Weekend Work

Systems of health care delivery have been changing at an increasing rate during this decade. Decisions to change must balance the needs of competing interests, which include patient concerns, cost pressures, and market realities. Cost pressures and pressure from consumers are forcing health care systems to reevaluate how they provide a wide variety of services from diagnostic testing to ambulatory care services. In these decisions the interests of physicians and other health care staff and their needs for job convenience and satisfaction come into play. In this issue, Krasuski and colleagues describe one such decision for change.¹ They report the evaluation of a decision to change when services are offered, in this case the provision of exercise electrocardiographic testing on weekends and holidays.

Historically, hospitals have operated with reductions in both the amount and type of services available on the weekend. For example, Chu and colleagues described in 1982 that over the weekend the daily number of regular laboratory test requests decreased more than the daily number of stat requests.² This practice and others like it are the result of implicit decisions made primarily for staffing convenience, since biological conditions do not respect the distinction between weekends and weekdays. The operating rule of thumb appears to be that a service is available if it is needed to meet a patient’s urgent clinical condition. If a service is not needed urgently for clinical reasons, it can wait until the weekend is over.

The increase in cost pressure on health care systems from employers and payers is changing how these decisions are made. Time has become a key element in cost reduction, and most health care systems are working hard to reduce the average length of a hospital stay. Tools developed in the manufacturing industry, such as critical pathways, are being applied to identify specific causes that delay hospital discharge. Strategies are then developed to prevent these delays. In this context, timely availability of a diagnostic test may not be necessary for an urgent clinical reason, but it may significantly increase the time spent on the critical path.

The study by Krasuski et al. demonstrates the application of this methodology. The opportunity for improvement was first identified in this journal in 1993, when Sheng and colleagues questioned whether the lack of cardiac testing on the weekend significantly contributed to a delay in hospital discharge.³ They found that patients admitted for chest pain at the end of the week had a length of stay that was 19% longer than that of similar patients admitted earlier in the week. Krasuski et al. evaluated whether removing this delay from the critical pathway would shorten the hospital admission. They found that 85% of the patients who received electrocardiographic exercise testing on the weekend were discharged on the same day rather than the next Monday. This change resulted in an average reduction in the length of stay of 1.4 days. No significant differences in outcomes were noted when patients tested on the weekend were compared with those tested on a weekday.

An average of $313 per patient was saved in this study, although the amount of money saved will be different in different institutions. One reason for institutional differences in cost savings is that there are institutional differences in the cost of testing and the cost of hospital days. Another reason is that hospitals with more empty beds on weekends than weekdays most likely will realize lower savings because the incremental cost of a weekend day is lower than the average cost of a hospital day. Although Krasuski et al. estimated the incremental cost of staffing the testing service over the weekend, some costs and implementation barriers are not easily measured. Any manager who has added a service in the evenings or on weekends knows the difficulty in finding the appropriate staff, whether the service depends on physicians, nurses, or other staff. Although staffing on the weekend is usually more expensive, Krasuski et al. assumed that the cost of physicians was the same on the weekend as during the week, an assumption that may not apply for all health systems. Moreover, getting staff to work these hours can be a higher barrier to implementing the service than cost. Despite these qualifications, Krasuski and colleagues make a persuasive argument for implementing a weekend electrocardiographic exercise testing service because it is a cost-saving strategy.

This study did not address whether the new strategy improved patient convenience. There has been an ongoing revolution in service industries with many types of services becoming more convenient and accessible. Automated teller machines and the ordering of goods and services over the Internet or using 24-hour telephone lines have increased customers’ expectations. The health care industry has begun to feel the pressure of these increased expectations. As a result, health systems are expanding the hours of service to include evenings, holidays, and weekends, not to reduce costs but to meet customer expectations. Some parts of the health care industry, including those that provide dental and optical services, already have reconfigured themselves substantially to meet these expectations.⁴ It is likely that other parts of the industry will follow as competitive and market pressures increase, and other weekend strategies have been implemented for other services such as those provided by nuclear medicine ⁵ and physical therapy.⁶

More effective changes in the critical pathway for the evaluation of chest pain have been developed since this study was performed in 1994 and 1995. One of the most recent developments is the creation of chest pain units that speed up the diagnostic process further. Patients are admitted to a chest pain unit rather than inpatient setting, and a myocardial infarction is ruled out by determining treponin levels. These patients then receive further testing with different stress-imaging techniques depending on the institutional preference.

We can expect further innovations in the future as our health care system strives to reduce cost and meet patient needs. Many of these changes may make the jobs of health care staff and physicians more inconvenient because they will require more clinical staffing on evenings, holidays, and weekends. These changes must be considered in an explicit manner that balances the demands for clinical quality, cost control, and patient convenience, and the needs of the health care staff.