Hip Fracture Management Conference

Novotel on Collins, Melbourne

3-4 December 2012

The National Hip Fracture DatabaseUK experience in improving care quality and outcomes

Colin Currie

Clinical Lead (Geriatric Medicine)

National Hip Fracture Database

Outline

• Hip fracture: the tracer condition for the current

epidemic of fragility fractures

• The National Hip Fracture Database: using the

synergy of standards, audit and feedback

• Impact of NHFD on care quality and outcomes

• The wider impact of a national clinical audit

Hip fracture

“The most common serious –

and the most serious

common – injury of older

people”

The tracer condition for the

current epidemic of fragility

fractures

Projected hip fractures worldwideProjected hip fractures worldwide

Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-9

Projected to reach 3.250 million in Asia by 2050

1990 2050

600

3250

1990 2050

668

400

1990 2050

742

378

1990 2050

10

0

629

Total number ofhip fractures:1990 = 1.66 million 2050 = 6.26 million

The fragility fracture careerThe fragility fracture career

Morbidity

50 60 70 80 90

Colles' fracture

Vertebral fracture

Hip fracture

Age

No fractures –increasing morbidity due to ageing alone

Added morbidity from fractures

AgeAdapted from Kanis JA, Johnell O; 1999

DH Falls & Bone Health Commissioning Toolkit 2009

19 December 2012

Objective 1: Improve outcomes and

improve efficiency of care after hip

fractures – by following the 6 “Blue Book” standards

Hip fracture patients

Objective 2: Respond to the first

fracture, prevent the second – through Fracture Liaison Services in acute and primary care

Non-hip fragility fracture patients

Objective 3: Early intervention to restore

independence – through falls care pathway linking acute and urgent care services to secondary falls prevention

Individuals at high risk of 1st fragility fracture or other injurious falls

Objective 4: Prevent frailty, preserve

bone health, reduce accidents –

through preserving physical activity, healthy lifestyles and reducing environmental hazards

Older people

Hip fracture – the patient experience

• A major life-event

• Recovery of mobility often limited

• Mortality high

• Loss of home much dreaded – and fairly common

Hip fracture – the patient experience

f r om

Hospital 16 (n= 444)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 11 21 31 41 51 61 71 81 91 101 111

120 days post admission

home

Residential Care

Long Term Care

other

ger rehab

Acute Ward

Orthopaedic Department

Died

Physiotherapy Primary Care

Nursing A&E Radiology

Supported Discharge OccupationalTherapy

Geriatric Medicine Anaesthetics

Social Management RehabilitationServices

G.P.Labs Portering

Orthopaedic SurgeryOrthopaedic Surgery

Hip fracture care – who’s involved?Hip fracture care – who’s involved?

CarersCarers

Hip fracture – service implications

• 30 years ago – an unwelcome and burdensome

caseload

• Now a major surgical, medical and rehabilitation

challenge

• Resource-intensive – amid growing service

pressures

• Service response much improved!

Hip fracture – a suitable case for audit?

• Common, serious, well-defined injury

• Good evidence base for care – and prevention

• Care is complex and costly

• Care, outcomes – and costs – vary

• Numbers rising as populations age

• Hip fracture care the central challenge of current global fragility fracture epidemic

Hip fracture audit: a brief history

• 1980’s onwards: ‘Rikshoft’ (Sweden)

– European bilaterals

– Scottish Hip Fracture Audit (1993-2010)

– Standardised Audit of Hip Fracture in Europe (SAHFE)

– Growing numbers of single-centre audits

• 2007 UK National Hip Fracture Database (NHFD)

– using the synergy of audit, standards and benchmarked feedback to improve care and outcomes

• 2011/12 International interest – and action! (Australia,

NZ, Ireland, Canada?)

National Clinical Governance for Hip Fracture Care: Scotland

The UK National Hip Fracture Database

• A clinically-led, web-based, continuous audit of hip fracture care and secondary prevention in England, Wales, and Northern Ireland

• Using the synergy of audit, standards and feedback to improve care and outcomes

• Valued by clinicians and managers, and by the Departments of Health

• Successive national reports show improvements in care and secondary prevention

www.nhfd.co.uk

Development: 2004-2007

• Strategic vision and ruthless acquisition/

plagiarism• Dataset from Rikshoft, SHFA, SAHFE etc

• IT from Myocardial Infarction National Audit Project (MINAP)

• Soft money and hard work• Industry funding (via national organisations) 2004-2009

• Committees large and small• To consult – and implement

• Making friends and influencing people• Media, meetings, lobbying, etc

Blue Book and NHFD: launched together in 2007

Progress: the NHFD 2007-2012

• NHFD launched – Sept. 2007

• Recognised by NCAAG in 2009 for funding by

HQIP as a national clinical audit

• Steady growth towards national coverage

• National reports: 2009, 2010, 2011, 2012

• Growing impact on care and outcomes

• International interest – and action!

Six Blue Book standards – monitored by NHFD

1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation

2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, during normal working hours

3. All patients with hip fracture should be assessed and cared for with a view to minimising the risk of developing a pressure ulcer

4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from the time of admission

5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures

6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls

Six Blue Book standards – why comply?

• Compliance with these standards

– raises quality in hip fracture care

– and reduces its costs!

• Cost and quality not in conflict

• ‘Looking after hip fracture patients well is cheaper than looking after them badly’

NHFD Reports: 2008-2011

12,983 records from 64 hospitals

36,556 records from 129 hospitals

NHFD National Report 2012

www.nhfd.co.uk

NHFD coverage: November 2012

• 188/188 (100%) of eligible hospitals registered

• 187/188 (99.5%) submitted data in the last three

months

• 228,000+ records submitted since launch

• c. 5000 records submitted per month (c. 95+%

of all eligible hip fractures – based on c. 65,000

p.a.)

The NHFD: audit and change

• Improving compliance with Blue Book standards

• Local use of audit for service change

• Trend data: 28 hospitals, 2008 – 2011

• Implementing Best Practice Tariff

Compliance with Blue Book standards: 2009-12

Standard 2009 2010 2011 2012

1. Admission to orthopaedic ward

within 4 hours

N/A 55% 56% 52%

2. Surgery within 48 hours and during

working hours

75% 80% 87% 83%

3. Patients developing pressure

ulcers

N/A 6% 3.7% 3.7%

4. Pre-operative assessment by an

orthogeriatrician

24% 31% 37% 43%

5. Discharged on bone protection

medication

N/A 57% 66% 69%

6. Received a falls assessment prior

to discharge

44% 63% 81% 92%

NHFD: audit and change locally

Hospital-level initiatives

• NHFD offers current, credible local data on workload and service performance

• Such data can prompt and monitor local initiativesagreed by clinicians and managers

• Many substantial improvements: e.g. reduced time to theatre, length of stay, mortality and service costs

Wansbeck and N. Tyneside

• Quality improvement programme: NHFD data; Kings Fund support – addressing whole care pathway

– Pain control improved (79% of patients get nerve block on admission)

– 95% have surgery within 36 hours

– 100% mobilise on first post-op day if medically fit

– Systematic feedback from patients and families consistently averages >9.3/10

St Peters Hospital, Chertsey

• Two orthogeriatricians appointed; quality initiative on hip

fracture care pathway (2010)

• In 2012, 60% of patients have surgery within 24 hours,

80% within 36 hours

• Length of stay reduced from 25 to 22 days, with

considerable efficiency savings

• 60% of patients discharged to original residence within

25 days, compared with 44% within 30 days in 2010

Chelsea and Westminster Hospital

• Meeting in May 2011 recognises hip fracture care as sub-optimal

• Changes include dedicated trauma theatre sessions, thrice-weekly ortho-geriatrician ward rounds, and weekly discharge planning rounds

• In-patient mortality reduced from 11% to 9%

• Average acute length of stay down from 24 to 19.5 days, with estimated savings of £91,000

Trend data: 2008-2011

• 28 hospitals– Early and sustained NHFD participation

– Good case ascertainment, data completeness

– 30,022 cases (1st April 2008 to 31stMarch 2011)

– Time to theatre, orthogeriatrician involvement, secondary prevention, mortality

Trend data: 2008-2011

Trend data: 2008-2011

Trend data: 2008-2011

Trend data: 2008-2011

Trend data: 2008-2011

Trend data: 2008-2011: the main points

• Overall mortality reduced by 15%!(binomial test p-value <0.001)

• Association with/impact of care process factors? – Ortho-geriatrician input? Time to theatre? Other?

• Further analysis pending

The Best Practice Tariff for hip fracture care

• A DoH initiative, based on NHFD participation

• Enhanced case-by-case payment if clinically

determined care standards met

– Surgery within 36 hours

– Joint care, joint protocol: surgeon, anaesthetist,

orthogeriatrician

– Early involvement of orthogeriatrician in care

– Multi-disciplinary rehabilitation

– Bone health, falls assessments

Best Practice Tariff: the first two years

Audit and change: how does it work?

• NHFD offers:

– the synergy of audit, standards and continuous feedback– a website providing key documents and literature database– helpdesk and supportive central staff – regional meetings – national reports

• ‘Together, these measures have succeeded in creating a critical mass of enthusiasm and expertise in hip fracture care…’*

*NHFD 2011 Summary Report on www.nhfd.co.uk

Progress in hip fracture care?

• NHFD and the Blue Book

– the synergy of audit, feedback and standards

• National-level evidence of:

– rising care standards

• Large-series evidence of:

– lower mortality

– associated with orthogeriatric care?

Progress in hip fracture care?

• Local evidence of:

– better care and outcomes

– lower costs too

• BPT a recent and effective incentive

– with double effect?

• ‘Looking after hip fracture patients well is

cheaper than looking after them badly’(Blue Book on the care of patients with fragility fracture)

Towards cost-effective care?

The length of acute + post-acute

Trust stay has fallen from 21.2 to

20.2 days over 2011-2012: a £14M

efficiency saving?

The length of acute + post-acute

Trust stay has fallen from 21.2 to

20.2 days over 2011-2012: a £14M

efficiency saving?

More effort required?

• Better documentation of longer-term care & outcomes– post-acute care

– mobility

– place of residence

• Sprint audits– ASAP in development

– other?

• Health economics– cost-effective care?

More progress in hip fracture care?

• Without audit, clinical standards are simply aspirational

• As a national clinical audit of hip fracture care, the NHFD has demonstrated the synergy of audit and standards in improving care

• NHFD has the potential to monitor compliance with the NICE Quality Standards

NHFD & the NICE Quality Standards for Hip Fracture

NHFD & the NICE Quality Standards for Hip Fracture

Monitoring compliance with NICE standards

The percentage of arthroplasties that are performed using a cemented prosthesis has risen from 63% in 2010 to 73% in 2012

The percentage of arthroplasties that are performed using a cemented prosthesis has risen from 63% in 2010 to 73% in 2012

NHFD & the NICE Quality Standards for Hip Fracture

NHFD & the NICE Quality Standards for Hip Fracture

• NHFD has the potential to monitor compliance with (some of) the NICE Quality Standards…

…and measure any impact on care and outcomes?

DH Falls & Bone Health Commissioning Toolkit 2009

19 December 2012

Objective 1: Improve outcomes and

improve efficiency of care after hip

fractures – by following the 6 “Blue Book” standards

Hip fracture patients

Objective 2: Respond to the first

fracture, prevent the second – through Fracture Liaison Services in acute and primary care

Non-hip fragility fracture patients

Objective 3: Early intervention to restore

independence – through falls care pathway linking acute and urgent care services to secondary falls prevention

Individuals at high risk of 1st fragility fracture or other injurious falls

Objective 4: Prevent frailty, preserve

bone health, reduce accidents –

through preserving physical activity, healthy lifestyles and reducing environmental hazards

Older people

The Falls and Fragility Fractures Audit Programme (FFFAP)

Element 1: continuation of the NHFD

(NHFD Workstream)

Element 2: feasibility study for a prospective database of non-hip fragility fractures (the FLSDB) in year 1

(FLSDB Workstream)

Element 4: audit of falls in care settings – pilot study in year 1

(Falls pathway Workstream)

Element 3: sprint audits – to be determined

(NHFD Workstream)

Element 5: intermittent spotlight audits – to be determined

(Falls pathway Workstream)

Hip fracture audit: an international opportunity?

• A common language for casemix, care and outcomes –to address the central challenge of current global fragility fracture epidemic?

• Now a mature technology – clinically led & user-friendly – that can improve quality and cost-effectiveness* in hip fracture care?

• A platform for regional, national and international research collaboration?

*Quality and cost-effectiveness not in conflict – because ‘looking after hip fracture patients well is cheaper than looking after them badly’.

International hip fracture audit: an emerging reality?

NHFD: a mature technology in a wired-up world

• Growing international interest – meetings etc: 2007 to date

• Emergent NHFD-based national hip fracture audits in 2012: – Australia

– New Zealand

– Ireland

– Canada?

• Further action via the international Fragility Fracture Network?

Acknowledgements

• Prof K-G Thorngren & Rikshoft

• SHFA colleagues

• Dave Marsh, Professor of Orthopaedic Surgery, RNOH, Chair/Co-chair, NHFD; Finbarr Martin, Co-chair, NHFD; Rob Wakeman, Lead Clinician, Orthopaedic Surgery, NHFD; Maggie Partridge, Project Manager, NHFD; NHFD Project Coordinators

• NHFD Steering Group, Dataset Sub-group, & Scientific and Publications Committee

• BOA & BGS

• Dept of Health and HQIP

• Blue Book Authorship Group

• Colleagues in NCASP/CCAD/NHS IC

• Quantics Consultancy

• Patients & staff in participating hospitals

www.nhfd.co.uk