The hospital is probably the last place you want to spend the Christmas holidays.
But being discharged from hospital at this time of year carries some significant risks, a new study shows.
Patients sent home around Christmas time are more likely to have bad outcomes than those discharged at other times, including increased higher risks of readmission and death.
The research, led by Dr. Lauren Lapointe-Shaw, an internist at Toronto General Hospital and a PhD student at the University of Toronto, confirms what health workers and patients alike know anecdotally: December holidays are a challenging time of year to be in the health system.
The new study, published in The BMJ, helps pinpoint how this plays out for hospital patients.
Dr. Lapointe-Shaw and her team examined data from more than 200 Ontario hospitals between 2002 and 2016. They compared discharge data for more than 200,000 patients sent home during the two-week period around Christmas and New Year’s with that of more than 450,000 similar patients discharged during November and January.
All the patients had spent significant time in hospital and were discharged home. The study excluded the sickest of the sick, patients who were sent to nursing homes, and long-term care and rehabilitation facilities.
The most striking finding was that those discharged during the holidays were far less likely to get follow-up care – 39 per cent less likely to see a physician within seven days and 35 per cent less likely after 14 days.
The Christmas patients were also 16 per cent more likely to be readmitted to a hospital within seven days, and nine per cent more likely to be readmitted within 30 days. They were also nine per cent more likely to end up in the emergency room.
Presented another way, Dr. Lapointe-Shaw’s data reveal that, for every 100,000 patients discharged during the Christmas period, there were 26 excess deaths, 188 excess hospital admissions, 483 excess ER visits, and 2,999 fewer follow-up appointments.
The study shows that those hit hardest are patients with serious conditions such as heart failure and chronic obstructive pulmonary disease.
Data such as these are helpful at pointing out problems, but they don’t really tell us the underlying causes.
However, the researchers do provide some useful speculation in their paper, largely informed by their clinical practice.
Hospitals remain open and continue to operate 24/7 during the holidays, but the same is not necessarily true of outpatient clinics and physician offices.
That can make booking an appointment and getting follow-up care difficult. These follow-up visits are essential, especially to people who have been hospitalized with a serious health condition. Physicians can review test results and medication, and spot symptoms that point to the deterioration of a patient’s condition.
However, Dr. Lapointe-Shaw points out that placing the blame of poorer outcomes on hospitals and health-care providers would be imprudent.
Many patients put off their health-care appointments because of travel or family obligations. Nobody wants to spend time in a waiting room – whether it’s a doctor’s office or the ER – if the alternative is spending that time with their grandchildren.
The holidays are also a stressful period, and a time of year where people tend to indulge, including drinking and smoking, consuming too much sodium and sugar, and getting less sleep. It’s also cold and flu season – and bugs tend to target the frail and vulnerable.
All of this can be particularly problematic for people with chronic health conditions – and let’s not forget that the three top reasons for hospital admission other than childbirth (new moms and newborns were excluded from the study) are heart problems, digestive problems and respiratory issues.
Regardless of the causes, the bottom line remains that the outcomes were worse.
The University of Toronto researchers are calling this the “Christmas effect” – an echo of earlier studies that noted a “July effect” and “weekend effect” where patients fare worse in those periods.
There are some common themes in all this research.
Over the years, we have taken to releasing patients from the hospital quicker and sicker. For the most part, this is a good thing because hospitals are noisy and full of germs, and patients tend to be immobile. But when you send people home to heal, follow-up care becomes all the more important.
When hospitals reduce staffing, and when related health services in the community, from clinics to family practices, reduce their hours or shut down – as happens on the weekends, during the summer holidays and the Christmas holidays - accessing care is more difficult, and patients pay a price.
Continuity and co-ordination of care matter, but they matter even more during these “down” times, because death and illness do not take holidays.