ARTICLE IN PRESS

BMC Geriatrics
Article in Press
https://doi.org/10.1186/s12877-026-07183-6
30-day readmission risk after hip fracture: a qualitative study in the Midlands, United Kingdom
Received: 2 April 2025
Accepted: 11 February 2026
E. Sutton, C. McMullan, H. Reilly, C. Miller, A. Topping & L. Lees Deutsch
Cite this article as: Sutton E., McMullan C., Reilly H. et al. 30-day readmission risk after hip fracture: a
We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply.
qualitative study in the Midlands, United
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doi.org/10.1186/s12877-026-07183-6
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Cover letter
Dear BMC Geriatrics
•		An explanation of why your manuscript should be published in BMC Geriatrics
We believe that our paper is of importance to BMC Geriatrics readers because the paper focusses on older persons equal to or over 65 and the health care system based challenges which may impact care after hip fracture. Fragility fracture of the hip is extremely prevalent globally (affecting 14.2 million people globally) and where harm (such as avoidable readmission) can be avoided, it should.
We believe that our findings will be of interest to an international audience who seek to improve the quality of care during admission and in all associated years lived post hip fracture.
•		An explanation of any issues relating to journal policies There are no issues relating to the journals policies.
•		A declaration of any potential competing interests – the authors do not have any competing interests
•		Confirmation that all authors have approved the manuscript for submission All authors have read and approved the final manuscript prior to submission.
•		Confirmation that the content of the manuscript has not been published, or submitted for publication elsewhere (see our Duplicate publication policy) The manuscript has not been published, or submitted elsewhere
Please note – We have followed submission guidance and placed tables less than one A4 or Letter page in length in the appropriate location within the manuscript. Tables larger than one A4 or Letter page in length are at the end of the document text file but we have indicated in the text where they should be inserted.
Peer reviewers
Matt Costa matthew.costa@ndorms.ox.ac.uk
Morten Kristensen morten.tange.kristensen@regionh.dk
Katie Sheehan katie.sheehan@kcl.ac.uk
James Gaywood james.gaywood@uhcw.nhs.uk
Title page
30-day readmission risk after hip fracture: A qualitative study in the Midlands, United Kingdom.
Sutton E^1,2,3; McMullan C^4; Reilly H^5 ;Miller, C^6 ; Topping A^1,; Lees Deutsch L^7,8
1		University of Birmingham, Department of Nursing and Midwifery, School of Health Sciences,,College of Medicine and Health, Edgbaston, Birmingham B15 2TT, United Kingdom
2University of East Anglia, School of Health Sciences, Norwich Research Park, Norwich, NR4 7TJ
3		University of Leicester School of Healthcare, College of Life Sciences, LE1 7RH^4Centre for Patient Reported Outcomes Research, University of Birmingham, United Kingdom
5		Midlands Mental Health and Neuroscience doctoral programme, Institute of Mental Health, Jubilee campus, University of Nottingham, Innovation Park, Triumph Road, NG7 2TU, United Kingdom
6		School of Infection, Inflammation and Immunology, College of Medicine and Health, University of Birmingham, Birmingham, United Kingdom
7		Coventry University, Centre for Healthcare and Communities, Richard Crossman Building, Jordan Well, Coventry, CV1 5RW, United Kingdom
^8University Hospital Coventry and Warwickshire NHS Trust, Centre for Care Excellence, Clifford Bridge Road, Coventry, CV2 2DX. United Kingdom.
Corresponding Author
Emma Sutton els50@leicester.ac.uk
Abstract
Background
Reducing unplanned 30-day readmission is imperative across health systems; particularly if they result from clinical failings, avoidable harms and are associated with unnecessary expenditure.
This study aimed to identify interventions capable of reducing avoidable 30-day readmission after fragility fracture of the hip in an area of high socio-economic deprivation in the United Kingdom (UK) and understand how these interventions could be informed by behaviour change theory.
Methods
A qualitative study was undertaken in the Midlands region of the UK in the National Health Service. Observational fieldwork of healthcare staff meetings, interviews with patients following hip fracture, carers and staff, and a theoretical mapping exercise were undertaken to examine patient’s journeys and factors affecting service delivery that might impact readmission risk. Observations were documented using electronic field notes. Semi-structured interviews explored experiences of the admission/readmission, transitions in care, readmission risks and interventions capable of reducing avoidable readmission. Analysis was conducted in four parts: 1) Inductive thematic analysis of interview and observational data explored patient journeys 2) Dyadic interviews analysis examined agreement/divergence within accounts 3) Deductive analysis identified readmission risk factors and candidate interventions 4) Candidate interventions were mapped with the constructs of the Theoretical Domains Framework. UK REC and HRA approval was obtained 3/WM/0242.
Results
Eleven non-participant observations were conducted in healthcare staff meetings in community (3) and acute (8) settings. Twenty-Four interviews were completed with 11 staff (five occupational therapists, three physiotherapists, one doctor, one trainee nurse practitioner, and one 
physiotherapy assistant), eight patients and five of the patients’ carers during July-September 2024. Three high level themes were identified – perceived burden, communication challenges and the health and social care system. Twenty-two candidate interventions relating to four challenges were identified: 1) adequacy of information, 2) individualised care, 3) access to services and 4) the hip fracture pathway.
Conclusions
This study identified interventions which staff, patients and carers proposed might reduce avoidable readmission after hip fracture in an area of high deprivation. Further work is needed to refine and rank the proposed interventions followed by an implementation plan to explain mode of delivery and who needs to do what differently.
Key words
Older people, hip fracture, readmission, Observation, semi-structured interviews, inductive thematic analysis.
Word count –
5138 excluding tables
1.		Background
Every year, more than 14.2 million people are affected by a fractured hip worldwide. These fractures impose major health, social and economic burden globally.^1 In well-resourced hospital systems declining or stabilizing trends in hip fracture mortality have been observed,^2 yet, the number of readmissions within 30 days of discharge are variable. 30-day readmission is an important proxy for health system performance and arguably an indicator of quality of care as it is associated with an increased risk of death and complications, and discharge to a residence other than the patient’s own home, often a care setting. The rates of 30-day readmission following discharge after fractured femur in the United States are 14.6%^3 to 16%^4 , Canada 23.1%^5 and Finland at 13.3%.^6 ^7While hip fracture mortality has fallen in England, Wales and Northern Ireland from 8% in 2013 to 5.6% in 2024^7 the readmission rate has only dropped by 1% in a decade (12.7% in 2013; 11.7% in 2023).^8 In some parts of England, readmission after hip fracture remains as high as 34.3% with the Midlands (the setting for this study) experiencing the second highest rate of 30-day readmission outside of London.^8 In the hip fracture population 30-day readmission is problematic with rates 10.1% higher than reported rates for all other orthopaedic subspecialities combined.^9
In the United Kingdom, readmission after hip fracture is expensive, costing an estimated £14.5 million GBP per year based on a length of stay of 8.7 days^10 and costs per day of hospitalisation of between £200 and £400.^11,12,13 30-day readmission after hip fracture is associated with low socioeconomic status (SES)^14, busier emergency departments, and hospitals that monitor whether patients receive physiotherapy during their first post-operative week.^15 In general 30-day readmission in older people is linked to delayed help seeking, inadequate investigations on previous admissions, and lack of specialist care in the community.^16 The post-operative recovery literature links 30-day readmission with wound problems^17 infection, rehabilitation issues^18 and medicines management (patient adherence, monitoring and prescribing errors).^19 Conversely, in a study examining observational associations of hospital-level organisational factors, hospitals with more attending staff grades and/or junior doctors were associated with fewer 30-day readmissions. As were hospitals with preoperative fluid management protocols in place; data recorded for the time between discharge and initiation of community therapy; and plans in place to reconfigure hip fracture services. Whilst causality cannot be inferred from these findings, they may indicate factors that influence 30-day readmission which are potentially amenable to change.^15 Self-care, individualised discharge planning and use of regional anaesthesia are also associated with lower readmission rates after hip fracture.^20 While some predictors of readmission such as age are not malleable, some system based factors could be addressed to tackle stubbornly high 30-day readmission and potentially reduce avoidable harm.
Addressing the challenge of 30-day readmission is especially important in the Midlands region of the UK with high levels of socio-economic deprivation^21 and above average readmission rates^8, that result in greater costs per patient for hip fracture.^22 While there is some certainty about what might reduce 30-day readmission for hip fracture patients, the exact combination of interventions, acceptability to patients, carers and staff and how they could best adopted and sustained has not been explored in depth. This study starts that process by asking “which interventions may be most capable of reducing avoidable readmission after fragility fracture of the hip in the Midlands region of England?”
2.		Methods
Study Design
To explore which interventions might reduce avoidable readmission, the study objectives included i) describe the patient journey and factors affecting service delivery for hip fracture patients and ii) investigate the characteristics of patients with a fractured hip who are admitted and readmitted within 30 days. The protocol for the Avoiding Readmission After Hip Fracture (ARTHUR) study^23 describes a mixed methods approach to understanding 30-day readmission after hip fracture and the qualitative results are described in this paper. A qualitative descriptive approach was adopted to gain an in-depth real world understanding of patient’s - who had sustained a fragility fracture - journeys through health and social care.
Setting
The study was conducted in two NHS Trusts in the Midlands region of England; one large acute trust (in excess of 1,000 beds) and a community trust (approximately 300 intermediate beds and rehabilitation services).
Recruitment
Patients who met the following criteria i) experience of a hip fracture within the last 6 months (a hip fracture was defined as a fracture occurring in the area between the edge of the femoral head and 5cm below the lesser trochanter^24); ii) a fragility fracture of the hip (defined as a fracture that results from a minimal trauma e.g. a fall from standing height or no identifiable trauma at all); iii) a Clinical Frailty Score^25,26 of less than 7; iv) were 65 or over v) and possessed mental capacity were eligible for the study . Patients were excluded if they were considered by their healthcare team as too unwell to be approached or experiencing post operative delirium. Patients were approached during acute hospital admission, or in community settings after discharge from acute in-patient care by a member of the healthcare team (a gatekeeper) who explained the study and established willingness to participate. If the participant expressed an interest, a research team member contacted them to explain the study and determine consent. Staff and carers needed to have experience of caring for a person equal to, or over the age of 65 with experience of a fragility hip fracture. Carers were recruited either through direct approach by the gatekeeper, or following nomination by patient participants. Staff were approached by gatekeepers in their own place of work who provided information about the study and contact details for the research team. Informed consent was obtained from all participants. Each participant was interviewed once within 1 month of enrolment.
Data Collection
Eleven multidisciplinary healthcare staff meetings where patients’ care plans were reviewed and clinical decision-making occurred, were purposively selected for observation. These included bed capacity, discharge and clinical team meetings in acute and community settings. Non-participant observation enabled consideration of professional interactions and how system-based challenges impacted decision-making such as, navigating the set-up of care packages and organising equipment provision. No patient care was directly observed, and no identifiable patient information was collected. An observation guide (supplemental file 1) was used to guide fieldwork and electronic (typed) field notes captured system-based challenges. Observations were conducted by ES and HR who are both registered healthcare professionals and employed in research roles (they were not part of the clinical teams). ES had attended an ethnographic research training course prior to data collection. A Confidential Advisory Group agreement (an independent body which provides advice on the use of confidential patient information) was in place prior to fieldwork.
Semi structured interviews were undertaken using a topic guide (supplemental file 2) with patients, carers and healthcare staff with experience of a fractured hip or caring for someone with a fractured hip. These provided a deeper understanding of the patient journey, and which interventions might (acts or omissions) mitigate readmission risk. Patient participants were invited to nominate a relative, carer or family member to participate in a ‘linked interview’ to gain insights from various actors that constitute the social unit. The ‘linked interviews’ were conducted together (as dyadic pairs), or separately. Linked interviews allow participants to ‘co-construct’ their version of events, 
possibly stimulating recall, leading to insights which might not emerge in a single person interview.^27–29
Interviews were audio recorded, transcribed verbatim by an approved transcription service and checked for accuracy by two investigators (ES, HR). Demographic data e.g. age at the time of fracture (patients) and professional grouping (staff) were collected.
The lead author (ES) mapped the interventions and the challenges associated with 30-day readmission – captured in the interviews and observational field notes –to the Theoretical Domains Framework (TDF) using guidance from Atkins et al.^30 The TDF offers a structured approach for exploring the determinants of individual behaviour and can be used to create a conceptual framework to plan intervention design.^30
Data analysis
The interview and observational data were analysed using a six-step approach:^31,32 . This involved becoming familiarised with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, producing the report. The data process was undertaken sequentially namely: inductive reflexive thematic analysis, dyadic interview analysis, deductive analysis, and Theoretical Domains Framework mapping.
1.		Inductive reflexive thematic analysis generated themes, which were documented, organised and managed using Microsoft© excel software. Coding was conducted by HR and ES for observations and by ES and CMc for the observations. A selection of transcripts were discussed with LLD using her qualitative research expertise.
2.		Where patients nominated a relative, carer or family member, they elected to be interviewed together at the same time (dyadic interviews). We adapted a process recommended by Tkachuk et al ^33 to analyse data generated from dyadic pairs. First, CM searched the dyadic transcripts for agreement or divergence within and between participants. Then meaning units (by each speaker) 
were identified. Finally, labels were given to account for combinations of perspectives. The agreement and divergence table was reviewed against the transcripts by ES to ‘check’ consistency.
3.		Deductive analysis was used to identify interventions and provide supporting quotes. During interviews, all participants were asked what factors (for example poor nutrition) could be associated with readmission risk, and these characteristics were listed and categorised according to citation frequency. Participants were also asked what could be done to prevent avoidable readmission (for example education on diet).
4		The Theoretical Domains Framework ^30 was employed as a lens to understand cognitive, affective, social and environmental influences on the challenges and proposed interventions identified. ES used the fourteen domains of the TDF to ‘overlay’ the data enabling extraction of behaviour change theory framed interventions, interpreting which may mitigate the risk of readmission.^30 For example, suggested interventions may target organisational and people-based challenges which stem from lack of knowledge, or lack of belief in a process or task. We propose that if the problems (associated with readmission and readmission risk) and associated solutions were not viewed through this lens, further intervention design and implementation efforts would be poorly informed.
Ethics
This study was conducted in accordance with the principles of the Declaration of Helsinki^34 and in full conformity with relevant regulations and with the ICH Guidelines for Good Clinical Practice ICH GCH E6 R2 (2017).^35 NHS research ethics approval was obtained (REC 23/WM/0242).
3.		Results
3.1		Demographic characteristics of participants interviewed
Interviews were conducted between July and September 2024. Thirty-one individuals following screening were identified who agreed to participate in an interview (22 in site 1 (acute) and nine in site 2 (community). All patient participants were aged between 69 and 84. Four paired patient and their carer interviews were conducted. In addition one adult child of a dyadic pair was interviewed separately. Staff interviews were completed with six acute hospital staff and five community staff who were: physiotherapists (n=3), occupational therapists (n=5), doctor (n=1) trainee nurse practitioner (n=1) and a therapy assistant (n=1). Interview average length was 20 minutes (patients), 29 minutes (carers and staff).
3.2		Characteristics of non-participant observations
Eleven clinical staff meetings were observed. All were held away from the patient’s bedside. These included: community huddle (n=3), and complex discharge (n=2) multidisciplinary team (MDT) (n=2), board round (n=1) bed capacity (n=2), post take (n=1) meetings. Definitions of each meeting type as described by staff at the site are shown in table 1.
Table 1: Description of NHS healthcare staff meeting types as defined by meeting attendees
Meeting type | Definition
Community Huddle (daily M-F) | Meetings where community teams discuss current case load and referrals, highlighting any problems which can be shared and resolved as a team.
Complex Discharge (daily M-F) | A meeting with a specialist team that provides a coordinated approach to support the discharge of patients with complex needs who will require ongoing support on discharge from hospital. This includes social and health assessment and normally agreement of a package of ongoing support

Multi Disciplinary Team acute (daily M-F) | Involved members of the older persons assessment MDT. A forum to discuss case load and referrals provided space for sharing information and team problem-solving
Board Rounds (daily M-S) | Board rounds involved ward staff and involved “a summary discussion of each patient’s care and progress along care pathway. They facilitate allocation of the daily tasks required for patient to progress, early identification and resolution of any needs/concerns that might delay a patient's hospital stay” (p e30) ^36
Bed Capacity (daily M-F) | This meeting examines hospital site data relating to bed occupancy across the hospital site, and patient flow. This can include decision-making regarding admissions awaiting bed allocation in the Emergency Department, and planned discharges.
Post-take meetings (daily M-S) | Post take meetings are held first thing in morning, they are multidisciplinary and led by the consultant on call from the previous day. All surgical patients admitted from the Emergency Department in the last 24 hours are discussed to confirm ongoing treatment and care plans.
*M-S Monday – Sunday, M-F Monday-Friday

3.3		Results of interviews and non-participant observations
Results mirror the four phases of analysis: Inductive reflexive thematic analysis, Dyadic interview analysis, Deductive analysis and Lastly the Theoretical Domains Framework (TDF) mapping. In the final TDF stage the barriers and enablers associated with various challenges, proposed interventions and mapped data are presented in tabular format (see supplemental file 3).
3.3.1		Inductive thematic analysis 
To describe the patient journey, three themes were identified – Perceived burdens for staff, patients and carers, multiple communication challenges and the health and social care system. Themes and sub themes are illustrated within Figure 1.
Perceived burdens for staff, patients and carers
The theme of perceived burdens was evident across accounts from all three participant groups. For staff, burden was characterized by pressure to achieve a task or a target. Firstly, timetable of care exerted a burden – for example, community staff were required to assess hip fracture patients soon after referral and acute staff felt pressured to discharge patients from hospital. This is illustrated:
“Everyone's pressurising to get patients out quicker to the home environment. I think that patients feel rushed” (staff).
Second, community staff reported pressure to achieve ‘completeness’ of care by undertaking a detailed assessment, ensuring that nothing was missed and this was was sometimes in conflict with ensuring the patient felt cared for: “he held my hand – he wanted me to sit with him” (field note) and this need was often left unmet..
Patients reported burdens as a consequence of deprivation, loneliness and feeling overloaded with tasks that they needed to do independently. During all three observations of community team meetings, and interviews with community staff (n=6), references were made to deprivation. For example, small or cramped living space in the home, poor condition of walls (for fixing wall rails) and carpets (fall-risk) and poor nutrition due to in-frequent or absence of hot meals. This was sometimes compounded by poor health literacy (being less aware of risks to health). Staff were aware that sometimes the extent of deprivation remained hidden if not disclosed : “At no point had he (patient) declared there was no hot running water, no heating, no electricity but also it hadn't been picked up on in our questioning” (Staff).
Loneliness was also associated with increased risk – first, the risk that hazards around the home may go un-noticed– when “they’re not eating, or sleeping, it all adds up [especially with] nobody visiting and noticing potential risks with that home” (staff). Second, feeling lonely was linked with low mood which contributed to risks such as poor adherence with rehabilitation. Staff and patients also noticed that social isolation might mean that patients were less likely to speak up or advocate for themselves “we end up having to advocate for them” (staff). Finally, patients felt overwhelmed by the burden of decision-making especially when information was absent or conflicting:
“I had different sets of people come in to me with different choices	I said well what would you recommend… they said I can’t help you there, you’ve got to make that decision yourself” (patient).
Carers burden was linked to the financial strain of visiting when the hospital was geographically distant from their home - “The travelling exhausted me, it was stressful and took up such a long time, costing me roughly £420 a week” (carer)
Employed or working care givers (and healthcare staff speaking about carers/family members) described the burden of visiting which could involve negotiating time off from work or working from home: “They cannot come down on a daily basis to help them, because they are engaged with their own life and work” (Staff). Carers/relatives also reported the burden involved in negotiating with staff: “I had to push continuously keep phoning them up and ask, what's happening today? Have the carers been booked?” (carer). Carers also described the weight of expectation placed on them by staff to be a continual support for their loved one.
Staff, patients and carers also reported the financial and practical burden related to purchasing additional care (e.g. private physiotherapy) and/or equipment (stair lift, bed, and chair).
Multiple communication challenges
Communication challenges were described at three levels – patient-carer, staff and organisational. 
Patient-carer communication
Staff discussed how some older patients do not seek help and used words like ‘stoical’ or ‘plod on’ related to older people even when they struggled. In contrast a problem voiced by patients related to asking for help and not being heard (for example unanswered ward call bells) whilst an inpatient. Inadequate (too little) communication with patients about what to expect and their role in their recovery caused challenges for both staff and patients. For example, staff identified that patients can be ‘shocked’ when the physiotherapists come on day one post-surgery to begin mobilisation. One patient described: “I don’t think I had much information –they could have come and gave me a few dos and don’ts - what you should be doing, what you shouldn’t be doing” (patient).
Communication was also described at the patient level as being largely absent “during all this we were really puzzled about what on earth could happen next” (carer). Miscommunication including incorrect, erroneous or conflicting information was problematic. Patients and carers reported being given wrong information about details of appointments, incorrect timing for discharge (resulting in family not being able to give adequate support), incomplete discharge letters, and conflicting advice from healthcare professionals. Miscommunication was also experienced by community staff who sometimes received erroneous address details for patients if the discharge destination differed from the patient’s usual domestic residence. This was compounded by challenging hospital environments which felt noisy and chaotic “A&E was absolute bedlam, the place was a bunfight” (carer) and feelings of not being listened to were common. One carer of a patient who did not speak English, described communication with staff as challenging:
“To get her concerns across to us and then for us to get them across to another person - it's frustrating for her and frustrating for us …. I’m trying to be her eyes, her ears, her voice” (carer) Finally, some patients and carers felt staff behaviour could be “snappy” and this led to reluctance to seek help. Conflict was perceived when patients/carers disagreed with management plans or chose not to comply as they felt advice received from healthcare staff was inconsistent.
These challenges were also countered by some reports of good communication where staff were perceived to be ‘responsive’, ‘compassionate’ and ‘consistent’.
Staff level communication
Communication between staff members in some meetings –- was observed to be mechanistic and abrupt (for example complex discharge meeting), or conversational and problem solving in nature (community team huddles).. Communication between staff in meetings was sometimes characterized by fear of doing the wrong thing (e.g. ordering equipment when the patient is not eligible), or litigation. Staff sometimes felt inadequate (due to lack of time to be with each patient due to administrative burden and high case volume) and conflicted between what they would like to do and what the system would allow. This was also emphasized in interviews: “they could go home but actually it just feels so wrong to send them” (staff). Culture was raised by staff who noticed that in some communities older people are taken to their bed when discharged home, but they also cited the benefits that multi-generational families can bring in terms of additional support. Staff also discussed conflict with patients and carers over health management plans and non-compliance due to ‘laziness’( field note) or lack of understanding (field note). Conflict between members of the health care team was also reported by staff in interviews and observed during meetings - questioning why referrals were made or not, and who should take ownership of the patient.
Organisational level communication
At the organizational level staff felt frustrated by the need to use multiple digital and paper systems to communicate within and between teams, and the complex processes required to order the right equipment and ensure it was installed. Community staff reported sometimes struggling to navigate the challenge of temporary accommodation (what equipment may or may not be provided and/or installed in this setting). Whereas patient and carer interviews commonly described inpatient settings as ‘chaotic’ and noisy (often associated with patients who experienced dementia) impacting on sleep quality and their ability to effectively interact with healthcare staff.
The health and social care system
The challenges associated with navigating ‘the system’ were apparent from both observational and interviews data. For example, the management of pre-operative fasting ‘nil by mouth’ was frequently raised and the potential impact on nutrition, hydration and ultimately risk of delirium associated with waiting for surgery. Discussion of the in-hospital pathway raised the (poor) quality of hospital food and access to meals brought by relatives: “We were very aware she wasn't eating very much and we’d try and take some food in that she might find appealing” (Carer) and timing of meals “I’d waited all day to go home, I just got something to eat, and the ambulance came to take me home straight away”” (Patient).
Discharge planning brought challenges particularly linked to communication about ordering or establishing eligibility for equipment, and when hospital staff felt they needed more information about the extent of community health and care provision. Staff were frustrated by a lack of rehabilitation (step-down) beds, and delays in accessing post-acute rehabilitation and GP services. Post discharge, rehabilitation was routinely provided for the first two weeks. If more was required patients were placed on a waiting list: “Therapy referral can vary from anything from four to 16 weeks, depending on capacity, so an outdoor mobility or progression on to sticks, they can potentially be on our waiting list for weeks if not months” (Staff) 
Staff tried to ‘trouble shoot’ or find ‘workarounds’ by referring patients for rehabilitation on the first day post discharge, using care staff imaginatively to continue exercises in routine personal care, or prolonging the initial two-week service to ‘bridge the gap’.
3.3.2		Dyadic interview analysis
Examples of observed agreement and divergence in the paired interviews can be viewed in table 2
Table 2 – Interviews with dyads: examples of agreeance and divergence
Dyad | Code | Agreement | Divergence
PAIR 1 | Home care | RES 1: Well we did know that we would get carers and a nurse coming in every day to give her injections, got six left actually, so we knew we were going to get plenty of visitors- :We knew we'd get plenty of support. RES2:Yes and physios. |
PAIR 3 | Level of mobility | | INT: No problems with mobility? RES1:No problems, no. RES2: He walks with a walking stick, it’s only because you’ve slowed down a bit haven’t you dad? RES1:Yes.
Agreement was observed on quality of hospital care and home care. Divergence was observed on

level of mobility, errors in communication and discharge planning, Evidence of co-producing data and joint memory recall was shown. It was observed that when interviewed with their loved one or carer more detail was revealed with the prompt of the carer. In some cases, reluctance to disclose an error was then highlighted by the relative or spouse.
3.3.3		Deductive analysis
Key characteristics of admitted and readmitted patients
All qualitative data were coded to obtain a summary of which key characteristics of admitted and readmitted people experiencing hip fracture could be associated with increased risk of readmission.
Staff described deprivation, including neglect of the home environment, malnutrition, loneliness and health literacy, related to readmission risk:
“They're not getting the calorie intake, the nutritional intake, eating, drinking, mobilising, I think is has a massive impact on their ability to heal, and that definitely causes potential for re-admission” (staff).
Financial constraints also limited people’s ability to optimise their recovery. For example, patients who could not afford private transportation frequently missed rehabilitation appointments. Conversely, access to financial resources reduced the risk of readmission because people were able to supplement their care— by purchasing equipment (chairs, beds, stair lifts) and services (cleaners, care packages, private physiotherapy, private consultant appointments, or private transport to hospital appointments).
Pre-admission health status was raised by all participant groups as risk for readmission. Patients described as “skeletally weak” (carer) with multiple co-morbidities and previous emergency department attendances were related to increased likelihood of readmission. Patients who were fit and independent before their admission with a broken hip were considered a lower readmission risk.
Social isolation was linked to readmission risk. Patients without close support may not feel able to advocate for themselves and discharge planning may take longer, especially if there is no family to take responsibility for arranging delivery of equipment, the positioning of furniture and/or to supervise mobility or transfers. When supportive family or friends were not available, patients were perceived to be less likely to be compliant with rehabilitation.
Twelve causes of readmission for hip fracture patients were identified and are illustrated in Figure 2 by frequency of citation within and across transcripts. Deconditioning was the most discussed concept relating to reluctance to mobilise leading to reduced mobility status. This reluctance was compounded by i) fear of falling ii) long waiting times for community rehabilitation iii) extended periods spent in bed on discharge home. Deconditioning was also associated with poorer mental health “there is a high proportion of them with anxiety, depression. I think they are risk factors meaning that they are highly likely to be deteriorating” (staff).
Which interventions could reduce avoidable readmission after fragility fracture of the hip?
The Interview participants were all asked what might alleviate risk of readmission. Responses were categorised as: adequacy of information, access to services, pathway, and individualised care. Then the barriers, enablers and interventions associated with each challenge are listed (supported by quotations). Some interventions were not specific (e.g reduce pressure to discharge), but these are still included to enable further scoping in future work.
3.3.4		Theoretical Domains Framework Mapping exercise.
Twenty-two interventions, were identified and these spanned challenges including (1) adequacy of information (2) Poor Access and (3) patient pathway issues (See Supplemental file 3). Each were mapped and aligned with the Theoretical Domains Framework presenting potential actionable findings from this study. ^30 An example from each is provided here Table 3.
1 Table 3: Examples of Interventions to reduce avoidable readmission mapped to Theoretical Domains Framework

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Challenge | Barriers and enablers | Intervention (suggested) | Data mapping (supported by quotes) | TDF Domain

| associated with the challenge | | |
Adequacy of information | Lack of patient education, lack of written information/resources, digital exclusion | Information provision - home exercises, nutrition, falls prevention | “The patients need a better understanding of what is going to help them - as in nutrition, the way of living, looking after yourself. This is why you need to be mobile and why you need to keep moving” (staff) | Knowledge, skill, motivation
Poor access to nutritional support in and out of hospital | Poor outdoor mobility, low socio-economic status, live alone, long waits pre-op nil by mouth, poor appetite (pain), food quality | food package or food parcel for the first day at home | “you need to make sure they've got a food parcel” (staff 2UQS) “they can't actually get out to have food and drink” (staff) | Environmental context and resources, social norms, beliefs about capabilities

Pathway

Conveying (additional) information in a way that patients can understand. Ability to simplify complex medical information

Increase time allowed for consenting

Most of the focus on pre-op communication with the patient is usually on just to sign the consent form There is no discussion on the factors that will help him speed up the recovery and that discussion I think can help the patient’s recover quickly (staff)

Skills, Environmental
Context and Resources

3

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4.		Discussion
This study has highlighted that while progress is being made in medical and surgical management, the older person who experiences a broken hip is beset by burdens compounded by communication and system level challenges which can all combine to create an increased risk of readmission. Accurate thirty day readmission is problematic to capture due to incomplete or under reporting.^37 When data does exist, data quality can be poor or misleading^38 with inconsistent recording and coding of type of readmission (e.g. all cause or orthopaedic only)^39 and timing of data collection.^40 However, despite these challenges, the problem of stubbornly high 30-day readmission rates should be tackled, as this is an independent risk factor for mortality in older people^41,42 and identified as an example of avoidable harm in the World Health Organisations global patient safety action plan (2021-2030).^43
A number of studies identify factors associated with an increased or decreased 30-day readmission for hip fracture patients^15,16,44 and wider populations^45 and the findings from this study adds further substance and nuance. For example, our participants discussed the impact of the ‘delay gap’ between discharge and initiation of community therapy. Previous work has highlighted that if teams better understand what contributes to delay that interrupt recovery then readmission risk might be lower.^15 This study extends this understanding by suggesting interventions (table 3) to produce marginal gains that could ameliorate challenges. Promoting better communication and access to information to facilitate discharge preparedness and putting efforts into preparing patients for what they will need to do themselves when they go home are such marginal improvements. Likewise nutritional support (provision of food parcels, written and oral advice) was regarded as critical to mitigate 30-day readmission risk in the current study and this is supported by previous work demonstrating that protein energy malnutrition is a modifiable risk factor for 30-day readmission in older people.^46 Other problems may be stubborn to resolve such as loneliness or aloneness. Likewise potential interventions to provide truly personalised care were poorly described, and further work would be needed with stakeholder groups to explore what personalisation means in this context. Our participants also suggested a large-scale public health initiative on falls prevention. Whilst it is known that screening, exercise or multifactorial interventions does not result in fewer fractures than advice by mail alone,^47 literature on public health efforts to impact 30-day readmission in poorer areas specifically is limited.
This study examined hip fracture in a setting in a high-income country serving a population with pockets of real gh deprivation with a healthcare system experiencing immense pressures. ^48 The aim was to isolate parts of the patient pathway that might be modifiable and therefore influence 30- day readmission. Whilst several factors that might achieve marginable gains were identified, it is not yet possible to fully explain which combination of interventions might reliably reduce readmissions. Currently in the English NHS there is pressure to address patient flow by reducing inpatient admissions, particularly emergency admissions, and speeding up discharge whilst also reducing 30- day readmission. This requires integrated health and social care systems^49 and improving care for those with fragility fractures is an ideal starting point given most will present with complex challenges that impact on optimum recovery and rehabilitation if independence is to be restored. Internationally there is a global call to action to provide better care for people who experience fragility fracture who are growing in volume with aging populations.^50 To ensure that only those people who need to come back to hospital are re-admitted, and help is put in place to support those who could safely remain at home, could have important ramifications at individual, societal and
economic levels.
Contingencies to reduce each risk during this study were offered. Research involving older adults particularly who have had a sudden traumatic event like a hip fracture which may result in a change of living arrangements, can elicit emotional disruption. Qualitative research inevitably requires participants to reflect on those experiences and may engender consideration of realities. These can be uncomfortable. A study specific standard operating procedure for manging distress was in place. In addition the team discussed concerns raised and escalated to the appropriate care team any risks and engaged in reflexive practice.
5.		Limitations
This study only recruited patients with hip fractures who had capacity; future work is needed to recruit patients with cognitive impairment and/or their carers t as at least 30% of hip fracture patients are affected and this adds further complexity to recovery. The Clinical Frailty Score (CFS) was used in screening participants as a marker of functional status as the study aimed generate understanding to inform the design of interventions to reduce avoidable readmission. Recruitment was restricted to those with clinical frailty scores (CFS) of less than 7 (namely patients who can stand themselves to wash and dress with limited help), hence focussed on the particular needs of individuals who are not bed bound. A future study should investigate the support needed to reduce readmission rate in patients following hip fracture who are bed bound. Finally, the use of dyadic interviews encouraged disclosures particularly about care received. We hypothesise this approach may have benefits in terms of trustworthiness. The validated linkage methods^51 used to map f data to the TDF presented in table 3 (for full version see supplemental file 3) could be replicated in future investigations ^51 to guide the selection of behaviour change techniques and gain consensus on which interventions should be prioritized.
6.		Conclusion
We explored avoidable readmission after hip fracture and identified factors that contributed to burdens, which impacted on communication and created system challenges; a number of these factors are potentially malleable. Twenty-two interventions were identified by participants that targeted four key challenges: adequacy of information, individualised care, access to services, and the (current) hip fracture pathway. The next step is further work to prioritise and refine interventions and to specifically explore methods to reduce avoidable readmission in persons with cognitive impairment following hip fracture.
References
1.		Dong Y, Zhang Y, Song K, Kang H, Ye D, Li F. What was the Epidemiology and Global Burden of Disease of Hip Fractures From 1990 to 2019? Results From and Additional Analysis of the Global Burden of Disease Study 2019. Clin Orthop Relat Res. 2023;481(6):1209–20.
2.		Sing CW, Lin TC, Bartholomew S, Bell JS, Bennett C, Beyene K, et al. Global Epidemiology of Hip Fractures: Secular Trends in Incidence Rate, Post-Fracture Treatment, and All-Cause Mortality. Journal of Bone and Mineral Research. 2023;38(8):1064–75.
3.		Colla C, Lewis V, C S, Usadi B, Gottlieb D. Changes in Use of Post-Acute Care Associated with Accountable Care Organizations in Hip Fracture, Stroke, and Pneumonia Hospitalized Cohorts. Med Care. 2019;57(6).
4.		Elkassabany NM, Passarella M, Mehta S, Liu J, Neuman MD. Hospital Characteristics, Inpatient Processes of Care, and Readmissions of Older Adults with Hip Fractures. J Am Geriatr Soc. 2016;64(8):1656–61.
5.		Stukel TA, Fisher ES, Alter DA, Guttmann A, Ko DT, Fung K, et al. Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals. JAMA. 2012;307(10):1037–45.
6.		Rajamaki B, Rajamaki B, Koponen M, Koponen M, Koponen M, Hartikainen S, et al. Length of hospital stay after hip fracture and readmission rates of persons with and without Alzheimer’s disease: A matched cohort study. BMC Geriatr. 2020 Jun 18;20(1).
7.		NHFD. A broken hip – three steps to recovery - Using the National Hip Fracture Database to understand and improve hip fracture care in 2024. 2024;(December 2023).
8.		NHS Digital Compendium - Emergency readmissions to hospital within 30 days of discharge by diagnosis (01 Apr 2013 to 31 Mar 2023).pdf [Internet]. 2023. Available from: https://digital.nhs.uk. 2023.
9.		Ali AM, Gibbons CER. Predictors of 30-day hospital readmission after hip fracture: a systematic review. Injury [Internet]. 2017;48(2):243–52. Available from: http://dx.doi.org/10.1016/j.injury.2017.01.005
10.		Kates SL, Behrend C, Mendelson DA, Cram P, Friedman SM. Hospital readmission after hip fracture. Arch Orthop Trauma Surg. 2014;135(3):329–37.
11.		Royal College of Physicians. Facing new challenges The National Hip Fracture Database report on 2020 In association with Commissioned by National Hip Fracture Database (NHFD). 2021;1–27.
12.		Leal J, Gray AM, Prieto-Alhambra D, Arden NK, Cooper C, Javaid MK, et al. Impact of hip fracture on hospital care costs: a population-based study. Osteoporosis International. 2016;27(2):549–58.
13.		Baji P, Patel R, Judge A, Johansen A, Griffin J, Chesser T, et al. Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort study. Lancet Healthy Longev. 2023;4(8):e386–98.
14.		Valentin G, Ravn MB, Jensen EK, Friis K, Bhimjiyani A, Ben-Shlomo Y, et al. Socio-economic inequalities in fragility fracture incidence: a systematic review and meta-analysis of 61 observational studies. Osteoporosis International. 2021;32(12):2433–48.
15.		Patel R, Judge A, Johansen A, Marques EMR, Griffin J, Bradshaw M, et al. Multiple hospital organisational factors are associated with adverse patient outcomes post-hip fracture in England and Wales: the REDUCE record-linkage cohort study. Age Ageing. 2022;51(8):1–9.
16.		Glasby J, Littlechild R, Le Mesurier N, Thwaites R. Who knows best? Older people’s and practitioner contributions to understanding and preventing avoidable hospital admissions. Health Econ Policy Law. 2020;15(2):225–46.
17.		Anderson O, Davis R, Hanna GB, Vincent CA. Surgical adverse events: A systematic review. Am J Surg. 2013;206(2):253–62.
18.		Hahnel J, Burdekin H, Anand S. Re-admissions following hip fracture surgery. Ann R Coll Surg Engl. 2009;91(7):591–5.
19.		Howard RL, Avery AJ, Slavenburg S, Royal S, Pipe G, Lucassen P, et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol. 2007;63(2):136–47.
20.		Sutton EL, Kearney RS. What works? Interventions to reduce readmission after hip fracture: A rapid review of systematic reviews. Injury. 2021;52(7):1851–60.
21.		GOV.UK. The English Indices of Deprivation 2019- Statistical Release. Ministry of Housing, Communities and Local Government [Internet]. 2019;2019:1–12. Available from: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019al-report
22.		Baji P, Patel R, Judge A, Johansen A, Griffin J, Chesser T, et al. Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort study. Lancet Healthy Longev. 2023;4(8):e386–98.
23.		Sutton E, Rahman U, Reilly H, Miller C, Vedutla T, Melody T, et al. Understanding readmission after hip fracture: a mixed methods study protocol. BMJ Open. 2025;15(e094163):1–6.
24.		National Clinical Guideline Centre. The management of hip fracture in adults [Internet]. London; 2017. Available from: https://www.nice.org.uk/guidance/cg124.
25.		ClinicalFrailtyScale. Department of Medicine at Dalhousie University, Geriatric Medicine Research (GMR). Clinical frailty scale [Internet]. 2009. Available from: https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html
26.		Pulok MH, Theou O, van der Valk AM, Rockwood K. The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine. Age Ageing. 2020;49(6):1071–9.
27.		Ummel D, Achille M. How Not to Let Secrets Out When Conducting Qualitative Research with Dyads. Qual Health Res. 2016;26(6):807–15.
28.		Taylor B, De Vocht H. Interviewing separately or as couples? Considerations of authenticity of method. Qual Health Res. 2011;21(11):1576–87.
29.		Morgan DL, Ataie J, Carder P, Hoffman K. Introducing dyadic interviews as a method for collecting qualitative data. Qual Health Res. 2013;23(9):1276–84.
30.		Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science. 2017;12(1):1–18.
31.		Braun V, Clarke V. Successful qualitative research a practical guide for beginners. London: SAGE; 2013.
32.		Braun V, Clarke V. Thematic Analysis A Practical Guide. Sage Publications Ltd, editor. SAGE; 2021.
33.		Tkachuk M, Russell-Mayhew S, Kassan A, Dimitropoulos G. Adapting descriptive psychological phenomenology to include dyadic interviews: Practical considerations for data analysis. Qualitative Report. 2019;24(2):352–70.
34.		WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects [Internet]. The World Medical Association. 2013 [cited 2015 Jan 10]. p. 1–8. Available from: http://www.wma.net/en/30publications/10policies/b3/index.html
35.		European Medicines Agency. EMA (2018). ICH E6 (R2) Good clinical practice - Scientific guideline European Medicines Agency. [online] European Medicines Agency. [Internet]. Vol. 6.	2018. p. 2018. Available from: https://www.ema.europa.eu/en/ich-e6-r2-good-clinical- practice-scientific-guideline
36.		Saqib A, Waugh W, Jayasinghe R, Banerjee S. Patient Journey Champions: A project to facilitate delivery of effective board rounds for inpatients, aiding flow through the hospital. Future Healthc J. 2020 Oct;7(3):e30–1.
37.		Van Heghe A, Mordant G, Dupont J, Dejaeger M, Laurent MR, Gielen E. Effects of Orthogeriatric Care Models on Outcomes of Hip Fracture Patients: A Systematic Review and Meta-Analysis. Calcif Tissue Int [Internet]. 2022;110(2):162–84. Available from: https://doi.org/10.1007/s00223-021-00913-5
38.		Daddato AE, Dollar B, Lum HD, Burke RE, Boxer RS. Identifying Patient Readmissions: Are Our Data Sources Misleading? J Am Med Dir Assoc. 2019;20(8):1042–4.
39.		Werner M, Macke C, Gogol M, Krettek C, Liodakis E. Differences in hip fracture care in Europe: a systematic review of recent annual reports of hip fracture registries. European Journal of Trauma and Emergency Surgery [Internet]. 2022;48(3):1625–38. Available from: https://doi.org/10.1007/s00068-021-01797-8
40.		Liem IS, Kammerlander C, Suhm N, Blauth M, Roth T, Gosch M, et al. Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures. Injury [Internet]. 2013;44(11):1403–12. Available from: http://dx.doi.org/10.1016/j.injury.2013.06.018
41.		Lam PH, Dooley DJ, Arundel C, Morgan CJ, Fonarow GC, Bhatt DL, et al. One- to 10-Day Versus 11- to 30-Day All-Cause Readmission and Mortality in Older Patients With Heart Failure. American Journal of Cardiology [Internet]. 2019;123(11):1840–4. Available from: https://doi.org/10.1016/j.amjcard.2019.03.007
42.		Shaw JA, Stiliannoudakis S, Qaiser R, Layman E, Sima A, Ali A. Thirty-Day Hospital Readmissions: A Predictor of Higher All-cause Mortality for Up to Two Years. Cureus. 2020;12(7):1–7.
43.		World Health Organization. Patient Safety Incident Reporting and Learning Systems Technical report and guidance [Internet]. Global patient safety action plan 2021–2030. 2021. 1689– 1699 p. Available from: https://www.who.int/teams/integrated-health-services/patient- safety/policy/global-patient-safety-action-plan
44.		Patel R, Judge A, Johansen A, Marques EMR, Griffin J, Bradshaw M, et al. Multiple hospital organisational factors are associated with adverse patient outcomes post-hip fracture in England and Wales: the REDUCE record-linkage cohort study. Age Ageing. 2022;51(8):1–9.
45.		Hansen LO, Young RS, Hinami K, Leung A WMV. IMPROVING PATIENT CARE Interventions to Reduce 30-Day Rehospitalization : A Systematic. Ann Intern Med. 2011;155(8):520–8.
46.		Robinson R. Low serum albumin and total lymphocyte count as predictors of 30 day hospital readmission in patients 65 years of age or older. PeerJ. 2015;2015(8).
47.		Lamb SE, Bruce J, Hossain A, Ji C, Longo R, Lall R, et al. Screening and Intervention to Prevent Falls and Fractures in Older People. New England Journal of Medicine. 2020;383(19):1848–59.
48.		Darzi A. Independent Investigation of the National Health Service in England [Internet]. 2024.
Available from: https://assets.publishing.service.gov.uk/media/66f42ae630536cb92748271f/Lord-Darzi- Independent-Investigation-of-the-National-Health-Service-in-England-Updated-25- September.pdf
49.		Powel T, Baker C FD. Capacity pressures in health and social care in England – House of Commons Library, UK Parliament [Internet]. 2024. p. 2024. Available from:
https://commonslibrary.parliament.uk/capacity-pressures-in-health-and-social-care-in- england/
50.		Dreinhöfer KE, Mitchell PJ, Bégué T, Cooper C, Costa ML, Falaschi P, et al. A global call to action to improve the care of people with fragility fractures. Injury. 2018 Aug 1;49(8):1393–7.
51.		Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Applied Psychology. 2008;57(4):660–80.
Declarations
•		Ethics approval and consent to participate
This study received NHS research ethics approval (REC 23/WM/0242). Informed consent to participate was obtained from all of the participants in the study. The research adhered to the principles outlined in the Declaration of Helsinki (October 2024).
•		Consent for publication
All participants signed a consent form which stated “I give my permission for the research team to use sections of my anonymised transcript within the completed Birmingham Health Partners Seed Fund report and accompanying publications and conference presentations. I understand that any quotations used will be completely anonymised. I understand that I will not be identified in any reports or publications resulting from the study”
•		Availability of data and materials
The datasets generated and/or analysed during the current study are not publicly available due to HRA and REC approval conditions which stipulate that all original field notes and interview transcripts are to be retained for viewing only by the immediate study team.
•		Competing interests
The authors declare that they have no competing interests
•		Funding
This study was funded by Birmingham Health Partners via a seed fund award (December 2022).
•		Authors' contributions
ES conceived the idea for this study, ES and HR coded all qualitative data. All authors contributed to editing the rationale, methods, results and discussion section of this manuscript. All authors read and approved the final manuscript.
•		Acknowledgements
We acknowledge the contribution of members of the ARTHUR study management group (Tarunya Vedutla, Teresa Melody, Ranaganayaki S Gudivada, Annie Topping, Caroline Miller) Steering group (Liz Lees-Deutch, Sally Godsby Tayor, Daisy Wilson, Usama Rahman, Gwen Gerald-Briscoe, CHAL, Rupinder, Monday Sepo, Faiza Yahya, Christel McMullan), the ARTHUR study PPI group, the University Hospitals Birmingham NHS Foundation Trust Clinical Research Ambassador Group (CRAG) and the gatekeepers who recruited the participants (Hafsa Eltaf, Ryan Petts, Shaenil Nemdharry, Hannah Wilson, Srihari Tippa, Hareesh Prabhakaran).
•		Authors' information (optional)
The Chief Investigator Emma Sutton is a Physiotherapist and chairs the Fragility Fracture Network (FFN) Fragility Fracture Recovery Research Special Interest Group). The Research Fellow (Hannah Reilly) is an Occupational Therapist and Wellcome Trust PhD fellow in admission avoidance for persons with Dementia
Figure 1:		Inductive thematic analysis (Patient Journey): themes and sub themes

Dislocation

Figure 2:		Characteristics of hip fracture patients: causes of readmission
Ordered by frequency of citation within coded interview transcripts and observation field notes
Deconditioning
Falls
Infection (wound or joint)
Urinary Tract Infection
Frailty
Musculoskeletal pain
inadequate package of
care/not coping
Abdominal pain
Chest Infection
Second side
NOF
Heart
/cardiac

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