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

BackgroundRecent 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.MethodsUsing 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.ResultsThe 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.ConclusionsThere 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-017-0825-5) contains supplementary material, which is available to authorized users.

Non-surgical in-hospital mortality predictors: a multivariable regression analysis of 2,855,029 hospitalizations

“…However, not all studies showed increased in -hospital mortality in patients admitted to the hospital at weekends. 40, 41 In our study, hospital admissions at weekends, as well as those on other nonworking days (public holidays), were significant predictors of in -hospital mortality. We also observed that the number of deaths was higher on Wednesdays, Thursdays, and Fridays than on Mondays.…”

Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the treatment of trochanteric hip fractures

“…Trochanteric fractures represent between one third and one half of hip fractures. 1,4,5 There is controversy regarding treatment. Some authorities recommend an extramedullary device (e.g.…”

Reporting and evaluating wait times for urgent hip fracture surgery in Ontario, Canada

“…Although most patients (> 75%) were admitted to hospital within 6 hours of presentation at the emergency department (mean 7.58 h [SD 11.87]), only 14 174 (33.5%) received surgery within the recommended time frame (24 h) ( Figure 1). 1,47,48 The proportion of patients with hip fracture is also reported by their time of presentation, admission and surgery in Appendix 2, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.170830/-/ DC1. Whereas 5837 patients (13.8%) arrived overnight, only 441 patients (1.0%) received surgery during this time.…”

“…Two-thirds (66%) of the participants did not receive surgery within the safe time frame (24 h). 1,47,48 Variation within Ontario's public health care system warrants performance improvement at the hospital level.Variation in wait times was attributable to treatment at different hospitals, as opposed to treatment by different phys icians. As such, initiatives for quality improvement may target hospitallevel processes preferentially rather than individual physician practices.…”