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Variation in timely surgery for hip fracture by day and time of presentation: a nationwide prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland
  1. Anjali Shah1,2,
  2. Gulraj S Matharu1,2,
  3. Dominic Inman3,4,
  4. Elizabeth Fagan4,
  5. Antony Johansen4,5,
  6. Andrew Judge1,2
  1. 1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  2. 2Musculoskeletal Research Unit, University of Bristol, Bristol, UK
  3. 3Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, North Shields, Tyne and Wear, UK
  4. 4Care Quality Improvement Department, Royal College of Physicians, London, UK
  5. 5Trauma Unit, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
  1. Correspondence to Dr Anjali Shah, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; anjali.shah{at}


Background and Objective Several studies report poorer quality healthcare for patients presenting at weekends. Our objective was to examine how timely surgery for patients with hip fracture varies with day and time of their presentation.

Methods This population-based cohort study used 2017 data from the National Hip Fracture Database, which recorded all patients aged 60 years and over who presented with a hip fracture at a hospital in England, Wales and Northern Ireland. Provision of prompt surgery (surgery within 36 hours of presentation) was examined, using multivariable logistic regression with generalised estimating equations to derive adjusted risk ratios (RRs). Time was categorised into three 8-hour intervals (day: 08:00–15:59, evening: 16:00–23:59 and night: 00:00–07:59) for each day of the week. The model accounted for clustering by hospital and was adjusted by sex, age, fracture type, operation type, American Society of Anesthesiologists grade, preinjury mobility and location.

Results We studied 68 977 patients from 177 hospitals. The average patient presenting during the day on Friday or Saturday was significantly less likely to undergo prompt surgery (Friday during 08:00–15:59, RR=0.93, 95% CI 0.91 to 0.96; Saturday during 08:00–15:59, RR=0.91, 95% CI 0.88 to 0.94) than patients in the comparative category (Thursday, during the day). Patients presenting during the evening (16:00–23:59) were consistently significantly less likely to undergo prompt surgery, and the effect was more marked on Fridays and Saturdays (Friday during 16:00-23:59, RR=0.83, 95% CI 0.80 to 0.85; Saturday during 16:00–23:59, RR=0.81, 95% CI 0.78 to 0.85). Patients presenting overnight (00:00–07:59), except on Saturdays, were significantly more likely to undergo surgery within 36 hours (RR>1.07).

Conclusion The provision of prompt hip fracture surgery was complex, with evidence of both an ‘evening’ and a ‘night’ effect. Investigation of weekly variation in hip fracture care is required to help implement strategies to reduce the variation in timely surgery throughout the entire week.

  • surgery
  • adverse events, epidemiology and detection
  • healthcare quality improvement
  • hospital medicine

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  • Contributors AJo and AJu conceived and designed the study. AS cleaned the data, did the statistical analyses, interpreted the findings and drafted the paper. GSM interpreted the findings, added clinical commentary, performed the literature review and drafted the paper. All authors, including DI and EF, contributed to the interpretation of the data and findings, and revised the manuscript. All authors approved the final manuscript submitted.

  • Funding This work was performed to provide individual hospitals participating in the NHFD with a picture of variation in their performance across the week, as part of a Royal College of Physicians audit programme commissioned by the HealthCare Quality Improvement Partnership (HQIP). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NHS or the Department of Health. The funding source had no role in the design and conduct of the study, in the collection, analysis and interpretation of the data, or in the preparation, review or approval of the manuscript. The corresponding author had full access to all the study data and had final responsibility for the decision to submit for publication.

  • Competing interests GSM has received financial support for other research work from Arthritis Research UK, the Orthopaedics Trust, Royal College of Surgeons of England and Royal Orthopaedic Hospital Hip Research and Education Charitable Fund. GSM has also received personal fees for undertaking medicolegal work for Leigh Day. AJu has received consultancy fees from Freshfields, Bruckhaus, Deringer and Anthera Pharmaceuticals Inc.

  • Patient consent for publication Not required.

  • Ethics approval Research ethics committee approval was not required for secondary analysis of administrative data in line with Governance Arrangements for Research Ethics Committee guidance.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Data were obtained from the National Hip Fracture Database, and permission to use their data must be sought (