Quality of care for patients with a fracture of the hip in major trauma centres

A comparative study of hip fracture care and outcomes in major trauma centres versus trauma units

INTRODUCTION

There is good evidence to support that major trauma networks significantly reduce morbidity and mortality in severely injured patients. However, following the introduction of major trauma centres (MTCs) in England in 2012, early concerns were raised regarding the effect on hip fracture patients. The aim of our study was to review data from the National Hip Fracture Database for fractured neck of femur (FNOF) patients, comparing patient outcomes between MTCs and trauma units (TUs), and the national regions of the UK.

METHODS

NHFD data from 2018 for all hospitals in England, Wales and NI was collected using the charts and dashboards available online. We recorded data for the following outcomes: time to surgery, acute hospital length of stay, overall hospital length of stay, discharge to original residence within 120 days, crude 30-day mortality and adjusted 30-day mortality. We conducted a one-way ANOVA test to calculate statistical differences for each outcome measure by MTC vs TU and then separately for the regions of the UK divided into England, Wales and Northern Ireland (NI).

RESULTS

Data for 175 hospitals are included in this study; 22 of which were MTCs. The total number of operative cases were 65,848. 9668 of these occurred in MTC compared to 56,180 in TUs. This equates to an annual average of 439 per MTC and 367 per TU. Despite this, there was no statistically significant difference observed in all outcomes for MTC vs TU. Patients in NI waited longer for their surgery (60.3 h, p < 0.001), whilst patients in Wales had the longest overall hospital length of stay (31.6 days, p < 0.001). However, there was no difference in patients' crude 30-day mortality (p = 0.480) or adjusted 30-day mortality (p = 0.191).

CONCLUSION

These findings are reassuring for MTCs in England. We found no evidence to suggest that FNOF patients are treated inferiorly, or have worse outcomes, at MTCs vs TUs. FNOF patients in NI waited longer for their surgery but this did not have any significant difference on 30-day mortality rates. The care of FNOF patients in NI may warrant further study.

Utilization and costs of formal and informal care, home adaptations, and physiotherapy among older patients with hip fracture

Aims

This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK.

Methods

A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer. Completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling.

Results

A total of 4,183 patients from the WHiTE cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3,524 (84.2%) completed the four-month health resource section. Estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2,843 (SD 5,467), £6,613 (SD 15,146), £706 (SD 1,706) and £9 (SD 33), respectively. Mean cost of informal care decreased to £660 (SD £1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day.

Conclusion

Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. Our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate.

Cite this article: Bone Joint Res. 2020;9(5):250–257.

Twelve month mortality rates and independent living in people aged 65 years or older after isolated hip fracture: A prospective registry-based study

INTRODUCTION

This study investigated which patient and injury characteristics are associated with 12-month mortality rates and living independently after isolated hip fracture.

METHODS

Older adults aged ≥65 years were included if they had an isolated hip fracture, were admitted to hospital between July 2009 and June 2016, inclusive, and were registered to the Victorian Orthopaedic Trauma Outcomes Registry. Mortality up to 12 months (365 days) post-injury, and functional outcomes (Glasgow Outcome Scale-Extended; GOS-E) at 12 months post-injury were examined. Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs), and multivariable logistic regression was used to identify predictors of living independently compared with severe disability or death on the GOS-E.

RESULTS

4,912 patients were included, of whom 28% died, 46% had moderate-severe disability, and 26% were living independently 12 months post-injury. Mortality rates were lower in women (aHR=0.56, 95%CI: 0.50, 0.63), and in people injured in a high fall vs low fall (aHR=0.47, 95%CI: 0.31, 0.72). Mortality rates were higher in people in the older age groups (75-84 years: aHR=1.53, 95%CI: 1.21, 1.93; 95+ years: aHR=3.58, 95%CI: 2.68, 4.77), living in areas with the highest level of socioeconomic disadvantage (aHR=1.25, 95%CI: 1.01, 1.55), with a Charlson Comorbidity Index weighting of one (aHR=1.60, 95%CI: 1.36, 1.88) or more than one (aHR=2.21, 95%CI: 1.94, 2.53), whose injury occurred in a residential institution versus at home (aHR=2.63, 95%CI: 1.97, 3.52), that resulted in intensive care unit admission (aHR=1.68, 95%CI: 1.21, 2.32), and in people who did not have surgery versus people who had internal fixation (aHR=1.65, 95%CI: 1.33, 2.04). Independent living was inversely associated with most of the same characteristics; however, people also had lower odds of living independently if they were from metropolitan residential areas versus rural areas (aOR=0.77, 95%CI: 0.62, 0.96), or had mild to moderate (aOR=0.33, 95%CI: 0.27, 0.39) or marked to severe (aOR=0.13, 95%CI: 0.09, 0.20) preinjury disability vs no preinjury disability.

CONCLUSIONS

Characteristics that are associated with social disadvantage, frailty, poor health and reduced independence before injury were associated with increased rates of death and reduced odds of living independently 12 months after isolated hip fracture.

Pay for performance and hip fracture outcomes: an interrupted time series and difference-in-differences analysis in England and Scotland

Aims

Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control.

Materials and Methods

We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay.

Results

There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay.

Conclusion

This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England.

Cite this article: Bone Joint J 2019;101-B:1015–1023.

Validation of a prospective cohort study of older adults with hip fractures

Aims

This study sought to determine the proportion of older adults with hip fractures captured by a multicentre prospective cohort, the World Hip Trauma Evaluation (WHiTE), whether there was evidence of selection bias during WHiTE recruitment, and the extent to which the WHiTE cohort is representative of the broader population of older adults with hip fractures.

Patients and Methods

The characteristics of patients recruited into the WHiTE cohort study were compared with those treated at WHiTE hospitals during the same timeframe and submitted to the National Hip Fracture Database (NHFD).

Results

Patients recruited to WHiTE were more likely to be admitted from their own home (83.5% vs 80.2%; p < 0.001) and to have a higher median Abbreviated Mental Test Score (AMTS) (9 (interquartile range (IQR) 6 to 10) vs 9 (IQR 5 to 10); p < 0.001) than those who were not recruited. In terms of WHiTE cohort generalizability, participating hospitals included a greater proportion of Major Trauma Centres (47.8% vs 7.8%) and large hospitals (997 (IQR 873 to 1290) vs 707 (459 to 903) beds) with high-volume Emergency Departments (median annual attendances of 43 981 (IQR 37 147 to 54 385) vs 35 964 (IQR 26 229 to 50 551)). However, there were few differences in baseline characteristics between patients in the WHiTE cohort and those recorded in the NHFD.

Conclusion

There is evidence of a weak selection bias towards recruiting fitter patients within the WHiTE cohort, which will help to put into context the findings of future studies. We conclude that the patients within the WHiTE cohort are representative of the national population of older adults with hip fractures throughout England, Wales, and Northern Ireland. Cite this article: Bone Joint J 2019;101-B:708–714.

The use of an electronic health record system reduces errors in the National Hip Fracture Database

AIM

to compare the validity of data submitted from a UK level 1 trauma centre to the National Hip Fracture Database (NHFD) before and after the introduction of an electronic health record system (EHRS).

PATIENTS AND METHODS

a total of 3224 records were reviewed from July 2009 to July 2017. 2,133 were submitted between July 2009 and October 2014 and 1,091 between October 2014 and July 2017, representing data submitted before and after the introduction of the EHRS, respectively. Data submitted to the NHFD were scrutinised against locally held data.

RESULTS

use of an EHRS was associated with significant reductions in NHFD errors. The operation coding error rate fell significantly from 23.2% (494/2133) to 7.6% (83/1091); P < 0.001. Prior to EHRS introduction, of the 109 deaths recorded in the NHFD, 64 (59%) were incorrect. In the EHRS dataset, all the 112 recorded deaths were correct (P < 0.001). There was no significant difference in the error rate for fracture coding. In the EHRS dataset, after controlling for sample month, entries utilising an operation note template with mandatory fields relevant to NHFD data were more likely to be error free than those not using the template (OR 2.69; 95% CI 1.92-3.78).

CONCLUSION

this study highlights a potential benefit of EHR systems, which offer automated data collection for auditing purposes. However, errors in data submitted to the NHFD remain, particularly in cases where an NHFD-specific operation note template is not used. Clinician engagement with new technologies is vital to avoid human error and ensure database integrity.

Does a dedicated hip fracture unit improve clinical outcomes? A five-year case series

INTRODUCTION

The aim of the study was to establish whether a dedicated hip fracture unit, geographically separate from the local major trauma centre, could improve clinical outcomes for patients sustaining proximal femoral fragility fractures.

MATERIALS AND METHODS

This study was a retrospective case series, using data collected from Brighton and Sussex University Hospitals NHS Trust's submissions to the National Hip Fracture Database between 1 April 2011 and 16 September 2016. The outcomes measured were mortality, length of hospital stay, time from admission to surgical intervention and return to premorbid residence. Patients were compared before and after reconfiguration of services into a separate dedicated hip fracture unit geographically distinct from the major trauma centre.

RESULTS

A total of 2117 patients (2178 injuries) were managed before the existence of the hip fracture unit, while 660 patients (673 injuries) were treated within the hip fracture unit. During the five-year study period, the 30-day mortality rate (pre-hip fracture unit 5.47% vs hip fracture unit 3.13%, P = 0.014), variance in the length of hospital stay (P < 0.001), mean time to surgical intervention (P = 0.044) and return to premorbid residence were significantly improved. An immediate 12-month comparison demonstrated significantly improved variance in length of hospital stay (P = 0.020) and return to premorbid residence (P = 0.015).

DISCUSSION

The reconfiguration of services significantly reduced variance in length of stay, enabling accurate resource planning in future. Multiple incremental improvements in service provision, in addition to the hip fracture unit, may explain the lower mortality observed.

CONCLUSION

While further research is required, replication of the hip fracture unit service model may potentially afford significant clinical and financial gains.

Infection Versus Hematoma Following Surgical Treatment of Proximal Femoral Fractures in Geriatric Patients

Introduction

The surgical treatment of proximal femoral fractures predominantly involves geriatric patients and is associated with high morbidity and mortality. However, analyses on postoperative infections or hematoma are rare.

Methods

Patients requiring surgical revision due to infection (n = 90) or hematoma (n = 77) in the postoperative phase were identified from an electronic database of 2000 consecutive patients surgically treated for proximal femoral fractures between 2006 and 2014. Demographic and clinical data were retrieved, including information on the pathogens in patients with infection. A follow-up on morbidity and mortality was conducted via telephone for at least 2 years postsurgery.

Results

The follow-up rate was 100%, and the mean age was 81.9 years. The incidence rate of infection was 4.1% (90/2000), and women were commonly affected. Staphylococcus aureus and Staphylococcus epidermidis were the most commonly detected pathogens (35.5% and 25.5%, respectively). Mixed infections were observed in 15 patients, and Methicillin-resistant Staphylococcus aureus infections were observed in only 4 patients. A total of 77 (85.6%) infections occurred within 30 days postsurgery. The implant was preserved in 76 (84.4%) patients, and resection arthroplasty was required in 14 patients. Dementia and pertrochanteric fractures were significantly more common in the infection than in the hematoma group. Although infections were associated with high mortality rates for up to 2 years postsurgery, the rates did not significantly differ from those in the hematoma control group.

Conclusion

One of every 2 patients who developed an infection following the surgical treatment of a proximal femoral fracture died within 2 years postsurgery. In addition, infections were significantly associated with dementia. Avoiding postoperative infection should be a high priority in the surgical treatment of proximal femoral fractures.

Regionalisation of trauma care in England

AIMS

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

PATIENTS AND METHODS

An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital.

RESULTS AND CONCLUSION

A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.

Data errors in the National Hip Fracture Database

Aims

We present an audit comparing our level I major trauma centre’s data for a cohort of patients with hip fractures in the National Hip Fracture Database (NHFD) with locally held data on these patients.

Patients and Methods

A total of 2036 records for episodes between July 2009 and June 2014 were reviewed.

Results

The demographics of nine patients were recorded incorrectly. The rate of incorrect data in operation codes was most significant with overall accuracy of 0.637 (95% CI 0.615 to 0.658). The sensitivity of NHFD coding ranged from 0.250 to 1.000 and the specificity 0.879 to 0.999. The recording of cementation had a sensitivity of 0.932 and specificity of 0.713. The recording of total hip arthroplasty had a sensitivity of 0.739 and specificity of 0.983. The overall accuracy of mortality data was 0.942 (95% CI 0.931 to 0.952), with sensitivity of 0.967 and specificity of 0.419.

Conclusion

This paper highlights the need for local audit of the integrity of data uploaded to the NHFD. Cite this article: Bone Joint J 2016;98-B:1406–9.