Abstract
Background
Hip fractures are devastating injuries causing disability, dependence, and institutionalisation, yet hospital care is highly variable. This study aimed to determine hospital organisational factors associated with recovery of mobility and change in patient residence after hip fracture.
Methods
A cohort of patients aged 60 + years in England and Wales, who sustained a hip fracture from 2016 to 2019 was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality records were linked to 101 factors derived from 18 hospital-level organisational metrics. After adjustment for patient case-mix, multilevel models were used to identify organisational factors associated with patient residence at discharge, and mobility and residence at 120 days after hip fracture.
Results
Across 172 hospitals, 165,350 patients survived to discharge, of whom 163,230 (99%) had post-hospital discharge destination recorded. 18,323 (11%) died within 120 days. Among 147,027 survivors, 58,344 (40%) across 143 hospitals had their residence recorded, and 56,959 (39%) across 140 hospitals had their mobility recorded, at 120 days. Nineteen organisational factors independently predicted residence on hospital discharge e.g., return to original residence was 31% (95% confidence interval, CI:17–43%) more likely if the anaesthetic lead for hip fracture had time allocated in their job plan, and 8–13% more likely if hip fracture service clinical governance meetings were attended by an orthopaedic surgeon, physiotherapist or anaesthetist. Seven organisational factors independently predicted residence at 120 days. Patients returning to their pre-fracture residence was 26% (95%CI:4–42%) more likely if hospitals had a dedicated hip fracture ward, and 20% (95%CI:8–30%) more likely if treatment plans were proactively discussed with patients and families on admission. Seventeen organisational factors predicted mobility at 120 days. More patients re-attained their pre-fracture mobility in hospitals where (i) care involved an orthogeriatrician (15% [95%CI:1-28%] improvement), (ii) general anaesthesia was usually accompanied by a nerve block (7% [95%CI:1-12%], and (iii) bedside haemoglobin testing was routine in theatre recovery (13% [95%CI:6-20%]).
Conclusions
Multiple, potentially modifiable, organisational factors are associated with patient outcomes up to 120 days after a hip fracture, these factors if causal should be targeted by service improvement initiatives to reduce variability, improve hospital hip fracture care, and maximise patient independence.
Hip fractures are devastating injuries causing disability, dependence, and institutionalisation, yet hospital care is highly variable. This study aimed to determine hospital organisational factors associated with recovery of mobility and change in patient residence after hip fracture.
Methods
A cohort of patients aged 60 + years in England and Wales, who sustained a hip fracture from 2016 to 2019 was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality records were linked to 101 factors derived from 18 hospital-level organisational metrics. After adjustment for patient case-mix, multilevel models were used to identify organisational factors associated with patient residence at discharge, and mobility and residence at 120 days after hip fracture.
Results
Across 172 hospitals, 165,350 patients survived to discharge, of whom 163,230 (99%) had post-hospital discharge destination recorded. 18,323 (11%) died within 120 days. Among 147,027 survivors, 58,344 (40%) across 143 hospitals had their residence recorded, and 56,959 (39%) across 140 hospitals had their mobility recorded, at 120 days. Nineteen organisational factors independently predicted residence on hospital discharge e.g., return to original residence was 31% (95% confidence interval, CI:17–43%) more likely if the anaesthetic lead for hip fracture had time allocated in their job plan, and 8–13% more likely if hip fracture service clinical governance meetings were attended by an orthopaedic surgeon, physiotherapist or anaesthetist. Seven organisational factors independently predicted residence at 120 days. Patients returning to their pre-fracture residence was 26% (95%CI:4–42%) more likely if hospitals had a dedicated hip fracture ward, and 20% (95%CI:8–30%) more likely if treatment plans were proactively discussed with patients and families on admission. Seventeen organisational factors predicted mobility at 120 days. More patients re-attained their pre-fracture mobility in hospitals where (i) care involved an orthogeriatrician (15% [95%CI:1-28%] improvement), (ii) general anaesthesia was usually accompanied by a nerve block (7% [95%CI:1-12%], and (iii) bedside haemoglobin testing was routine in theatre recovery (13% [95%CI:6-20%]).
Conclusions
Multiple, potentially modifiable, organisational factors are associated with patient outcomes up to 120 days after a hip fracture, these factors if causal should be targeted by service improvement initiatives to reduce variability, improve hospital hip fracture care, and maximise patient independence.
Original language | English |
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Article number | 459 |
Journal | BMC Geriatrics |
Volume | 23 |
DOIs | |
Publication status | Published - 27 Jul 2023 |
Bibliographical note
Funding Information:We are grateful to the British Orthopaedic Association (BOA) who supported the REDUCE grant, and the REDUCE Study Advisory Board for their valued input. We are also grateful to Dr Jenny Neuburger for providing code to assist with cleaning, merging and deriving HES-ONS-NHFD-PEDW datasets. REDUCE Study Group members Rita Patel1, Andrew Judge1,2,3, Antony Johansen4,5, Elsa M. R. Marques1,3, Tim Chesser6, Xavier L. Griffin7,8, Muhammad K. Javaid2, Petra Baji1,9, Marianne Bradshaw1, Sarah Drew1, Rachael Gooberman-Hill1,3, Jill Griffin10, Katie Whale1,3, Yoav Ben-Shlomo11,12, Celia L. Gregson (Study Group representative)1,131Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Learning and Research Building, Level 1, Bristol BS10 5NB, UK2Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK3NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK4School of Medicine, University Hospital of Wales, Cardiff University, Cardiff, UK5National Hip Fracture Database, Royal College of Physicians, London, UK6Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK7Barts Bone and Joint Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK8Royal London Hospital, Barts Health NHS Trust, London, UK9Corvinus University of Budapest, Budapest 1093, Hungary10Clinical & Operations Directorate, Royal Osteoporosis Society, Bath, UK11Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK12National Institute for Health Research (NIHR) Applied Research Collaboration West (ARC West), University of Bristol and United Hospitals Bristol NHS Foundation Trust, Bristol, UK13Older People’s Unit, Royal United Hospital NHS Foundation Trust Bath, Combe Park, Bath, UK
Funding Information:
This work is funded by Versus Arthritis (reference 22086) awarded to CLG https://www.versusarthritis.org/ . The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This study is supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol. MKJ is supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC). YBS is theme lead and partially funded by the National Institute for Health Research (NIHR) Applied Research Collaboration West (ARC West) at University of Bristol and United Hospitals Bristol NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR or the Department of Health and Social Care.
Funding Information:
AJo is the clinical lead for the National Hip Fracture Database, at the Royal College of Physicians, London. Since completing the analyses RP is now funded by CeramTec UK Ltd. on an unrelated study. TC is the past British Orthopaedic Association (BOA) representative and previous board member of the Falls and Fragility Fracture Audit Project (which includes the National Hip Fracture Database), he helped set up and perform many of the BOA multidisciplinary peer reviews for hip fractures, he has design and educational contracts with Stryker, Acumed and Swemac. MKJ has received honoraria, unrestricted research grants, travel and/or subsistence expenses from: Amgen, Consilient Health, Kyowa Kirin Hakin, UCB, Abbvie, Sanofi and Besin healthcare. EMRM has received research funding from CeramTec UK limited. AJu has received consultancy fees from Freshfields, Bruckhaus, Derringer and Anthera Pharmaceuticals Ltd. JG has an educational contract with Stryker. Other authors declare that they have no competing interests.
Funding Information:
We are grateful to the British Orthopaedic Association (BOA) who supported the REDUCE grant, and the REDUCE Study Advisory Board for their valued input. We are also grateful to Dr Jenny Neuburger for providing code to assist with cleaning, merging and deriving HES-ONS-NHFD-PEDW datasets.
Publisher Copyright:
© 2023, The Author(s).
Research Groups and Themes
- HEHP@Bristol
Keywords
- Hip - Orthopaedic & Trauma Surgery
- Geriatric Medicine
- Delivery of Health Care
- Hospital Services
- Fragility fracture