Is surgery immediately before vs after the weekend associated with postoperative outcomes? YES, A bubbameisa that may be true!
Myron Yaster MD, Genie Heitmiller MD, and Allison Kinder Ross MD
Over the past few years in the Pediatric Anesthesia Article of the Day (PAAD), we’ve challenged a variety of anesthetic beliefs, believed to be dogma, that were instilled in us by our founding fathers/mothers/teachers/textbooks. Many of these beliefs, or bubbameises (“old wives’ tales”), lack significant evidence for their risks or benefits. They include long pre-anesthesia fasting times for clear liquids and breast milk, the use of cricoid pressure during rapid sequence intubation, and the fear of using ketamine in patients with, or at risk of developing, increased intracranial pressure. OK, I know I won’t catch a cold if I go outside in the winter with wet hair (the GOAT bubbameisa), but what about the common belief (superstition/bubbameisa?) that surgery performed on a Friday will have significantly increased risks of complications, readmissions, and mortality compared with those treated after the weekend? In today’s PAAD, Ranganathan et al.1 conducted a large, retrospective ADULT cohort study to find out. The result: some bubbameisas, especially this one, may be true! Myron Yaster MD
Original Article
Ranganathan S, Riveros C, Tsugawa Y, Geng M, Mundra V, Melchiode Z, Ravi B, Coburn N, Jerath A, Detsky AS, Wallis CJD, Satkunasivam R. Postoperative Outcomes Following Preweekend Surgery. JAMA Netw Open. 2025 Mar 3;8(3):e2458794. doi: 10.1001/jamanetworkopen.2024.58794. PMID: 40036038; PMCID: PMC11880952.
“The weekend effect refers to the potential for worse patient outcomes during the weekends, compared with weekdays. In surgery, this concept may also apply to those undergoing surgery immediately before the weekend, who receive postoperative care during the weekend.2,3 To date, few studies have examined the weekend effect on postoperative outcomes comprehensively, across a variety of outcomes (e.g., mortality and complications) at short-term (30 days), intermediate (90 days), and long-term (1 year) time periods among multiple surgical specialties, including both elective and emergent procedures. The authors of today’s PAAD hypothesized that surgery performed immediately before a weekend is associated with worse postoperative outcomes compared with surgery performed after the weekend.”1
Today’s PAAD is a population-based, retrospective cohort analysis of adults undergoing common surgical procedures in Ontario, Canada, between January 1, 2007, and December 31, 2019. The authors identified representative procedures across a variety of subspecialties, including cardiothoracic surgery, general surgery, neurosurgery, obstetrics and gynecology, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, urology, and vascular surgery.
OK, what did they find? Of the 429,691 patients (mean [SD] age, 58.6 [16.9] years; 270 002 female patients [62.8%]) in the study cohort, 199,744 (46.5%) underwent surgery before the weekend, and 229,947 (53.5%) underwent surgery after the weekend. Patients in the preweekend group were more likely than those in the postweekend group to experience the composite outcome of death, complications, and readmissions at 30 days (adjusted odds ratio [aOR], 1.05; 95% CI, 1.02-1.08), 90 days (aOR, 1.06; 95% CI, 1.03-1.09), and 1 year (aOR, 1.05; 95% CI, 1.02-1.09) after surgery. Odds of mortality were increased in the preweekend group vs the postweekend group at 30 days (aOR, 1.09; 95% CI, 1.03-1.16), 90 days (aOR, 1.10; 95% CI, 1.03-1.17), and 1 year (aOR, 1.12; 95% CI, 1.08-1.17).
Wow! This study “is consistent with the majority of published literature, indicating a greater risk of adverse postoperative outcomes among patients undergoing surgery before the weekend.”1,4,5 What accounts for this effect? “System-level factors, such as staffing differences, service availability, and obstacles with care coordination, likely play a contributing role. In a study6 quantifying workforce staffing, numbers for all staff members (doctors, nurses, and other clinical staff) were shown to sharply decline over the weekend. This may contribute to the observed weekend effect via a failure-to-rescue mechanism—that is, a short-staffed weekend team may be less likely to detect and act on acute complications early in their evolution, leading to a higher complication rate for patients.”1 “In addition to reduced personnel, there are also variations in personnel expertise over the weekend. Our results demonstrate that more junior surgeons (those with fewer years of experience) are operating on Friday, compared with Monday; this difference in expertise may play a role in the observed differences in outcomes. Furthermore, weekend teams may be less familiar with the patients than the weekday team previously managing care. In addition, these deficiencies are likely magnified by the reduced availability of resource-intensive tests, interventional procedures, and tools, which may be otherwise available on weekdays. Patients are less likely to be discharged over the weekend, which may be related to differences in medical personnel availability, leading to delays in discharge decision-making and increasing length of stay.”1
It should be noted that the only characteristics with a standardized difference exceeding 0.10 were surgeon age and years in practice, but these differences were not as significant as one would think. The preweekend surgeons had a mean age of 47 years vs 48 years for postweekend surgeons, the difference in median time in practice was 14 vs 17 years. All other measures with regard to anesthesiologists and hospital characteristics were balanced.
Ranganathan et al. concluded: “This study found a weekend effect across multiple surgical specialties, as evidenced by a small but significant increase in the risk of perioperative complications and long-term mortality of patients undergoing surgery immediately before the weekend. Our findings underscore the need for a critical examination of current surgical scheduling practices and resource allocation. One approach for consideration is the optimization of perioperative care pathways to mitigate adverse outcomes. This may involve initiatives to improve adherence to standardized postoperative protocols, such as mobilization and Foley catheter removal, as well as enhanced communication strategies. Furthermore, systems-level approaches and health care policy efforts can also play a role in mitigating these disparities.”1
Would the same results occur in a pediatric population? Without the data we simply do not know, but suspect that the results would be similar. It actually may be even more remarkable in institutions that are children’s hospitals within adult hospitals because of shared operating room staff on nights and weekends who may be less familiar or skilled working with infants and young children.
We do know from a study using National Surgical Quality Improvement Program data that “Pediatric patients undergoing common urgent surgical procedures during a weekend admission have a higher adjusted risk of death, blood transfusion, and procedural complications,”7 but these were only urgent cases. In looking at a mix of elective and urgent cases, Forbes and Butterworth found that primary renal tumour resections (such as Wilm’s Tumor) performed off-hours were associated with “an increase in major (intraoperative) complications compared to those performed in standard hours.”8 Regarding ability to rescue, we know from the Pediatric Resuscitation Quality (pediRES-Q) Collaborative that there was “higher survival to hospital discharge when arrests occurred during the day (vs. nights), or on weekdays (vs. weekends), and this difference was not related to disparities in CC quality.”9 Interestingly, a multi-center study by the Pediatric Heart Network Investigators on infants born with single-ventricles found that “neither weekend admission, nor end-of-the-week Norwood procedure was associated with increased use of hospital resources or poorer outcomes.”10 The authors speculated that the “complex postoperative course following the Norwood procedure outweighs any impact that day of admission or operation may have on these outcomes”.
This is an ideal study for our colleagues who are information technology maven/savants and hope that they will take this issue head on and perform it in the future. What are your thoughts? Please send your comments to Myron who will post in a Friday reader response.
PS from Myron: my wife recently had to undergo urgent/emergency surgery over a holiday weekend. At the time, I was unaware of this article, but her surgeon delayed her surgery until the Monday after the weekend because he “anticipated diminished access to resources over the weekend”. Fortunately, she had a miraculous recovery. Did delaying surgery help? I’ll never know but am so thankful that he waited until Monday morning!
References
1. Ranganathan S, Riveros C, Tsugawa Y, et al. Postoperative Outcomes Following Preweekend Surgery. JAMA network open 2025;8(3):e2458794. (In eng). DOI: 10.1001/jamanetworkopen.2024.58794.
2. Zapf MA, Kothari AN, Markossian T, et al. The "weekend effect" in urgent general operative procedures. Surgery 2015;158(2):508-14. (In eng). DOI: 10.1016/j.surg.2015.02.024.
3. Zare MM, Itani KM, Schifftner TL, Henderson WG, Khuri SF. Mortality after nonemergent major surgery performed on Friday versus Monday through Wednesday. Annals of surgery 2007;246(5):866-74. (In eng). DOI: 10.1097/SLA.0b013e3180cc2e60.
4. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ (Clinical research ed) 2013;346:f2424. (In eng). DOI: 10.1136/bmj.f2424.
5. Smith SA, Yamamoto JM, Roberts DJ, et al. Weekend Surgical Care and Postoperative Mortality: A Systematic Review and Meta-Analysis of Cohort Studies. Medical care 2018;56(2):121-129. (In eng). DOI: 10.1097/mlr.0000000000000860.
6. Xie Y, Khanna S, Good N, Boyle J. Weekly Hospital Workforce Data: A Data Visualisation Exercise. Stud Health Technol Inform 2017;239:153-159. (In eng).
7. 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):1087-91. (In eng). DOI: 10.1016/j.jpedsurg.2014.01.001.
8. Forbes C, Butterworth SA. Perioperative outcomes of primary renal tumour resections: comparison of in-hours to out-of-hours surgery. Pediatr Surg Int 2014;30(10):1003-7. (In eng). DOI: 10.1007/s00383-014-3560-4.
9. Esangbedo I, Yu P, Raymond T, et al. Pediatric in-hospital CPR quality at night and on weekends. Resuscitation 2020;146:56-63. (In eng). DOI: 10.1016/j.resuscitation.2019.10.039.
10. Johnson JT, Sleeper LA, Chen S, et al. Associations Between Day of Admission and Day of Surgery on Outcome and Resource Utilization in Infants With Hypoplastic Left Heart Syndrome Who Underwent Stage I Palliation (from the Single Ventricle Reconstruction Trial). Am J Cardiol 2015;116(8):1263-9. (In eng). DOI: 10.1016/j.amjcard.2015.07.044.