The research, led by the University of Bristol, and funded by the charity Versus Arthritis, investigated how the ways NHS hospitals provide care to patients with a hip fracture influences how well patients recover after a hospital admission with the fracture.
Researchers used anonymous routinely collected hospital records from 178,757 older adults in England and Wales, who broke their hip between 2016 and 2019. They were interested to find out how hospital care might affect a patient’s chance of survival, how long patients needed to stay in hospital, and once home, how often patients needed to be readmitted to hospital because of a complication.
Each year more than 70,000 older adults are admitted to a UK hospital after a hip fracture, which can lead to a decline in quality of life, high mortality risk and, after discharge, high risk of emergency hospital readmission.
The team found that how well patients recovered after a hip fracture varied enormously between the 172 hospitals studied across England and Wales. In some hospitals one in ten of patients died within a month of their fracture, whilst in other hospitals the figure was less than half of this.
The time patients spent in hospital also varied widely. In some hospitals people with hip fractures stayed on average about 12 days, whilst in other hospitals this was more than a month. The chance of patients needing to come back into hospital after getting home was also very variable. In some hospitals the risk was low – about four in 100 people, whilst in others it was high – about 30 in 100 people needing to be readmitted to hospital.
Celia Gregson, Professor in Clinical Epidemiology in the Musculoskeletal Research Unit at the University of Bristol and chief investigator of the study, said: “Patients should be able to expect to receive the same, high-quality care if they break their hip, irrespective of where they live or which hospital they attend.
“The results of our study have shown multiple, important points in the pathway of patient care which hospitals can focus on to streamline and improve the quality of their hip fracture services and patient outcomes.”
In hospitals where staff were able to get at least 90% of their hip fracture patients out of bed promptly the day after surgery, patients stayed on average two days less than in hospitals that didn’t manage to mobilise their patients as well.
Deborah Alsina MBE, Chief Executive Officer of Versus Arthritis said:“This research highlights the worrying state of care for older people who break their hip. The findings show that older people have a high chance of dying in the weeks after breaking a hip, and that whether or not they survive varies enormously between NHS hospitals in England and Wales.
“Hip fractures mainly affect older people, many of whom live with multiple long-term conditions, and quality of care for people with hip fractures is a key indicator of whether we’re getting older people’s care right in general. This research suggests we are not.
“With a deepening NHS crisis, clinical care teams need all the support they can get to achieve consistent, sustainable and high-quality hip fracture care across the UK. The clinical tools being developed through this research will help the NHS achieve this.”
Professor Antony Johansen, Clinical Lead for the National Hip Fracture Database and an author on the study, added: “It’s vital that hospitals have enough staff - nurses and physiotherapists – so they can help patients get back on their feet quickly after a hip fracture, otherwise patients will lose their independence, and may even lose the will to recover.”
The researchers identified that patients had a lower risk of dying in hospitals where hip fracture staff met regularly, at monthly clinical governance meetings, to discuss as a team, feedback from patients.
Dr Rita Patel, Senior Research Associate (REDUCE Study Statistician/Data Manager) in the Bristol Medical School: Translational Health Sciences (THS) and lead author of the study, explained: “It seems likely that teams prepared to put time aside to examine their patients’ experiences are motivated to improve their service.
"One of the key factors of the need for patients to come back into hospital appears to be due to communication. Those hospitals where rehabilitation staff understood how soon services in the community would be able to start supporting a patient after discharge saw far fewer patient readmissions.”
Professor Gregson reflected: “The fact that some hospitals discharge patients into the community without knowing when follow-on care might start is a sad reminder of how disjointed hospital and community services can be across the country.”
It is estimated 890 excess readmissions might be avoided each year in England and Wales if all hospitals understood delays between discharge and initiation of community therapy, as this knowledge would contribute to reducing risk when planning discharge.
Overall, the team found 41 different ways in which hospitals delivered patient care, that were linked to patient outcomes. Many of these differences could be changed, providing the potential to improve patient outcomes and reduce the variability in how services are delivered between hospitals.
This is the first paper to be published from the REDUCE Study (REducing unwarranted variation in the Delivery of high-qUality hip fraCture services in England and Wales).
The research findings will feed into the development of a new ‘Toolkit’ designed for use by hospital managers and senior doctors. Each ‘tool’ will address different aspects of the care pathway for hip fracture patients and should make it easier for hospitals to improve the service they provide to patients.
The Toolkit, which is currently being built in collaboration with the Royal Osteoporosis Society, will be freely available on the Society’s website in 2023.
Jill Griffin, core investigator on the project and Clinical Engagement Lead at the Royal Osteoporosis Society (ROS), said: “The research findings have given us valuable information and shown us how we can work with healthcare providers and hospitals to improve patient recovery after a hip fracture.
“The study data has enabled us to make recommendations that we are using to build a toolkit for healthcare professionals and our aim is that it will dramatically improve the quality of care for everyone who suffers a hip fracture.”
Paper
‘Multiple hospital organisational factors are associated with adverse patient outcomes post hip fracture in England and Wales: the REDUCE record-linkage cohort study’ by Celia L Gregson, Rita Patel et al. in Age and Ageing
[open access]