk profiles of patients scheduled for surgery may be inherently different based on clinical decision making. We attempted to mitigate this selection bias by optimizing our procedure cohort and only selecting commonly performed procedures with non-urgent indications and adjusting for patient factors such as CCC and increased case severity in our regression models. Nevertheless, the generalizability of our conclusion that a select few elective weekend surgeries can be performed without the “weekend” effect is limited to settings such as specialized children’s hospitals in healthy patients without chronic issues.
5. Conclusion
The performance of elective weekend surgeries at specialized children’s hospitals was infrequent, but the rate has remained stable over time. No increased likelihood of complications, but a mild increase in estimated hospital costs, were observed for elective weekend surgeries compared to weekday surgeries. As hospitals consider increasing operative capacity by leveraging weekend operating room availability, evaluation of patient and provider perspectives, unexpected human resource costs, and thorough case selection is required to deliver high quality, safe surgical care.
Supplementary Material
Figure 1.
Cohort creation to evaluate elective weekend versus weekday surgery.
Highlights:
Pediatric surgeries performed during the weekend compared to scheduled weekday hours are at higher risk of morbidity and mortality called the “weekend effect” and tend to have more urgent/emergent indications.
This study explores whether elective pediatric surgeries during the weekend are subject to the “weekend effect” and/or increased hospital costs.
FUNDING:
Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number T37MD014248. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
ABBREVIATIONS:
- PHIS
Pediatric Health Information System
- CMS
Center for Medicare & Medicaid Services
- DRG
Diagnostic Related Group
- CPT
Current Procedural Terminology
- ICD-10
International Classification of Diseases, Tenth Edition
- IRB
Institutional Review Board
- STROBE
Strengthening Reporting of Observational Studies in Epidemiology
- ED
Emergency Department
- CCC
Complex Chronic Condition
- SD
Standard Deviation
- CI
Confidence Interval
- aOR
Adjusted Odds Ratio
- COVID-2019
Coronavirus disease of 2019
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
MEETING PRESENTATION: This manuscript was presented as an oral e-poster presentation at the American College of Surgeons Clinical Congress held in Boston MA from October 24-26, 2023.
CONFLICT OF INTEREST: There are no conflicts of interest regarding these data.
References
- 1.Salazar JH, Goldstein SD, Yang J, et al. Regionalization of pediatric surgery trends already underway. Ann Surg. 2016;263(6): 1062–1066. doi: 10.1097/SLA.0000000000001666 [DOI] [PubMed] [Google Scholar]
- 2.Bruns NE, Shah MA, Dorsey AN, Ponsky TA, Soldes OS. Pediatric surgery - A changing field: National trends in pediatric surgical practice. J Pediatr Surg. 2016;51(6):1034–1038. doi: 10.1016/j.jpedsurg.2016.02.079 [DOI] [PubMed] [Google Scholar]
- 3.McManus ML, França UL. Availability of Inpatient Pediatric Surgery in the United States. Anesthesiology. 2021;134(6):852–861. doi: 10.1097/ALN.0000000000003766 [DOI] [PubMed] [Google Scholar]
- 4.França UL, Mcmanus ML. Trends in Regionalization of Hospital Care for Common Pediatric Conditions. Pediatrics. 2018;141(1):20171940. http://publications.aap.org/pediatrics/article-pdf/141/1/e20171940/1066546/peds_20171940.pdf [DOI] [PubMed] [Google Scholar]
- 5.França UL, McManus ML. Availability of definitive hospital care for children. JAMA Pediatr. 2017;171(9). doi: 10.1001/jamapediatrics.2017.1096 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Berry JG, Rodean J, Leahy I, et al. Hospital Volumes of Inpatient Pediatric Surgery in the United States. Anesth Analg. 2021;133(5):1280–1287. doi: 10.1213/ANE.0000000000005748 [DOI] [PubMed] [Google Scholar]
- 7.Short HL, Sarda S, Travers C, Hockenberry JM, McCarthy I, Raval MV. Trends in common surgical procedures at children’s and nonchildren’s hospitals between 2000 and 2009. J Pediatr Surg. 2018;53(8):1472–1477. doi: 10.1016/j.jpedsurg.2017.11.053 [DOI] [PubMed] [Google Scholar]
- 8.Lorch SA, Myers S, Carr B. The regionalization of pediatric health care. Pediatrics. 2010;126(6):1182–1190. doi: 10.1542/peds.2010-l119 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.VonAchen P, Davis MM, Cartland J, D’Arco A, Kan K. Closure of Licensed Pediatric Beds in Health Care Markets Within Illinois. Acad Pediatr. 2022;22(3):431–439. doi: 10.1016/j.acap.2021.06.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Availability of Pediatric Inpatient Services in the United States. Pediatrics. 2021;148(1). doi: 10.1542/PEDS.2020-041723 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Goldstein SD, Papandria DJ, Aboagye J, et al. The “weekend effect” in pediatric surgery - Increased mortality for children undergoing urgent surgery during the weekend. J Pediatr Surg. 2014;49(7): 1087–1091. doi: 10.1016/j.jpedsurg.2014.01.001 [DOI] [PubMed] [Google Scholar]
- 12.Smith SA, Yamamoto JM, Roberts DJ, et al. Weekend Surgical Care and Postoperative Mortality. Med Care. 2018;56(2):121–129. doi: 10.1097/MLR.0000000000000860 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Desai V, Gonda D, Ryan SL, et al. The effect of weekend and after-hours surgery on morbidity and mortality rates in pediatric neurosurgery patients. J Neurosurg Pediatr. 2015;16(6):726–731. doi: 10.3171/2015.6.PEDS15184 [DOI] [PubMed] [Google Scholar]
- 14.Egberg MD, Galanko JA, Kappelman MD. Weekend Surgical Admissions of Pediatric IBD Patients Have a Higher Risk of Complication in Hospitals Across the US. Inflamm Bowel Dis. 2020;26(2):254–260. doi: 10.1093/ibd/izzl39 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ott KC, McMahon MA, Vacek JC, et al. The costs and benefits of emergent surgical workflow for acute appendicitis in children. J Pediatr Surg. 2022;57(12):896–901. doi: 10.1016/J.JPEDSURG.2022.06.018 [DOI] [PubMed] [Google Scholar]
- 16.Olson JK, Deming LA, King DR, et al. Single visit surgery for pediatric ambulatory surgical procedures: a satisfaction and cost analysis. J Pediatr Surg. 2018;53(1):81–85. doi: 10.1016/J.JPEDSURG.2017.10.021 [DOI] [PubMed] [Google Scholar]
- 17.Leverage Clinical and Resource Utilization Data. Accessed December 20, 2023. https://www.childrenshospitals.org/content/analytics/product-program/pediatric-health-information-system
- 18.Simon TD, Group for the C of E on Q of CM for C with CN (COE4CCN) MCW, Cawthon ML, et al. Pediatric Medical Complexity Algorithm: A New Method to Stratify Children by Medical Complexity. Pediatrics. 2014;133(6):e1647–e1654. doi: 10.1542/PEDS.2013-3875 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Bell CM, Redelmeier DA. Mortality among Patients Admitted to Hospitals on Weekends as Compared with Weekdays. New England Journal of Medicine. 2001;345(9):663–668. doi: 10.1056/nejmsa003376 [DOI] [PubMed] [Google Scholar]
- 20.Rabbitts JA, Groenewald CB. Epidemiology of Pediatric Surgery in the United States. Paediatr Anaesth. 2020;30(10):1083–1090. doi: 10.1111/PAN.13993 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Cheng O, Cheng L, Burjonrappa S. Facilitating factors in same-day discharge after pediatric laparoscopic appendectomy. J Surg Res. 2018;229:145–149. doi: 10.1016/J.JSS.2018.03.072 [DOI] [PubMed] [Google Scholar]
- 22.Zheng Y, Qi S. Feasibility of Same-Day Discharge After Appendectomy in Pediatric Patients: A Systematic Review and Meta-Analysis. Front Pediatr. 2022; 10. doi: 10.3389/FPED.2022.944405 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Scott AR, Rush AJ, Naik AD, Berger DH, Suliburk JW. Surgical follow-up costs disproportionately impact low-income patients. Journal of Surgical Research. 2015;199(1):32–38. doi: 10.1016/J.JSS.2015.04.013 [DOI] [PubMed] [Google Scholar]
- 24.Skarda DE, Danko ME, Glick RD, et al. Dollars and Sense: The Business of Pediatric Surgery. J Surg Res. 2023;285:220–228. doi: 10.1016/J.JSS.2022.12.038 [DOI] [PubMed] [Google Scholar]
- 25.Matava C, So J, Williams R, Kelley S. A Canadian Weekend Elective Pediatric Surgery Program to Reduce the COVID-19–Related Backlog: Operating Room Ramp-Up After COVID-19 Lockdown Ends—Extra Lists (ORRACLE-Xtra) Implementation Study. JMIR Perioper Med. 2022;5(1):e35584. doi: 10.2196/35584 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Mattingly AS, Rose L, Eddington HS, et al. Trends in US Surgical Procedures and Health Care System Response to Policies Curtailing Elective Surgical Operations during the COVID-19 Pandemic. JAMA Netw Open. 2021;4(12). doi: 10.1001/jamanetworkopen.2021.38038 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.