BMJ Open Understanding readmission after hip fracture: a mixed methods study protocol

Emma Sutton ® ,1.2 Usama Rahman € ,3 Hannah Reilly,4,5 Caroline Miller © ,4,6 Tarunya Vedutla,4 Teresa Melody,2 Ranaganayaki Gudivada,7 Annie E Topping © 1,2

To cite: Sutton Ε, Rahman U, Reilly Η, et al. Understanding readmission after hip fracture: a mixed methods study protocol. BMJ Open 2025;15:e094163. doi:10.1136/ bmjopen-2024-094163
► Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/ bmjopen-2024-094163).
Received 24 September 2024 Accepted 01 July 2025

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© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group. Department of Nursing and Midwifery School of Health Sciences College of Medicine and Health, University of Birmingham, Birmingham, UK 2School of Nursing, ΑΗΡ and Midwifery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK Darts Bone and Joint Health, Queen Mary University of London, London, UK "University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK 5Institute of Mental Health, University of Nottingham, Nottingham, UK 6School of Infection, Inflammation and Immunology, University of Birmingham, Birmingham, UK Dirmingham Community Healthcare NHS Foundation Trust, Birmingham, UK
Correspondence to
Dr Emma Sutton;
e.sutton.1@bham.ac.uk

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ABSTRACT
Introduction Around 75 000 people suffer from hip fractures yearly in the United Kingdom (UK) leading to significant mortality and morbidity. Although mortality has dropped from 8% to 5% between 2013 and 2023 after hip fractures, those undergoing surgery for hip fractures have a 30-day readmission rate which has remained stagnant at around 11% over the same decade in the UK.
This study protocol describes a mixed-methods investigation (The ARTHUR Study—avoiding readmission after hip fracture) which aims to understand and offer solutions to prevent avoidable 30-day readmission after hip fracture surgery. The study will focus on two hospitals in acute and community settings in a large urban and ethnically diverse city in the UK.
Methods and analysis We describe two work packages. Work Package One (WP1) involves analysis of 5 year’s worth of routinely collected health data provided by PIONEER, a Health Data Research UK data hub in Acute Care for our local population. Work Package Two (WP2) will involve semistructured interviews with patients, carers or family members as well as non-participant observations of hospital processes to understand systems-based issues related to readmissions after hip fracture surgery. Although recruitment may be an issue, our timeline for recruitment reflects this. We also aim to recruit a diverse population, which has often been under-represented in studies into hip fractures and aim to explore relevant interventions which can be widely generalisable.
Ethics and dissemination This protocol was submitted via IRAS: 330074 and obtained UK NHS REC approval via the West Midlands Coventry and Warwickshire Research Ethics Committee (REC 23/WM/0242) on 25 January 2024. The results of this study will be published in relevant scientific journals and presented at orthopaedic, fragility fracture and geriatric specialty conferences and scientific meetings. A lay summary of the findings will be publicly available on the HRA website.
INTRODUCTION
A broken hip ‘hip fracture’ is a serious injury which in the UK leads to over 70 000 people needing surgery followed by rehabilitation. Mortality for hip fracture in England, Wales and Northern Ireland has fallen from 8.4% in 2013 to 6% in 2025. Yet, the number of 30-day readmissions remains high, dropping by only 1% in England over the last decade (12.7%-11.7%). Some areas of England

STRENGTHS AND LIMITATIONS OF THIS STUDY

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The proportion of patient readmissions cited to be potentially avoidable ranges between 5% and 79%11; with the underlying causes of readmission relating to wound problems, infection, ' rehabilitation issues 3 and medicines management (patient adherence, monitoring and prescribing errors).14 These avoidable readmissions may be reduced by self-care, individualised discharge planning, regional anaesthesia,15 collaborative working, improved management of hip fracture pathway documents,16 implementing a preoperative fluid management protocol, reporting how soon community therapy will start after discharge, higher volumes of orthopaedic non-consultant doctors and having plans to reconfigure the service.1' Despite individual, societal and economic impact of reducing avoidable readmission for older people, it is not yet known which specific combination of interventions or dose is effective in reducing readmissions which could be avoidable. This study will ask:
1.		How is avoidable readmission defined and categorised by caregivers and patients?
2.		What are the characteristics of patients with a fractured hip who are admitted and readmitted within 30 days?
3.		Which interventions are most capable of reducing avoidable readmission after fragility fracture of the hip in the Midlands area of England whose population experiences health and wealth inequality?
METHODS AND ANALYSIS
Using mixed methods, this study will:
► Explore how avoidable readmission is understood by caregivers and patients.
► Investigate the characteristics of patients with a fractured hip who are admitted and readmitted within 30 days.
► Describe the patient journey and factors affecting service delivery for hip fracture patients in two National Health Service (NHS) Trusts in the Midlands region of England.
Work package one: PIONEER
Five years of anonymised routinely collected data will be extracted from PIONEER,18 a Health Data Research Hub in Acute Care (https://wwwr.pioneerdatahub.co.uk), relating to admitted fragility hip fracture patients from an acute NHS Trust in the Midlands region of England, (1 January 2019 to 31 December 2023). This data will be retrospectively analysed to identify trends such as age, gender, deprivation, ethnicity and length of in hospital stay. Additionally, we will map number of primary patient admissions and readmissions with hip fracture. We will identity reasons for readmission, and we will analyse wardbased assessments, surgical factors and medical factors which may be associated with readmission. Finally, we will explore data that can be used for health economic evaluation on 30-day readmission. PIONEER data points will be collected from:
► Patients with a hip fracture—a hip fracture refers to a fracture occurring in the area between the edge of the femoral head and 5 cm below the lesser trochanter.19
► Patients with a fragility fracture of the hip—a fracture that results from minimal trauma (eg, a fall from standing height) or no identifiable trauma at all.
► Patients equal to and over the age of 65.
PIONEER will provide licensed access to anonymised data. PIONEER will conduct a technical security assessment of the proposed data storage environment to v ensure it is secure and meets all the license requirements. 2 Data will be analysed under the direction of a PIONEER o statistician who will link primary admission data to read- & missions to identify trends and correlations. Associations 2 with categorical variables will be analysed using X2 tests 8 or Fisher’s exact as appropriate; for continuous variables, 2 we will use t-tests if normally distributed or Kruskal-Wallis 6 tests. Multivariable logistic regression will be performed.- 5 o
Data sharing agreement	5
The anonymised participant data, analytical code and 5 a data dictionary defining each field will be available to 8 others through application to PIONEER via the corre- spending author.
in
Identification of hip fractures, re-admissions and planned analyses a Incident hip fractures will be identified using OPCS 2 (Office of Population Censuses and Surveys), ICD (Inter-o national Classification of Diseases) and Snomed CT J (Systematized Nomenclature of Medicine Clinical Terms)5 codes through the combined electronic health records a system, which is consistently used across all of the included 3 admitting sites. Readmissions will be identified using the o same method and primary readmission diagnoses will be a analysed based on these codes. A measure of deprivation- will be determined using the patient’s primary address A linked to freely available public health local super output — area (LSOA) data.	S
Work package two: observational field work and interviews• Non-participant observations (where researchers collect “ data without actually interacting or participating in the 2 activity being observed) of staff clinical meetings in two 3 NHS Trusts in the Midlands region of England will be D used to understand system-based challenges affecting 6 service delivery (ie, when readmission could have been S avoided/in what circumstances, referral processes); what 9 counts as an avoidable readmission; how people arrive co at a decision/how are processes enacted by staff that 09 may impact on avoidable admission. Clinical meetings such as bed capacity and multidisciplinary team (MTD) meetings have been deliberately selected to observe staff clinical decision-making which will provide insight into systems-based challenges which could affect readmission or readmission risk. Patients will not be observed, and no identifiable patient information will be recorded. All observation activities will be conducted by members of the ARTHUR study team who have received training
on ethnographic observations and will be delegated to undertake this task.
An observation guide will be used to structure field notes (online supplemental file 1). A total of approximately 12—20 meetings over a 4-montli period will be observed. These data will be analysed concurrently using thematic analysis2021 to develop and review codes and work to the principle of information data saturation20 estimated to be reached between 12 and 20 meeting observations.
During Work Package Two (WP2) health and social care staff (in care homes and the NHS) and patients and carers either in hospital or at their discharge destination will be interviewed. Interview data will help to understand what avoidable means and explain why patients who experience a fragility fracture of the hip may be readmitted within 30 days. The eligibility criteria for patient participants are:
►		Experience of a hip fracture within the last 6 months.
►		Equal to or over the age of 65 at the time of sustaining the primary hip fracture.
►		Clinical Frailty Score (CFS) below 7 (either documented in the patient health record or assessed by healthcare staff).
►		Have capacity to consent.
Patients will be excluded if they are considered by their healthcare team (gatekeepers) not to be well enough to be approached or if they are experiencing postoperative delirium at the point of recruitment.
To be eligible for the study, health and social care staff and carers must have experience of caring for someone who is equal to or over 65 at the time of their hip fracture.
Identification of patients and carers: potential participants for the interview study will be identified by members of the patient’s healthcare team. These gatekeepers are able to identify eligible patients, and/or those who care for them for the interview study. A member of the ARTHUR study team will telephone (or visit) the ‘gatekeeper’ to identify patients and their carers on a daily basis. Once the gatekeeper has judged a patient well enough to be approached, they will give the patient a ‘consent to contact’ card. If the patient and/or their carer is happy to discuss the study with a researcher, a member of the research team will go to the ward to provide the patient with a study information sheet. The researcher will answer any questions about the study and give the patient and carer time (as much as is needed) to consider participating. Then, when they are ready and if willing to participate, consent will be sought either before discharge, or if discharged, consent will be taken on the day of the interview.
The recruitment target is 5-10 patients with a hip fracture (and 5-10 of their carers), 5-10 readmitted patients (and 5-10 of their carers) and 5-10 healthcare staff from a variety of the following professional groups—medical, nursing, allied health professional and care home manager. This recruitment target is realistic over a 4-month period, when using gatekeepers who are not part of the dedicated research staff; we estimate that between 4 and 6 patients with hip fracture are admitted per day via the Emergency Department in the acute hospital site. The literature describes several system and patient-level factors that may influence 30-day readmission rate; therefore, the whole pathway will be analysed by targeting both admitted and readmitted patient groups. A 30-day readmission is an admission to hospital within 30 days of discharge from hospital after the index incident (the original admission due to hip fracture). Where participants have capacity v but are unable to give written consent, verbal consent 2 will be taken, and the researcher will sign the consent q form on behalf of the participant in the presence of an & independent witness.	2
A multiperspective approach will enable the research g team to seek consent from the carers/family members of 2 enrolled patients. Before patients give consent, they will 6 understand that they will be asked to nominate a carer F or family member and then consent would be obtained 3 from each individual (patient and carer) in turn. This will 5 allow data from patients to be linked with that of their 5 carers or family members to explore how perspectives 8 compare. If it is not possible to recruit the carer at the • 1	c same time as the patient, the patient will be recruited.• This is because understanding the perspective of patients" who do not have an obvious carer or family member may 3 also be important to understanding readmission. When 2 interviewing a carer or family member separately from the j patient, care will be taken to maintain the confidentiality J of the patient, particularly as carers and family members 5 may be concerned about what the patient has said.228
Each patient participant will be interviewed once, a The researchers will aim to conduct the interview within 6 1 month of being enrolled. Interviews which are sched- 3 uled post discharge will take place in a variety of settings- as some patients may be discharged into residential care P and others to their own home (or equivalent domestic — setting).	aj
All interviews will be semistructured for 30-45 min. If 3. English is not the patient’s first language, and they would P like an interpreter, the research team will aim to provide“ one to facilitate participation. All interviews will be audio 2 recorded, but where this is not practical or the inter- 3 viewee refuses permission, field notes will be taken. ST
The semistructured interview topic guide was designed 6 to provide a deeper understanding of the patient journey- (including transitions between care locations and ο discharge planning—for example) and which interven- co tions might (acts or omissions) mitigate readmission risk (see online supplemental file 2).

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Interviews will be transcribed verbatim and coded manually (in Microsoft Word or Excel) or via NVivo analysis software. We will follow guidance from Braun and 7	20 21	6 Clarke et al.' ‘ Analysis will occur concurrently with data collection. In the next step, we will follow guidance from Vogl et al,2324 where inter-related accounts from members of the same social unit (a patient and a carer) will be compared and triangulated.

Data management and archiving
Confidentiality will be strictly maintained; participant data will be anonymised wherever possible.
All electronic study data will be stored in the Chief Investigator’s Higher Education Institute secure Research Data Store (RDS) which is password protected and only accessible to members of the ARTHUR study management group. Non-electronic data (eg, signed consent forms) will be kept securely at the recruiting site. All data will be stored for the duration of the study. The sponsor’s and NHS Trust’s current archiving procedures will be adhered to. Data will be stored according to guidance from the sponsor for a maximum of 10 years after the study closes.
Safety reporting
Work Package 2 uses qualitative methodology, and it is unlikely that there would be any adverse reactions recorded during the observations or interview study. If there is any distress caused to the patient or their carer, it will be documented in the patients’ medical records. Where a participant reports or discloses safety concerns, or where the researchers are concerned for the patient’s welfare, or in the unlikely event a member of the study team witnesses a safety issue, the ARTHUR study team will follow site-specific standard operating procedures.
Patient and public involvement statement
We also acknowledge our ARTHUR study Patient and Public Involvement group and members of the Clinical Research Ambassador Group (CRAG) for their advice and support during the construction of the research question and study procedures.
ETHICS AND DISSEMINATION
This study will be conducted in accordance with the principles of the Declaration of Helsinki and in full conformity with relevant regulations and with the ICH Guidelines for Good Clinical Practice ICH GCH Ε6 R2 (2017).25 This research will also be governed by the UK policy framework for Health and Social Care research, which sets out the principles of good practice in the management and conduct of health and social care research. NHS research ethics approval has been obtained (REC 23/WM/0242). PIONEER have UK Health Research Authority and Research Ethical Committee approvals as a research database and can provide ethics under licence for this dataset.18 Ethical approvals for the PIONEER data are provided by the East Midlands - Derby REC (20/ EM/0158).
Discussion and limitations
There is currently a global call to action to provide better care for people who experience fragility fracture who are growing in volume along with the global ageing population.26 In England, while far less people die after a fragility fracture of the hip, the number of people who are readmitted within 30 days of discharge remains stubbornly high and this is especially problematic for people who experience health inequalities and/or living in deprivation. The ARTHUR study attempts to understand what avoidable readmission means in a large urban centre in the UK in order to design an intervention or bundle of interventions which could be trialled in the future. This is important so that the people who need to come back to hospital continue to be readmitted; whereas, those that do not have the right care in place to maximise their v recovery outside of the acute hospital setting. Any inter- 2 vention(s) developed to reduce readmission can success- o fully support those people who can safely stay at home to & remain there.	2
Patient and Public Involvement (PPI) can help to 8 improve the quality of research which aims to tackle 2 health inequalities through improving study design, data 6 collection and analysis.2' However, the ARTHUR team B have identified early challenges to obtaining genuine 3 representation of the regional community. The known E trend of ‘recruiting the usual suspects’ in PPI is begin- 5 ning to be reversed and researchers are being called to 8 task to get out into the community to meet the diverse- communities, take time to get to know them, build trust and break down any barriers that may contribute to " making people feel alienated or afraid to contribute to 3 a research group.28 Yet, the resource restrictions within- academic research teams may still be prohibitive to this, o

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This study is not without risk and the contingencies J to mitigate these have been carefully considered. First, 5 research! involving older adults, particularly who have had a a sudden traumatic event like a hip fracture which may 3 have resulted in a change of living arrangements such as o move to a care home, can surface emotive concerns such a as illness, vulnerability and end-of-life. Based on advice- provided by the National Institute for Health and Care P Research (NIHR) ENRICH (Enabling Research In Care — Homes) group, the team will keep a reflexive diary and S discuss any issues that are causing concern in the PPI- meetings, study management group meetings and with a their mentors. Second, given the stresses some patients “ experience after a traumatic injury, some of these experi- ^ ences may be exposed in the interviews. The researcher 3 is trained to help if this happens. The ARTHUR study 00 research team will refer to a standard operating proce- ff dure on how to remedy distress during an interview if 9 needed. Third, there is a risk of inadequate recruitment, ο This study aims to recruit patients who live in deprived c and ethnically diverse areas which may be challenging. J We will minimise the risk associated with recruitment bias by employing a translator where needed and by implementing strong PPI engagement. A time frame of 4 months has been planned to conduct WP2 which will allow adequate patient flow (based on existing throughput) to enable us to hit our recruitment targets. Finally, the risk that participants may be identified will be mitigated by adopting unique participant identification codes. Every effort will be made to ensure it is not possible
to identify who took part in the study. The ARTHUR study team recognise the need for further intervention development work to be conducted with a patient population who experience cognitive impairment in the future. It is estimated that around one quarter of patients with hip fractures experience cognitive impairment,2930 are at higher risk of surgical and medical complications and are often excluded from clinical research.31
Through the use of mixed methods, this study will explore ‘avoidable’ 30-day readmission after hip fracture and explain which interventions are most capable of reducing avoidable readmission after fragility fracture of the hip in the Midlands area of England. Future studies will (i) explore pertinent issues relating to readmission in persons with cognitive impairment and (ii) design and test interventions which may be capable of reducing avoidable readmission.
X Caroline Miller @c_ahern26
Acknowledgements The University of Birmingham takes on the sponsor role for protocol development oversight and as data controller. In addition to the Study Management Group (who are all listed as coauthors), the Study Steering Group has provided advice and support throughout protocol development. Steering group members are Mrs Sally Godsby Taylor, Professor Liz Lees-Deutch, Dr Daisy Wilson, Mr Anastasios Nikolaidis, Mr Usama Rahman, Mrs Gwen Gerald-Briscoe, Lorraine Galligan, Rupinder Chal, Monday Sepo, Ms Faiza Yahya and Miss Jaqui Holmes. We also acknowledge support from the ENRICH (Enabling Research in Care Homes) team at Clinical Research Network West Midlands and ExtraCare Charitable Trust, a not for profit retirement village development which supports nursing and allied health professional HEI work in Birmingham. We also acknowledge our ARTHUR Study Patient and Public Involvement group and members of the Clinical Research Ambassador Group (CRAG).
Contributors ES is the guarantor of the work. All authors are all responsible for the conception and design of this work. UR, ES and HR prepared the manuscript with critical review by TM, ΑΕΤ, CM, RG and TV. ES, HR, TM, ΑΕΤ, CM, RG and TV sat on the study management group and ES, HR and UR sat on the steering group. All authors approved the final manuscript to be published.
Funding The author (Dr ES) disclosed receipt of the following financial support for the research, protocol development and publication of this article: this work was supported by a grant from Birmingham Health Partners. Caroline Miller is funded by the National Institute of Health Research through a Senior Clinical Practitioner Research Award (NIHR 304557). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Competing interests The lead author (Dr Emma Sutton) chairs the Fragility Fracture Network Special Interest Group - Fragility Fracture Recovery Research. The authors declare no other potential conflicts of interest with respect to the research, authorship and publication of this article.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study. Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. All data relevant to the study are included in the article or uploaded as supplementary information.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/ licenses/by/4.0/.
ORCID IDs
Emma Sutton http://orcid.org/0000-0003-4318-9555
Usama Rahman http://orcid.org/0000-0002-7558-689X	v
Caroline Miller http://orcid.org/0000-0002-4866-0847	o
Annie Ε Topping http://orcid.org/0000-0002-0111-2341	6 o O.
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are also more likely to experience worse post- surgical outcomes including readmission.6 Readmitted patients have an increased risk of
death, complications and being discharged to a residence which is not their own home.7
Readmission is also expensive, costing an estimated £14.5 million per year based on an average length of stay for each readmission after hip fracture of 8.7 days and costs per day of hospitalisation between £200 and £400.8-10 Costs per patient for hip fracture are substantially higher in the Midlands than other regions in England.
Some readmission predictors, such as age, cannot be altered, but others are malleable.