Chronic Obstructive Pulmonary Disease Exacerbations: The Killing Weekends

Alexandros G. Mathioudakis MD1, Victoria Chatzimavridou-Grigoriadou MS2, Georgios A. Mathioudakis MD, PhD2.
1 Medical Department, Southport and Ormskirk NHS Trust, 2 Respiratory Department, General Hospital of Nikaia St. Panteleimon

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Cite as: Mathioudakis AG, Chatzimavridou-Grigoriadou V, Mathioudakis GA. Chronic Obstructive Pulmonary Disease Exacerbations: The Killing Weekends. Alveolus 2013; 1(1):9-12


The weekend effect and generally the off-hour effect have been studied thoroughly during the last couple of years. Both terms refer to the hypothesis that during the weekends/nights, the hospital staff which lacks in numbers, expertise and sometimes experience could possibly pose a burden on the acutely ill patients[1]. Recent cohort studies show increased mortality in weekend admissions for trauma[2-4], stroke[5-6], atrial fibrillation[7], gastrointestinal bleeding[8,9], pulmonary embolism[10], myocardial infarction[11] and COPD[12,13]. Another interesting study show an increased rate of errors in the clinical management of hospitalised patients during the weekend[14].

COPD exacerbations are among the leading causes of morbidity and mortality, while their hospital management is responsible for more than half of the costs of treating respiratory diseases in both Europe and the USA[15]. This data resulted in a quest for the identification of all the potential risk factors for COPD exacerbations and their mortality. The hospital admission during weekends emerged as a significant risk factor associated with increased mortality, by several extensive cohorts[12, 13, 16, 17(N/S)]. However, the causes of this association have not been adequately investigated yet.

Although the weekend effect would be the obvious answer, van den Borst and Wesseling, in their very interesting letter to the editor[18], points that the weekend variation could be secondary to the reluctance of the COPD patients to visit hospital during the weekend. This implies that only the most severe exacerbations would reach the hospital during the weekend, while the rest would either be treated empirically or wait until Monday. The significantly decreased admissions of COPD exacerbations during Saturday and Sunday compared to the weekdays, showed by Barba et al[12], supports this assumption. The significantly increased rates of respiratory failure in the weekend admissions are also supportive.

We should not forget that COPD patients are chronic patients, informed and experienced regarding their disease. Many of them have antibiotics, oxygen and nebulisers in their homes and are able to cope with most of their exacerbations by themselves. They usually can wait until Monday to go to the hospital, in contrary to the patients with trauma, MI, GI bleeding or stroke.

On the other hand, the significant decrease in the mortality of patients admitted with COPD exacerbations during the weekend, after opening a MAU in their hospital, noted by Brims et al[13], supports the weekend effect. As a result, we could hypothesize that both parameters are implicated in the increased mortality of the weekend COPD exacerbation admissions.

The anticipated next step would have been to stratify the admitted patients according to the severity of the exacerbation. Unfortunately, systemic review shows that there is no recognised, reliable severity index. Several indices have been proposed, including CURB-65[19], CAT (COPD Assessment test)[20], MRCD (Medical Research Council Dyspnoea Scale) and eMRCD (extended MRCD)[21], the BODE index[22], demographics and comorbidities[23], spirometry changes, sputum neutrophilia[24], CRP[25], pro-BNP and troponins[26,27]. As a result, we are planning to initiate a clinical study, to evaluate all these indices and their predictive values for increased severity and mortality of a COPD exacerbation. Since this is anticipated to be an extensive study and an extensive design and population will be needed, we would accept suggestions for co-operation from other departments with pleasure.

Table 1. Medical Research Council Dyspnoea Scale.



[1] Cram P, Hillis SL, Barnett M, Rosenthal GE. Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med. 2004 Aug 1;117(3):151-7.

[2] Schneider EB, Hirani SA, Hambridge HL, et al. Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) patients admitted on weekends. J Surg Res. 2012 Jul 7. [Epub ahead of print]

[3] Di Bartolomeo S. The 'off-hour' effect in trauma care: a possible quality indicator with appealing characteristics. Scand J Trauma Resusc Emerg Med. 2011 Jun 9;19:33.

[4] Carr BG, Reilly PM, Schwab CW, et al. Weekend and night outcomes in a statewide trauma system. Arch Surg. 2011 Jul;146(7):810-7. Epub 2011 Mar 21.

[5] Palmer WL, Bottle A, Davie C, et al. Dying for the Weekend: A Retrospective Cohort Study on the Association Between Day of Hospital Presentation and the Quality and Safety of Stroke Care. Arch Neurol. 2012 Jul 9:1-7. doi: 10.1001/archneurol.2012.1030. [Epub ahead of print]

[6] McKinney JS, Deng Y, Kasner SE Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality. Stroke. 2011 Sep;42(9):2403-9. Epub 2011 Aug 25.

[7] Deshmukh A, Pant S, Kumar G, Bursac Z, Paydak H, Mehta JL. Comparison of outcomes of weekend versus weekday admissions for atrial fibrillation. Am J Cardiol. 2012 Jul 15;110(2):208-11. Epub 2012 Apr 3.

[8] Soncini M, Chilovi F, Triossi O, Leo P. Weekend effect in non-variceal upper gastrointestinal bleeding: data from nine italian gastrointestinal units. Am J Gastroenterol. 2012 Apr;107(4):635-6. doi: 10.1038/ajg.2011.431.

[9] Jairath V, Kahan BC, Logan RF, et al. Mortality from acute upper gastrointestinal bleeding in the United kingdom: does it display a "weekend effect"? Am J Gastroenterol. 2011 Sep;106(9):1621-8. doi: 10.1038/ajg.2011.172. Epub 2011 May 24.

[10] Nanchal R, Kumar G, Taneja A, et al. Pulmonary Embolism: The Weekend Effect. Chest. 2012 Mar 29. [Epub ahead of print]

[11] Clarke MS, Wills RA, Bowman RV, et al. Exploratory study of the 'weekend effect' for acute medical admissions to public hospitals in Queensland, Australia. Intern Med J. 2010 Nov;40(11):777-83. doi: 10.1111/j.1445-5994.2009.02067.x.

[12] Barba R, Zapatero A, Losa JE, et al. The impact of weekends on outcome for acute exacerbations of COPD. Eur Respir J. 2012 Jan;39(1):46-50. Epub 2011 Jun 9.

[13] Brims FJ, Asiimwe A, Andrews NP, et al. Weekend admission and mortality from acute exacerbations of chronic obstructive pulmonary disease in winter. Clin Med. 2011 Aug;11(4):334-9.

[14] Buckley D, Bulger D. Trends and Weekly and Seasonal Cycles in the Rate of Errors in the Clinical Management of Hospitalized Patients. Chronobiol Int. 2012 Jun 4. [Epub ahead of print]

[15] Wouters EF. Economic analysis of the Confronting COPD survey: an overview of results. Respir Med. 2003 Mar;97 Suppl C:S3-14.

[16] Kinnunen T, Säynäjäkangas O, Keistinen T. Features of hospitalisations for acute exacerbation of COPD resulting in death. Monaldi Arch Chest Dis. 2007 Mar;67(1):10-4.

[17] Clarke MS, Wills RA, Bowman RV, et al. Exploratory study of the 'weekend effect' for acute medical admissions to public hospitals in Queensland, Australia. Intern Med J. 2010 Nov;40(11):777-83. doi: 10.1111/j.1445-5994.2009.02067.x.

[18] van den Borst B, Wesseling G. Acute exacerbations of COPD: it's the weekend but it can't wait until Monday. Eur Respir J. 2012 Jun;39(6):1547.

[19] Chang CL, Sullivan GD, Karalus NC, et al. Audit of acute admissions of chronic obstructive pulmonary disease: inpatient management and outcome. Intern Med J. 2007 Apr;37(4):236-41.

[20] Mackay AJ, Donaldson GC, Patel AR, et al. Usefulness of the Chronic Obstructive Pulmonary Disease Assessment Test to Evaluate Severity of COPD Exacerbations. Am J Respir Crit Care Med. 2012 Jun 1;185(11):1218-24. Epub 2012 Jan 26.

[21] Steer J, Norman EM, Afolabi OA, et al. Dyspnoea severity and pneumonia as predictors of in-hospital mortality and early readmission in acute exacerbations of COPD. Thorax. 2012 Feb;67(2):117-21. Epub 2011 Sep 6.

[22] Bu XN, Yang T, Thompson MA, et al. Changes in the BODE index, exacerbation duration and hospitalisation in a cohort of COPD patients. Singapore Med J. 2011 Dec;52(12):894-900.

[23] Anzueto A, Miravitlles M, Ewig S, Identifying patients at risk of late recovery (≥8 days) from acute exacerbation of chronic bronchitis and COPD. Respir Med. 2012 Jun 30. [Epub ahead of print]

[24] Zanini A, Della Patrona S, Facchini AL, Spanevello A. Induced sputum in the management of COPD: clinical implications. Monaldi Arch Chest Dis. 2012 Mar;77(1):23-5.

[25] Alavi SA, Soati F, Forghanparast K, Amani H. HsCRP in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Iran Red Crescent Med J. 2011 Oct;13(10):713-8. Epub 2011 Oct 1.

[26] Medina AM, Marteles MS, Sáiz EB, et al. Prognostic utility of NT-proBNP in acute exacerbations of chronic pulmonary diseases. Eur J Intern Med. 2011 Apr;22(2):167-71. Epub 2011 Jan 5.

[27] Marcun R, Sustic A, Brguljan PM, et al. Cardiac biomarkers predict outcome after hospitalisation for an acute exacerbation of chronic obstructive pulmonary disease. Int J Cardiol. 2012 Jun 3. [Epub ahead of print]


Conflicts of Interest: None