The association between the day of the week of milestones in the care pathway of patients with hip fracture and 30-day mortality: findings from a prospective national registry - The National Hip Fracture Database of England and Wales

Abstract

Background: Recent publications indicate increased mortality in patients admitted to hospital at the weekend, but these findings may be subject to inadequate adjustment for case-mix and the complexities of resource provision. Hip fractures generally occur in a frail comorbid population with a consistent diagnosis precipitating admission as an emergency. We therefore aimed to examine the association between the day of the week of milestones in the care pathway and 30-day mortality in this population.

Methods: Using data from a prospective national database of hip fractures, we investigated the association between day of the week of admission, surgery, inpatient stay, and discharge (care pathway milestones) and 30-day mortality using generalised linear models. Data was collected between January 1, 2011, and December 31, 2014, on 241,446 patients. An incremental case-mix adjustment strategy was performed using patient characteristics, non-surgical interventions, surgical interventions and discharge characteristics.

Results: The day of admission was not associated with 30-day mortality. Sunday surgery (OR, 1.094; 95% CI, 1.043-1.148; P < 0.0001) and a delay to surgery of more than 24-hours (OR, 1.094; 95% CI, 1.059, 1.130; P < 0.0001) were both associated with a 9.4% increase in 30-day mortality. Discharge from the hospital on a Sunday (OR, 1.515; 95% CI, 1.224, 1.844; P < 0.0001) or out-of-hours discharge (OR, 1.174; 95% CI, 1.081, 1.276; P < 0.0001) were associated with a 51.5% and 17.4% increase in 30-day mortality, respectively. Mortality during the inpatient stay was 5.6% lower (IRR, 0.944; 95% CI, 0.909, 0.980; P = 0.003) at the weekend compared to weekdays.

Conclusions: There is limited evidence of a generalised weekend effect in patients admitted to hospital for hip fracture. Optimising resource utilisation is an essential element of planning and delivering healthcare services. Interventions that lead to surgery within 24-hours of admission are justified. Factors such as Sunday operations, discharge and out-of-hours discharge require further investigation.

Keywords: 30-day mortality; Admission; Day of the week; Day of the week effects; Discharge; Hip fracture; Mortality; National Hip Fracture Database; Neck of femur fracture; Surgery; Time to surgery; Weekend effect.

Fig. 1

The care pathway of patients admitted for hip fracture

Fig. 2

Patient inclusion/exclusions into the study

Fig. 3

Number of inpatient deaths in patients admitted with hip fracture between February 1, 2011, and December 31, 2014. The upper panel models the incidence of death across the period of interest using an elapsed month model. The lower panel models the incidence of death across the period of interest using cubic splines with knot points every 74 days. Solid lines indicate weekdays, whereas dashed lines indicate the weekend