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Hip fracture care among elderly has improved, national audit shows

Publicising clinical outcomes and cash incentives make all the difference

Caroline White

Wednesday, 13 July 2011

National clinical audit, supportive networks, and incentive payments for hospitals have improved the quality of hip fracture care, shows a new report published today from the National Hip Fracture Database (NHFD).

Around 70,000 older people sustain a serious hip fracture in the UK each year. And doctors say this approach is both practical and achievable and should now be followed more widely.
The NHFD 2011 National Report covers more than 53,000 cases admitted between April 2010 and March 2011, and shows consistent improvements in compliance with the six clinical standards measured.

Since the audit began more patients are being admitted promptly to orthopaedic wards; delays for operation have been reduced, with most patients now having surgery within 48 hours. Fewer patients develop pressure ulcers; and more have specialist preoperative assessment by geriatrician.
Prevention of future fractures is being addressed too: 71 per cent of patients will receive both falls and bone health assessments before leaving hospital.

Looking after hip fracture patients well is cheaper than looking after them badly, says the NHFD: minimising unnecessary delay and providing good rehabilitation enables patients to recover more quickly and return home sooner as well as reducing costs.

Several factors have contributed to the improvements, says the NHFD, including the recent introduction by the Department of Health of the Best Practice Tariff (BPT) for hip fracture care, which rewards hospitals for each patient who receives the specified BPT care standards.

Continuous feedback on clinical care and service improvement, an increasing recognition of the value of collaboration have also made a difference, it says and prompted “a critical mass of enthusiasm and expertise in the care of an injury which, though common, had not previously attracted the attention its seriousness merited.”

But despite such substantial national and local improvements, the report shows that there is still some way to go before every hip fracture patient can expect the best care, and significant variation persists across the country.

Two per cent of medically fit patients still wait more than four days for surgery—with serious implications for their recovery and survival; and detailed case mix-adjusted statistical analysis of 30 day mortality shows that a small number of hospitals have rates that require detailed attention and further analysis.

Documentation of overall length of stay remains incomplete, and further work using Hospital Episodes Statistics (HES) data that measures overall NHS length of stay will need to be undertaken. This is important, because patients want to return home as soon as it is safe to do so, and length of stay is the major determinant of the overall cost of hip fracture care, says the report.

Dr Colin Currie, consultant geriatrician and chair of the NHFD implementation group, said: “This report shows how a national audit addressing the care of a serious common injury can make a difference on a national scale.

The combination of reliable data, achievable standards, continuous feedback, and available know-how has attracted widespread clinical and managerial support, with real gains in both the quality and cost-effectiveness of hip fracture care. Clinical teams can look at their own data, spot problems, work together, make changes, and see measurable benefits resulting for the patients they look after.”

Peter Kay, President of the British Orthopaedic Association, said: “The importance of this report cannot be over-stated. Not only does it demonstrate how we can improve the care of some of our frailest and most vulnerable patients, but it also highlights the enormous benefit of aligning NHS funding, as a driver of change, with best clinical practice.”

Professor Norman Williams, President of the Royal College of Surgeons, said: “This report shows once again that transparent publicly reported clinical outcome measures lead to a better understanding of how to organise surgery and better results for patients. The Royal College of Surgeons would like to see this approach be made mandatory across surgery.”

The NHFD 2011 National Report

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