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Hip Fracture Care: High Mortality Rate, Wide Cost Variation

An observational study has found a high mortality rate at 1 year after hip fracture and significant variations in health costs among different NHS hospitals and regions.

The study, published online this week in the Lancet Healthy Longevity, aimed to understand how variations in hospital-level organisational factors impacted both costs and long-term patient outcomes after hip fracture across NHS hospitals in England and Wales.

Researchers conducted a cohort study following on from their previous work in the REDUCE study (REducing unwarranted variation in the Delivery of high-qUality hip fraCture services in England and Wales), using national databases to link records for all patients aged 60 years and older who sustained a hip fracture in England and Wales with hospital metrics from 18 other organisational data sources. 

The study sample included 178,757 patients who broke their hip between 1 April 2016 and 31 March 2019 and were treated in 172 NHS hospitals across England and Wales. Most patients (70.6%) were female, and median age was 84 in England and 83 in Wales. Patients spent a median 21days (IQR 11–41) in hospital in England and 29 [13–61] in Wales.

Notably, more than a quarter of patients, 28.2%, died within a year of their hip fracture.

The team described the inpatient costs of treating hip fracture as "substantial", at an average of £14,642 per patient, which they note was a cost similar to that incurred in the year after a stroke, and exceeding that of many common cancers. However, they found huge variation in costs among hospitals, with a range from £10,867 to £23,188 per patient — a more than two-fold difference in spending.

Orthogeriatrician Involvement Reduced Mortality

The research identified 11 organisational factors that were independently associated with mortality, 24 factors associated with number of days in hospital, and 25 with inpatient costs. Lower mortality at 1 year was associated with:

  • Assessment of all patients by an orthogeriatrician within 72 hours of admission
  • Attendance of an orthogeriatric consultant at daily trauma meetings
  • Clinical governance meetings attended by the nursing lead
  • Protocols in place for preoperative nutritional supplementation
  • Fracture liaison services (which systematically identify and assess people who have had a fragility fracture to reduce the risk of refracture)
  • Hospitals able to report their reoperation rates
  • Routine review of patient experience feedback in hip fracture clinical governance meetings
By contrast, the researchers note that hospitals reporting 100% compliance with UK best practice tariffs for fragility hip fracture care criteria actually recorded higher mortality rates, as did hospitals where a consultant surgeon attended clinical governance meetings or where a trauma and orthopaedic manager attended the daily trauma meeting.

Orthogeriatricians, Physiotherapy, Early Mobilisation Reduce Costs

Factors associated with cost savings included:

  • Assessment of all patients by an orthogeriatrician within 72 hours (produced a mean saving per patient of £529 [95% CI, £148–910]
  • Consultant orthogeriatrician attendance at clinical governance meetings — £356 (95% CI, £188–525)
  • Provision of physiotherapy to patients on weekends — £676 (95% CI, £67–1285)
  • A higher proportion (>71% vs ≦71%) of patients mobilised quickly post-operatively — £346 (95% CI, £142-550)
  • All patients receiving an inpatient delirium assessment — £275 (95% CI, £138–412)

"Multiple, potentially modifiable hospital-level organisational factors associated with important clinical outcomes and inpatient costs were identified that should inform initiatives to improve the effectiveness and efficiency of hip fracture services," the team said. Their results highlight "the urgent need for evidence-based quality improvement strategies" to improve patient outcomes and reduce spending.  

"Unacceptable" State of Care

"This research shows the unacceptable state of care for older people who break their hip," said Caroline Aylott, head of research delivery at Versus Arthritis, which funded the study. "The findings show that older people have a high chance of dying within a year of a hip fracture, and that quality of care varies hugely between NHS hospitals in England and Wales."

She added, "As hip fractures mainly affect older people, many of whom live with multiple long-term conditions, this research suggests we are not getting older people's care right. That must change."

Chief investigator Celia Gregson, professor in clinical epidemiology in the Musculoskeletal Research Unit at the University of Bristol, said: "The variation we have seen in patient outcomes and health spending following hip fracture are difficult to justify on purely clinical grounds; it tells us that the way we organise the delivery of care can be improved nationally."

The research team has worked with the Royal Osteoporosis Society to develop a toolkit to support the quality improvement of fracture service provision within acute hospital settings. The REDUCE hip fracture service implementation toolkit is available for free to all healthcare professionals and service managers.

Lancet Healthy Longevity. Published online 10 July 2023. Full text

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