Reducing unwarranted variation in the delivery of high quality hip fracture services in England and Wales (REDUCE): protocol for a mixed-methods study

Rita Patel, Sarah Drew, Antony Johansen, Tim Chesser, M Kassim Javaid, Xavier L Griffin, Tim Jones, Jill Griffin, Marianne Bradshaw, Katie Whale, Estela Capelas Barbosa, Elsa Marques, Yoav Ben-Shlomo, Rachael Gooberman-Hill, Andrew Judge, Celia L Gregson

Research output: Contribution to journalArticle (Academic Journal)peer-review

4 Citations (Scopus)
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Introduction Substantial variation in the delivery of hip fracture care, and patient outcomes persists between hospitals, despite established UK national standards and guidelines. Patients’ outcomes are partly explained by patient-level risk factors, but it is hypothesised that organisational-level factors account for the persistence of unwarranted variation in outcomes. The mixed-methods REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE) study, aims to determine key organisational factors to target to improve patient care. Methods and analysis Quantitative analysis will assess the outcomes of patients treated at 172 hospitals in England and Wales (2016-2019) using National Hip Fracture Database (NHFD) data combined with English Hospital Episodes Statistics (HES); Patient Episode Database for Wales (PEDW); Civil Registration (deaths); and multiple organisational-level audits to characterise each service provider. Statistical analyses will identify which organisational factors explain variation in patient outcomes, and typify care pathways with high-quality consistent patient outcomes. Documentary analysis of 20 anonymised British Orthopaedic Association (BOA) hospital-initiated peer-review reports, and qualitative interviews with staff from four diverse UK hospitals providing hip fracture care, will identify barriers and facilitators to care delivery. The Covid-19 pandemic has posed a major challenge to the resilience of services and interviews will explore strategies used to adapt and innovate. This system-wide understanding will inform the development, in partnership with key national stakeholders, of an ‘Implementation Toolkit’ to inform and improve commissioning and delivery of hip fracture services. Ethics and dissemination This study was approved: quantitative study by London, City & East Research Ethics Committee (20/LO/0101); and qualitative study by Faculty of Health Sciences University of Bristol Research Ethics Committee (Ref:108284), National Health Service (NHS) Health Research Authority (20/HRA/71) and each NHS Trust provided Research and Development approval. Findings will be disseminated through scientific conferences, peer-reviewed journals, and online workshops.
Original languageEnglish
Article numbere049763
Number of pages10
JournalBMJ Open
Issue number5
Publication statusPublished - 19 May 2021

Bibliographical note

Funding Information:
Competing interests None for RP, SD, XLG, TJ, JG, MB, KW, ECB, YB-S, RG-H, CLG. AJohansen is the clinical lead for the National Hip Fracture Database, in the Royal College of Physicians, London. TC is the British Orthopaedic Association (BOA) representative and sits on the board 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. EMRM has received funds for an unrelated independent study sponsored by CeramTec UK limited. AJudge has received consultancy fees from Freshfields, Bruckhaus, Derringer and Anthera Pharmaceuticals Ltd.

Funding Information:
Funding This work is funded by Versus Arthritis (reference 22086). 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). 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.

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  • hip
  • orthopaedic & trauma surgery
  • geriatric medicine
  • qualitative research


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