Does performance-based remuneration improve outcomes in the treatment of hip fracture?

National Institute of Health and Care Excellence Guidelines for Displaced Intracapsular Hip Fractures: Examining Satisfaction With the Guidelines and Effects on Outcomes

BACKGROUND

The objectives of the study were to: (1) evaluate satisfaction with the new 2023 National Institute of Health and Care Excellence (NICE) criteria for selecting total hip arthroplasty (THA) over hemiarthroplasty and surgical recommendations for treatment of displaced intracapsular hip fractures; (2) describe why THA is performed when NICE criteria are not met; and (3) determine whether satisfaction with these guidelines is associated with improved outcomes.

METHODS

A retrospective chart review of patients who had a displaced intracapsular hip fracture treated with THA at a single tertiary academic center between 2010 and 2022 was performed. Preoperative patient characteristics were reviewed to determine if the indication for THA met NICE criteria. Operative details, perioperative complications, reoperation, and revision arthroplasty within 12 months of surgery were recorded.

RESULTS

Data from 196 patients (63% women; age 67 ± 10 years) were used. There were 161 THAs (82.1%) that satisfied NICE criteria. The 2 most common reasons for performing a THA when NICE criteria were not met (n = 35) included preoperative radiographic osteoarthritis (Tönnis grade ≥ 2; 48.6%) and decreased patient age (< 65 years; 31.5%). Satisfaction with the NICE criteria was associated with fewer perioperative complications (0.6 versus 37.1%; P < .001), reoperations (0.6 versus 31.4%; P < .001), and revisions (0.6 versus 28.6%; P < .001). The most common reason for revision was periprosthetic fracture, possibly secondary to the use of uncemented femoral stems (171 of 196, 87.2%).

CONCLUSIONS

Satisfaction with the new NICE criteria is associated with improved perioperative outcomes. Further studies are necessary to determine if preexisting hip osteoarthritis and younger age merit consideration in patient selection.

Adherence to clinical care standards and mortality after hip fracture surgery in New South Wales, 2015-2018: a retrospective population-based study

OBJECTIVES

To determine whether adherence to hip fracture clinical care quality indicators influences mortality among people who undergo surgery after hip fracture in New South Wales, both overall and by individual indicator.

STUDY DESIGN

Retrospective population-based study; analysis of linked Australian and New Zealand Hip Fracture Registry (ANZHFR), hospital admissions, residential aged care, and deaths data.

SETTING, PARTICIPANTS

People aged 50 years or older with hip fractures who underwent surgery in 21 New South Wales hospitals participating in the ANZHFR, 1 January 2015 - 31 December 2018.

MAIN OUTCOME MEASURES

Thirty-day (primary outcome), 120-day, and 365-day mortality (secondary outcomes) by clinical care indicator adherence level (low: none to three of six indicators achieved; moderate: four indicators achieved; high: five or six indicators achieved) and by individual indicator.

RESULTS

Registry data were available for 9236 hip fractures in 9058 people aged 50 years or older during 2015-2018; the mean age of patients was 82.8 years (standard deviation, 9.3 years), 5510 patients were women (69.4%). Complete data regarding adherence to clinical care indicators were available for 7951 fractures (86.1%); adherence to these indicators was high for 5135 (64.6%), moderate for 2249 (28.3%), and low for 567 fractures (7.1%). After adjustment for age, sex, comorbidity, admission year, pre-admission walking ability, and residential status, 30-day mortality risk was lower for high (adjusted relative risk [aRR], 0.40; 95% confidence interval [CI], 0.30-0.52) and moderate indicator adherence hip fractures (aRR, 0.61; 95% CI, 0.46-0.82) than for low indicator adherence hip fractures, as was 365-day mortality (high adherence: aRR, 0.59 [95% CI, 0.51-0.68]; moderate adherence: aRR, 0.74 [95% CI, 0.63-0.86]). Orthogeriatric care (365 days: aRR, 0.78; 95% CI, 0.61-0.98) and offering mobilisation by the day after surgery (365 days: aRR, 0.74; 95% CI, 0.67-0.83) were associated with lower mortality risk at each time point.

CONCLUSIONS

Clinical care for two-thirds of hip fractures attained a high level of adherence to the six quality care indicators, and short and longer term mortality was lower among people who received such care than among those who received low adherence care.

The use of minimum common data set in the development of the Greek Fragility Hip Fracture Registry in the Greek health care setting: the first year of its pilot implementation

The first Fragility Hip Fracture Registry has been established in Greece. The in-hospital length of stay was 10.8 days and was significantly influenced by the delayed surgical fixation. The increased age, the higher ASA grade, and the male gender influenced negatively the 30-day mortality, which reached 7.5%.

BACKGROUND

The increased incidence of fragility hip fractures constitutes a great challenge to the health care professionals and causes a significant burden on national health care systems around the globe. Fragility hip fracture registries have been used in many countries in order to document the cotemporary situation in each country and to identify potential weaknesses of the local health care systems.

AIM

The aim of the herein study is to present the results of the pilot implementation of the first fragility hip fracture registry in Greece, which was developed by the Greek Chapter of Fragility Fracture Network (FFN Gr), and use the neural networks in the analysis of the results.

MATERIALS AND METHODS

Seven orthopaedic departments from six different hospitals in Greece participated in the present pilot study. All fragility hip fractures from September 2022 until December 2023 were prospectively collected and documented using a central database. For this purpose, the 22 points of minimum common data set, proposed by the Global Fragility Fracture Network, with the addition of the 30-day mortality was used.

RESULTS

A total of 1009 patients who sustained a fragility hip fracture were included in the study. The mean age of the cohort was 82.2 ± 8.6 years with the majority of patients being female (72%). Sixty percent (60%) of the patients had an extracapsular hip fracture, with a mean ASA grade 2.6 ± 0.8. Intramedullary nailing and hip hemiarthroplasty were the surgical treatments of choice in the majority of extra- and intra-capsular hip fractures respectively. The mean hospital length of stay of the patients was 10.8 ± 8.5 days, and the 30-day mortality was 7.5%. The multivariant analysis revealed that the age, the ASA grade and the male gender had a significant contribution to the 30-day mortality. The neural network model had a significant under-the-curve predictive value (0.778), with age being the most important predictive factor. The length of stay was significantly influenced only by the delayed surgical fixation (more than 36 h from admission).

CONCLUSIONS

The present pilot study provides evidence that establishing a fragility hip fracture registry in Greece is feasible and demonstrates that the minimum common data set can be used as the base of any new registry. In Greece, patients with a fragility hip fracture stay in the hospital for approximately 11 days and have 7.5% 30-day mortality. Unfortunately, due to the logistics of the public healthcare system, they do not receive surgical fixation in a timely manner, which is a factor that negatively affects their length of in-hospital stay.

Factors influencing the achievement of early surgery in proximal femoral fractures under a Japanese incentive policy

BACKGROUND

Proximal femoral fractures in geriatric patients are a major challenge in orthopedics, often leading to major functional impairment. Early surgical intervention is crucial for improving patient recovery and overall health outcomes. Thus, Japan's Ministry of Health, Labour and Welfare initiated a reimbursement policy in April 2022 to encourage early surgery for these fractures in patients aged ≥75 years. This study investigated the impact of this policy on early surgery rates in Japan and identified factors influencing the timing of surgical interventions.

METHODS

We retrospectively analyzed the data of patients who underwent surgery for proximal femoral fractures at our institution between April 2022 and March 2023. Patients were categorized into two groups based on the timing of surgery relative to the injury: ≤48 h and >48 h. Demographic and clinical data, including age, sex, fracture type, and various health- and admission-related factors, were assessed.

RESULTS

Of the 192 patients, 152 were included in the study. Among them, 38% underwent early surgery (≤48 h), and 15% of the patients arrived more than 48 h post-injury. Significant differences were found in admission routes and residence types between the groups. The ≤48 h group had shorter intervals from injury to admission and surgery than the >48 h group. Factors such as the admission process, day of the week, and C-reactive protein levels significantly influenced the timing of surgery.

CONCLUSIONS

After introducing incentives for early surgery in Japan, 38% of patients with proximal femoral fractures underwent surgery within 48 h of injury. Factors contributing to patients not receiving early surgery included transport from another hospital, weekend hospitalization, and elevated CRP levels. These findings suggest that achieving surgery within 48 h of injury is challenging through hospital efforts alone, and the time criteria might be more appropriate if changed to "admission to surgery."

The RELIEF feasibility trial: topical lidocaine patches in older adults with rib fractures

BACKGROUND

Lidocaine patches, applied over rib fractures, may reduce pulmonary complications in older patients. Known barriers to recruiting older patients in emergency settings necessitate a feasibility trial. We aimed to establish whether a definitive randomised controlled trial (RCT) evaluating lidocaine patches in older patients with rib fracture(s) was feasible.

METHODS

This was a multicentre, parallel-group, open-label, feasibility RCT in seven hospitals in England and Scotland. Patients aged ≥65 years, presenting to ED with traumatic rib fracture(s) requiring hospital admission were randomised to receive up to 3×700 mg lidocaine patches (Ralvo), first applied in ED and then once daily for 72 hours in addition to standard care, or standard care alone. Feasibility outcomes were recruitment, retention and adherence. Clinical end points (pulmonary complications, pain and frailty-specific outcomes) and patient questionnaires were collected to determine feasibility of data collection and inform health economic scoping. Interviews and focus groups with trial participants and clinicians/research staff explored the understanding and acceptability of trial processes.

RESULTS

Between October 23, 2021 and October 7, 2022, 206 patients were eligible, of whom 100 (median age 83 years; IQR 74-88) were randomised; 48 to lidocaine patches and 52 to standard care. Pulmonary complications at 30 days were determined in 86% of participants and 83% of expected 30-day questionnaires were returned. Pulmonary complications occurred in 48% of the lidocaine group and 59% in standard care. Pain and some frailty-specific outcomes were not feasible to collect. Staff reported challenges in patient compliance, unfamiliarity with research measures and overwhelming the patients with research procedures.

CONCLUSION

Recruitment of older patients with rib fracture(s) in an emergency setting for the evaluation of lidocaine patches is feasible. Refinement of data collection, with a focus on the collection of pain, frailty-specific outcomes and intervention delivery are needed before progression to a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN14813929.

The burden of periprosthetic femoral fractures in England and Wales: Insights from the first two years of data collection in the National Hip Fracture Database and regional variation in care

INTRODUCTION

Periprosthetic femoral fractures (PPFFs) represent an important healthcare problem, with a rising incidence noted due to an increase in the number of arthroplasty surgeries being performed. There is a current lack of national consensus as to how these complex, often frail patients are managed.

AIMS

Our primary aim was to present the epidemiology of PPFFs in England and Wales over the first two years of data collection by the National Hip Fracture Database (NHFD). Secondary aims included how well the NHFD Key Performance Indicators (KPIs) are met for PPFF patients, whether centres reporting a higher burden of PPFF patients are more likely to meet KPIs compared to lower volume centres, and to also identify if regional variation in care for these patients exist.

METHODS

Patients aged 60 years or over, admitted to any acute hospital in England or Wales with a PPFF within the period 1st January 2020 to 31st December 2021 were included. Fractures were classified using the Vancouver system. The primary outcome of interest was the incidence of PPFF in England and Wales. Secondary outcomes included i) geographical distribution, ii) pattern of injury, iii) treatment received, iv) KPI performance nationally, v) KPI performance by top 5 highest volume hospitals vs the rest, vi) KPI performance by region and vii) KPI performance compared with native hip fracture patients.

RESULTS

A total of 5,566 PPFFs were reported during our study period. A 31 % increase in cases was seen between 2020 and 2021 (2,405 to 3,161). The South-West of England reported the highest burden of PPFFs (14 % of all cases reported in 2021). Vancouver B subtypes were most common around hip replacements (62 %) and C subtype around knee replacements (55 %). A total of 4,598 patients (82.6 %) underwent operative management. There was regional variation in KPI attainment. When compared to KPI attainment for native hip fractures PPFF care under performed in most regions and domains. High volume PPFF centres were not associated with improved attainment of KPIs.

CONCLUSION

We have described the incidence, nature, and management of PPFF at national and regional levels using routinely collected NHFD data. Both numerically and due to case complexity, PPFF are a considerable challenge to patients and health services alike. This epidemiology is not captured by other existing datasets and increased case contribution to the NHFD is encouraged to improve understanding and enable prioritisation and delivery of further care and research.

Epidemiology & management of complex ankle fractures in the United Kingdom: A multicentre cohort study

BACKGROUND

Patient factors are known to contribute to decision making and treatment of ankle fractures. The presence of poor baseline mobility, diabetes, neuropathy, alcoholism, cognitive impairment, inflammatory arthritis or polytrauma can result in a higher risk of failure or complications. Limited evidence is available on the optimum management for this challenging cohort of patients herein described as complex ankle fractures. This UK multicentre study assessed and evaluated the epidemiology of ankle fractures complicated by significant comorbidity and patient factors and use of specialist surgical techniques such as hindfoot nails (HFN) / tibiotalarcalcaneal (TCC) nails and enhanced open reduction and internal fixation (ORIF).

PATIENTS AND METHODS

A UK-wide collaborative study was performed of adult distal AO43/AO44 fractures, associated with 1 or more of the patient factors listed above. Primary outcomes included patient demographics, comorbidities, surgical technique and implants. Secondary outcomes included surgical complications and early post-operative weight bearing instructions. Statistical analysis was performed to assess patient and fracture characteristics on outcome, including propensity matching.

RESULTS

One-thousand three hundred and sixty patients, with at least one of the above complex factors, from 56 centres were included with a mean age of 53.1 years. 90.2% (1227) patients underwent primary fixation which included 78.9% (1073) standard open reduction internal fixations (ORIF), 3.25% (43) extended ORIF and 8.1% (111) primary HFN / TCC. Overall wound complications and thromboembolic events were similar in the hindfoot nail group and the ORIF group (11.7% vs 10.7%). Wound complications were greater in diabetic patients versus non-diabetic patients independent of fixation method (15.8% vs 9.0%). After propensity matching for comorbidities and fracture type, overall complications were lower in the hindfoot nail (11.8%) and extended ORIF groups (16.7%), than the standard ORIF group (18.6%).

CONCLUSION

Only a minority of complex ankle fractures are treated with specialised techniques (HFN/TCC or extended ORIF). Though more commonly used in older and frail patients their perceived advantages are often negated by a reluctance to bear weight early. These techniques demonstrated a better complication profile to standard ORIF but hindfoot nail with joint preparation for fusion was associated with more complications than hindfoot nail for fixation.

LEVEL OF EVIDENCE

III.

Cost-utility analysis of dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults

Aims

To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults.

Methods

Using data from a multicentre randomized controlled trial (World Hip Trauma Evaluation 8 (WHiTE-8)) in the UK, a within-trial economic evaluation was conducted. Resource usage was measured over 120 days post randomization, and cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY), gained from the UK NHS and personal social services (PSS) perspective in the base-case analysis. Methodological uncertainty was addressed using sensitivity analysis, while decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves.

Results

The base-case analysis showed that high-dose, dual-antibiotic cement had a significantly higher mean cost (£224 (95% confidence interval (CI) -408 to 855)) and almost the same QALYs (0.001 (95% CI -0.002 to 0.003)) relative to single-antibiotic cement from the UK NHS and PSS perspective. The probability of the high-dose, dual-antibiotic cement being cost-effective was less than 0.3 at alternative cost-effectiveness thresholds, and its net monetary benefit was negative. This finding remained robust in the sensitivity analyses.

Conclusion

This study shows that high-dose, dual-antibiotic cement is unlikely to be cost-effective compared to single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults.

Lessons learned from hip fracture registries - From the Scottish perspective to global practice

Hip fracture is the most common serious orthopaedic injury affecting older people. In Scotland, 7000 patients sustain a hip fracture each year, and this is projected to rise to 10,300 a year by 2029. In this narrative review, we describe the origin and evolution of the Scottish Hip Fracture Audit, including key elements which have improved hip fracture care and outcomes within Scotland, and the current state of play of hip fracture registries around the world. We go on to discuss future directions for data driven improvements in hip fracture care, including international standardised data collection and a global minimum common dataset for hip fracture registries.

Service availability and readiness for hip fracture care in low- and middle-income countries in South and Southeast Asia

Aims

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Methods

The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up.

Results

Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals.

Conclusion

This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system.

Standardization of global hip fracture audit could facilitate learning, improve quality, and guide evidence-based practice

Aims

National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

Methods

We compared 17 hip fracture registries covering 20 countries (Argentina; Australia and New Zealand; China; Denmark; England, Wales, and Northern Ireland; Germany; Holland; Ireland; Japan; Mexico; Norway; Pakistan; the Philippines; Scotland; South Korea; Spain; and Sweden), setting each of these against the 20 core and 12 optional fields of the MCD.

Results

The highest MCD adherence was demonstrated by the most recently established registries. The first-generation registries in Scandinavia collect data for 60% of MCD fields, second-generation registries (UK, other European, and Australia and New Zealand) collect for 75%, and third-generation registries collect data for 85% of MCD fields. Five of the 20 core fields were collected by all 17 registries (age; sex; surgery date/time of operation; surgery type; and death during acute admission). Two fields were collected by most (16/17; 94%) registries (date/time of presentation and American Society of Anesthesiologists grade), and five more by the majority (15/17; 88%) registries (type, side, and pathological nature of fracture; anaesthetic modality; and discharge destination). Three core fields were each collected by only 11/17 (65%) registries: prefracture mobility/activities of daily living; cognition on admission; and bone protection medication prescription.

Conclusion

There is moderate but improving compatibility between existing registries and the FFN MCD, and its introduction in 2022 was associated with an improved level of adherence among the most recently established programmes. Greater interoperability could be facilitated by improving consistency of data collection relating to prefracture function, cognition, bone protection, and follow-up duration, and this could improve international collaborative benchmarking, research, and quality improvement.

International orthopaedic trials

Musculoskeletal diseases are having a growing impact worldwide. It is therefore crucial to have an evidence base to most effectively and efficiently implement future health services across different healthcare systems. International trials are an opportunity to address these challenges and have many potential benefits. They are, however, complex to set up and deliver, which may impact on the efficient and timely delivery of a project. There are a number of models of how international trials are currently being delivered across a range of orthopaedic patient populations, which are discussed here. The examples given highlight that the key to overcoming these challenges is the development of trusted and equal partnerships with collaborators in each country. International trials have the potential to address a global burden of disease, and in turn optimize the benefit to patients in the collaborating countries and those with similar health services and care systems.

Long-term outcome collection after hip fracture in Ireland: a systematic review of traditional and grey literature

This review aimed to describe the methods and results from recent Irish research about post-acute hip fracture outcomes. Meta-analyses estimate the 30-day and 1-year mortality rate at 5% and 24% respectively. There is a need for standardised recommendations about which data should be recorded to aid national and international comparisons.

PURPOSE

Over 3700 older adults experience hip fracture in Ireland annually. The Irish Hip Fracture Database national audit records acute hospital data but lacks longer-term outcomes. This systematic review aimed to summarise and appraise recent Irish studies that collected long-term hip fracture outcomes and to generate pooled estimates where appropriate.

METHODS

Electronic databases and grey literature were searched in April 2022 for articles, abstracts, and theses published from 2005 to 2022. Eligible studies were appraised by two authors and outcome collection details summarised. Meta-analyses of studies with common outcomes were conducted where the sample was generalisable to the broad hip fracture population.

RESULTS

In total, 84 studies were identified from 20 clinical sites. Outcomes commonly recorded were mortality (n = 48 studies; 57%), function (n = 24; 29%), residence (n = 20; 24%), bone-related outcomes (n = 20; 24%), and mobility (n = 17; 20%). One year post-fracture was the most frequent time point, and patient telephone contact was the most common collection method used. Most studies did not report follow-up rates. Two meta-analyses were performed. The pooled estimate for one-year mortality was 24.2% (95% CI = 19.1-29.8%, I² = 93.8%, n = 12 studies, n = 4220 patients), and for 30-day mortality was 4.7% (95% CI = 3.6-5.9%, I² = 31.3%, n = 7 studies, n = 2092 patients). Reports of non-mortality outcomes were deemed inappropriate for meta-analysis.

CONCLUSION

Hip fracture long-term outcomes collected in Irish research are broadly in line with international recommendations. Heterogeneity of measures and poor reporting of methods and findings limits collation of results. Recommendations for standard outcome definitions nationally are warranted. Further research should explore the feasibility of recording long-term outcomes during routine hip fracture care in Ireland to enhance national audit.

Inter-departmental variation in surgical treatment of proximal femoral fractures: A nationwide observational cohort study

BACKGROUND AND PURPOSE

Hip fractures should be treated based on the best available evidence and cost-effectively to optimize the outcome for this large group of frail patients. This study examined nationwide variation in surgical methods used for hip fractures.

METHODS

In this cohort study 46,243 patients ≥65 years with a trochanteric hip fracture (THF) or a femoral neck fracture (FNF) registered in the Swedish Fracture Register (SFR) between 1 January 2016 and 31 December 2020 were included. Fractures were classified according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification system. The choice of surgical methods was assessed for each fracture type to compare national variation.

RESULTS

21,312 THFs and 24,072 FNFs (67% women) with a mean age of 83 years (SD 8) were surgically treated. In the treatment of two-fragment THFs (AO/OTA A1) departments ranged from using 90% short intramedullary nails to 98% sliding hip screws. Treating displaced FNFs (AO/OTA B3), the proportion of hemiarthroplasty ranged from 9 to 90%, and internal fixation between 0.6 to 21%, depending on the department.

INTERPRETATION

A mature national fracture register permits the monitoring of treatment provided and thus serves as an important aid in assessing compliance with guidelines. The large inter-departmental variation in the surgical management of hip fractures in Sweden appears unwarranted based on the current evidence, indicating a need for updated national guidelines. Further research will have to clarify the impact of this variation on mortality and re-operation rates.

Challenges and opportunities in the care of chronic subdural haematoma: perspectives from a multi-disciplinary working group on the need for change

INTRODUCTION

A chronic subdural haematoma (cSDH) is a collection of altered blood products between the dura and brain resulting in a slowly evolving neurological deficit. It is increasingly common and, in high income countries, affects an older, multimorbid population. With changing demographics improving the care of this cohort is of increasing importance.

METHODS

We convened a cross-disciplinary working group (the 'Improving Care in Elderly Neurosurgery Initiative') in October 2020. This comprised experts in neurosurgical care and a range of perioperative stakeholders. An Implementation Science framework was used to structure discussions around the challenges of cSDH care within the United Kingdom. The outcomes of these discussions were recorded and summarised, before being circulated to all attendees for comment and refinement.

RESULTS

The working group identified four key requirements for improving cSDH care: (1) data, audit, and natural history; (2) evidence-based guidelines and pathways; (3) shared decision-making; and (4) an overarching quality improvement strategy. Frequent transfers between care providers were identified as impacting on both perioperative care and presenting a barrier to effective data collection and teamworking. Improvement initiatives must be cognizant of the complex, system-wide nature of the problem, and may require a combination of targeted trials at points of clinical equipoise (such as anesthetic technique or anticoagulant management), evidence-based guideline development, and a cycle of knowledge acquisition and implementation.

CONCLUSION

The care of cSDH is a growing clinical problem. Lessons may be learned from the standardised pathways of care such as those as used in hip fracture and stroke. A defined care pathway for cSDH, encompassing perioperative care and rehabilitation, could plausibly improve patient outcomes but work remains to tailor such a pathway to cSDH care. The development of such a pathway at a national level should be a priority, and the focus of future work.

Developing a minimum common dataset for hip fracture audit to help countries set up national audits that can support international comparisons

AIMS

The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

METHODS

We compared all ten established national hip fracture registries: England, Wales, and Northern Ireland; Scotland; Australia and New Zealand; Republic of Ireland; Germany; the Netherlands; Sweden; Norway; Denmark; and Spain. We tabulated all questions included in each registry, and cross-referenced them against the 32 questions of the MCD dataset. Having identified those questions consistently used in the majority of national audits, and which additional fields were used less commonly, we then used consensus methods to establish a revised MCD.

RESULTS

A total of 215 unique questions were used across the ten registries. Only 72 (34%) were used in more than one national audit, and only 32 (15%) by more than half of audits. Only one registry used all 32 questions from the 2014 MCD, and five questions were only collected by a single registry. Only 21 of the 32 questions in the MCD were used in the majority of national audits. Only three fields (anaesthetic grade, operation, and date/time of surgery) were used by all ten established audits. We presented these findings at the Asia-Pacific FFN meeting, and used an online questionnaire to capture feedback from expert clinicians from different countries. A draft revision of the MCD was then presented to all 95 nations represented at the Global FFN conference in September 2021, with online feedback again used to finalize the revised MCD.

CONCLUSION

The revised MCD will help aspirant nations establish new registry programmes, facilitate the integration of novel analytic techniques and greater multinational collaboration, and serve as an internationally-accepted standard for monitoring and improving hip fracture services. Cite this article: Bone Joint J 2022;104-B(6):721-728.

Fragility Fracture Systems: International Perspectives - Asia & Australia

Background:

The incidence and burden of fragility fractures have reached the level where comprehensive systematic care is warranted to optimize the care of these patients. Hip fractures are the most frequently lethal and independence level changing fragility fractures, responsible for 30-day mortality comparable to high-energy trauma patients with injury severity scores over 12. It is a reasonable expectation that countries have a hip fracture treating system of care in place for this high-risk population. This review explores the systems of care from the Asia-Pacific Perspective.

Methods:

From the International Orthopaedic Trauma Association's member societies, nations from the Asia-Pacific Region were requested to contribute with an overview of their fragility fracture management systems. The content or the review was standardized by a template of headings, which each country endeavored to cover.

Results:

Australia, Japan, and South Korea contributed voluntarily from the 5 member countries of the region. Each country has made considerable efforts and achievements with diverse approaches to standardize and improve the care of fragility fractures, particularly hip fractures. Beyond the individual nations’ efforts there is also an existing Asia-Pacific Collaborative. The data collection and in some counties the existence of a registry is promising; funding and recognition of the problem among competing health care budget priorities are common.

Conclusions:

Our review covers some of the countries with strongest economy and highest health care standards. The lack of a universal robust system for hip fracture care is apparent. The data collection from registry initiations is expected to drive system development further in these countries and hopefully fast track the development in other countries within the most populous geographical region of the Earth.

Long-term outcomes after hip fracture in Ireland: a protocol for a systematic review of traditional and grey literature

Background: Hip fracture is experienced by almost 3,500 older people in Ireland annually. The Irish Hip Fracture Database (IHFD), which drives clinical improvements in acute hospitals, aims to allow recording of longer-term outcomes. Feasible and robust methods of data collection need to be identified to inform this activity. The aim of this systematic review is to identify, describe and appraise studies that have collected long-term outcomes after hip fracture in Ireland in the last 15 years and to generate pooled estimates of outcomes if appropriate. Methods: A search of electronic databases (MEDLINE, Embase, Scopus, Web of Science and CINAHL) and grey literature sources will be conducted for journal articles, conference abstracts, academic theses, and reports. Search terms related to hip fracture and Ireland will be included for most sources. The search will be supplemented by email contact with relevant professionals. Observational and interventional studies published between 2005 and 2021 will be included if outcome data were collected in the Republic of Ireland in patients with hip fracture. Outcomes of interest will include data collected after discharge from an inpatient setting or at a fixed time-point greater than 30 days after fracture, hospital admission or surgery. Information relating to study characteristics, description of researchers, data collection methods, patient characteristics and long-term outcomes will be extracted from each study and summarised in tables. Studies will be assessed for risk of bias by two review authors. Where outcomes are sufficiently homogeneous, meta-analyses of estimates will be conducted. Conclusion: Results from this study will inform the planning of further qualitative research to explore barriers and facilitators of long-term outcome collection in Ireland. It will form the basis of education and training for future data collectors in this setting.