174557 IC HIP Frac Report A4

The National Hip Fracture DatabasePreliminary National Report 2009

F O R H E A L T H A N D S O C I A L C A R E

In partnership with:

British Orthopaedic Association

This report was prepared by the members of the Implementation Group: Mr. Rob Wakeman, NHFD Orthopaedic Lead;Dr. Colin Currie NHFD, Geriatrician Lead; Mr. Stewart Fleming, Software Developer, NHS Information Centre; and Maggie Partridge,NHFD Project Manager; with the assistance of Mrs Bev Vaughan, Project Co-ordinator; and Mrs Sarah Allport of the British Geriatrics Society

Brief extracts from this publication may be reproduced provided the source is fully acknowledged.

For enquiries or comments about this publication please contact: NHFD, British Geriatrics Society, Marjory Warren House, 31 St. John’s Square,London EC1M 4DN

Further copies of this report and details of how the charts were produced, can be foundat www.nhfd.co.uk accessed using theUsername: nhfd demouser; Password: password

The National HipFracture DatabasePreliminary NationalReport 2009

The National Hip Fracture Database

Preliminary National Report 2009

CONTENTS Pages

Foreword ....................................................................................................................................4

Introduction ............................................................................................................................5-8

Main findings and recommendations ...............................................................................9-10

Participating hospitals.............................................................................................................11

Data completeness ..................................................................................................................12

Casemix: ....................................................................................................................................13

Age at admission..........................................................................................................14

Sex ................................................................................................................................15

Place of residence.........................................................................................................16

ASA...............................................................................................................................17

Walking ability ..............................................................................................................18

Fracture type ...........................................................................................................19-20

Process: ................................................................................................................................21-22

Surgery within 48 hrs ...................................................................................................23

Reason for no operation within 48 hrs ........................................................................24

Patients treated without surgery ..................................................................................25

Operation performed ..............................................................................................26-29

Cemented arthroplasties ..............................................................................................30

Development of pressure ulcers..............................................................................31-32

Preoperative medical assessment .................................................................................33

Assessment of need for anti-resorptive therapy......................................................34-37

Falls assessment............................................................................................................38

Secondary prevention overview....................................................................................39

Length of stay .........................................................................................................40-42

Discharge destination ...................................................................................................41

Casemix adjusted outcome:

Return home from home .............................................................................................43

Mortality .......................................................................................................................44

Facilities audit .....................................................................................................................45-50

Glossary (terms denoted by �).............................................................................................51-53

References...........................................................................................................................54-55

Appendix A – Funding and Acknowledgements ...............................................................56-58

Appendix B – Data completeness ...........................................................................................59

Appendix C – Casemix adjusting.........................................................................................60-61

4

ForewordHip fracture is a common, serious and costly injury, and, as the UKpopulation ages, its numbers will rise from around 70,000 a year now to around 100,000 by 2020. The impact of hip fracture on patients’ livescan be great, ranging from temporary loss of mobility to permanent loss of home; and mortality – particularly for the frailest – remains high. The cost of hip fracture care is great – £1.4Bn per annum – and its quality is demonstrably uneven across the NHS.

Improving the care of hip fracture and reducing its incidence are thereforeimportant goals. In recognition of this, the British Orthopaedic Association(BOA) and the British Geriatrics Society (BGS) have, via a formalMemorandum of Understanding set up in 2007, together established theNational Hip Fracture Database (NHFD), a collaborative initiative developedby orthopaedic surgeons, elderly care physicians, and other clinicians.

The NHFD, by documenting case-mix, care and outcomes, and auditingcare – which includes implementation of proven prevention strategies –against the evidence-based care standards set out in BOA/BGS Blue Bookon the care of patients with fragility fractures, allows clinicians and servicesto benchmark their performance against national data, and to trackprogress as they seek to improve the care they provide.

Optimum care of patients with hip fracture is complex and involves manyprofessional disciplines. Delivering high quality care – with prompt surgery,good medical care, early rehabilitation, effective care for the preventive offurther fractures and an early return home – depends critically on clinicalteamwork that focuses on the patient’s experience. By providing standardsand models of care, together with reliable local and comparative data,NHFD and the Blue Book have the power to support effective teamwork,improve the quality of care and make it more cost-effective too.

This preliminary report demonstrates the progress made since the launchof the NHFD and the Blue Book in September 2007. As it acknowledges,full NHFD participation is challenging, and the challenge of providingcomplete, high-quality data on hip fracture care is not to beunderestimated; but the scope and detail of casemix, care and outcomespresented is most impressive, and the promise it shows for future progressmost encouraging.

We therefore welcome this report, with its clear demonstration of howclinically-led audit can address complex care challenges, deliver usefulcomparisons, and thus contribute to the improvement of care for a largeand often vulnerable group of patients.

Professor Graham MulleyPresident BGS

Miss Clare MarxPresident BOA



5

Background

The National Hip Fracture Database was set up as acollaborative venture by the British OrthopaedicAssociation and the British Geriatrics Society inorder to improve hip fracture care and secondaryprevention. It was launched, along with the jointlyproduced Blue Book on the care of patients withfragility fracture1, in September 2007.

This publication, the NHFD's Preliminary NationalReport, documents the considerable progress madesince then. It provides details of case-mix, care andoutcomes on 12,983 cases of hip fracture from 64hospitals that submitted more than 60 cases overthe year 1st October 2007 to 30th September 2008and shows how the care provided matches up tothe standards set out in the Blue Book; and thussets out a substantial but still incomplete picture ofhip fracture care in England, Wales and NorthernIreland in 2008.

Work towards the establishment of NHFD started in2004, when a series of meetings of clinicians drawnmainly from the British Orthopaedic Association andthe British Geriatrics Society began to examine theexperience of a range of existing hip fracture auditswith a view to building a preliminary nationaldatabase and establishing a nationally agreeddataset. By 2007 – with the support of the NHSInformation Centre, and using the web-based datacollection, analysis and feedback methods of thehighly successful Myocardial Infarction NationalAudit Project (MINAP) – NHFD was able to provideparticipating trauma services with a comprehensiveand technically advanced national audit that couldhelp them monitor and improve the care theyprovide for their hip fracture patients.

Integral to this effort, and proceeding in parallelwith it, was the development of the Blue Book. Amulti-disciplinary authorship group that includedanaesthetic, orthogeriatric, general practice,

nursing, orthopaedic and pharmacological expertisereviewed the current evidence on fragility fracturecare, with a particular emphasis on the stages ofhip fracture care and on prevention, andsummarised these in a concise and practical 75-page handbook.

The group, together with the NHFD Executive, alsoagreed six standards for hip fracture care. Theseare: prompt admission to orthopaedic care; earlysurgery; prevention of pressure ulcers; access toacute orthogeriatric care; assessment for boneprotection therapy; and falls assessment - the lattertwo standards reflecting the importance ofsecondary prevention in reducing the risk ofsubsequent fractures.

Used together, NHFD and the Blue Book providethe synergy of audit, standards and feedback in theimprovement of the care and prevention of hipfracture. Participating units can measure their ownperformance against the standards; benchmark thecare they provide against national data; use NHFDas the basis of local audit to assess specific aspectsof care; and evaluate the impact on care outcomesof local changes in clinical care and in serviceorganisation.

Together, NHFD and the Blue Book aim to raise thequality and reduce the costs of hip fracture care;and it should be clearly noted that in hip fracturecare quality and cost-effectiveness are not inconflict. Prompt surgery, good medical care, earlyrehabilitation and robust early supported dischargearrangements will all serve to increase patientsatisfaction and lower cost per case. Conversely,delay at any stage, poor medical care, andinadequate rehabilitation arrangements willdiminish quality and can greatly increase costs.

Introduction

6

Participation

Following the NHFD launch, press coverage,presentations at relevant national meetings, andword of mouth ensured that the rate of recruitmentwas rapid. By 31st January 2009, 136 hospitals hadregistered interest in participating in NHFD – some69% of those eligible – and 92 were contributingcases to the NHFD database. Encouragingly, therate of growth of the audit over these monthsapproaches that of MINAP at a comparable stage inits development. The total number of recordssubmitted since July 2007 is 22,213. However,there are concerns about both the completenessand the quality of data that have to beacknowledged. These will be addressed in moredetail below.

Data collection

A few hospitals already carrying out hip fractureaudit were able to upload substantial numbers ofcases. The majority, however, were auditing hipfracture for the first time. They registered withNHFD and use the web-based technology to uploadtheir data as cases accumulated. In hospitals nowparticipating, the reaction – from both clinical andmanagement staff – has been broadly favourable,with local audit data and comparative national dataseen as helpful from the start.

Full participation in NHFD requires commitment andresources. Web-based technology facilitatesinformation transfer, data handling, analysis andfeedback; and advice and user support are availablefrom the project team. But the responsibility for thefunding and organisation of data collection lies withthe participating hospital; and although NHFDprovides detailed advice on the practicalities ofparticipation in the form of a downloadable‘toolkit’, the progression from interest toorganisation and eventual full participation is notautomatic – a fact reflected in the discrepancybetween the number of centres registering interestand the number currently contributing data.

Continuous and comprehensive data capture ischallenging, and hard to achieve using already busyclinical staff with inevitably conflicting priorities. In

particular, rigorous documentation of time of arrivalto orthopaedic care on an orthopaedic ward(Standard 1) proved difficult; as did telephone orother follow-up at 30 and 120 days. Thispreliminary NHFD report reflects these difficulties,along with some more general concerns about datacompleteness (See chart on page 12). While manyparticipating units appear to have gone to greatefforts to ensure that all eligible cases of hipfracture were recorded and that all data fields werecompleted, there is no doubt that some units,particularly those with more informal arrangementsfor data capture, were not able to document allcases. Other problems arose in relation to apparentinaccuracies in (e.g.) the recording of fracture typesor nature of surgery – sometimes quite complex interms of precise definition. Follow-up at 30 daysalso presented problems, and the nature andduration of care after discharge from the acuteorthopaedic unit – important in terms both ofpatient outcomes and overall cost of care –sometimes proved elusive. And it should be notedthat, paradoxically, sub-optimal data collection mayproduce apparently better results, as when patientsin poor clinical condition are omitted – withspuriously good mortality data emerging; or whenlittle attention is paid to pressure area care, andulcers are simply not reported.

Experience in previously established hip fractureaudits – in particular those in Scotland andNorthern Ireland – has shown that impressive levelsof data completeness, including that of follow-updata, can best be achieved by staff with a clinicalbackground (usually nursing) who are employedand trained with hip fracture audit data collectionas a specific commitment.

Although the cost of reliable data collection isestimated at around £50-60 per case, that costshould be seen in relation to the overall cost of hipfracture care: Recent evidence suggests that eachhip fracture costs the NHS alone (i.e. excludingsocial care costs) £12,137, over £7,000 more thanthe figure used in the earlier estimates2. The cost ofaudit amounting to 0.5% of this total.



7

The cost of high-quality audit data should thereforebe seen as an investment in clinical governanceinformation essential to the improvement of thequality and the cost-effectiveness of hip fracture care.

ReportingPrompt and reliable feedback to participating unitsis an essential feature of successful audit. Web-based technology, and the support provided byNHS Information Centre (IC) staff, has madepossible from the start the provision of local andcomparative – nationally benchmarked – feedbackto clinicians and managers involved in NHFD. Suchfeedback not only promotes and maintains interestin the audit, but allows clinical teams to monitorcase volume, case-mix, details of care provided, andoutcomes of that care. In this respect alone, NHFDrepresents a considerable advance on all pre-existing UK hip fracture audits.

However, there remains also a need for publishedreports – which provide a permanent record ofprogress, and can serve to raise the profile of NHFDand bring it to the notice of non-participating units,commissioners of hip fracture care, relevantprofessional bodies, and strategic health authorities.

In June 2008 NHFD published a limited reportbased on the work of the 26 participating hospitalsentering 50 or more case records over the periodthe 1st July 2007 to 31st March 2008. Data waspresented anonymously, though specific hospitalreports were also prepared in order to allowparticipants to compare local with national data.Using a star system based on performance againstthe six standards ranked by quartiles, it was possibleto derive overall hospital performance rankings, andto indicate these in individual hospital reports. Thispublication met with considerable interest andappears to have contributed to recent recruitmentto NHFD of more centres.

The sequence of presentation in this report isbroadly that of case-mix, process and outcome, andcharts relating to compliance with the six standardsare clearly identified as such. Data is presentedpredominantly in the form of horizontally displayed

bar charts, generally with a national average barappended for comparison purposes. Casemix-adjusted outcome data relating to death within 30days and return home within 30 days are displayedin the form of funnel plots.

As with the June 2008 publication, hospitalidentities and case-mix, process and outcome dataare anonymised as it was felt that this properlyrecognised the emergent status of the audit, andthus also acknowledged concerns about aspects ofdata completeness and quality. However, details ofhospital facilities for hip fractures care have beenpresented in an identifiable form.

It is anticipated that data quality issues can beaddressed in the near future by well-funded andtherefore greatly improved data collection, and bythe use of data quality checking mechanisms similarto those developed for MINAP; and that futureNHFD national reports will, in accordance withestablished practice for national audits, fully identifyall hospitals.

NHFD: an emerging national auditStructure and governance

NHFD is run by an Executive representing the coreclinical specialties, and also including representationfrom a patient group. A larger and more broadly-based Steering Group provides advice; and asmaller Implementation Group, based in the BGSheadquarters, deals with project development, dataanalysis, and the generation of reports. Recruitmentand support of participating centres, and day-to-day organisational matters, are in the hands of aproject manager and two project coordinators. A data set subgroup is responsible for themonitoring and further development of the NHFDstandard data set. Links with the InformationCentre are close, with senior IC presence on theImplementation Group, and the support of an ICsoftware developer working half-time with NHFD.Details of current membership of the above groupsare available.Appendix A

8

Funding

The development of NHFD since 2004 hasdepended hitherto upon the support of the BOA,the BGS and other relevant professional groups;and on generous funding from the ABPI and ABHI,the professional bodies of the pharmaceutical anddevices industries respectively.Appendix A In addition, a substantial development grant from theDepartment of Health has supported regionalmeetings, publications, and statistical consultancyinputs to case-mix adjusted outcome reporting.

Total income for 2007/2008 was £519,605 with atotal expenditure for the same period of £458,188.

Such funding has been much appreciated and wasappropriate to NHFD’s development stage; but,with the recent growth of the audit, a more securesource of funding was seen as necessary. It wastherefore encouraging to learn in December 2008,following the clarification of processes supportingthe selection and funding of national clinical audits,that NHFD had been identified by Health QualityImprovement Partnership (HQIP) for recognition asone of 11 new national clinical audits. Subject to abid currently under discussion, central HQIP fundingfor NHFD will/may be secured from April 2009 for aperiod of two years.

Difficulties remain with the funding of datacollection locally. However, in the context of LordDarzi’s second stage review3 and the growingemphasis within the Department of Health onmetrics that reflect the quality of care provided, the potential contribution of NHFD is increasinglyrecognised. At least one NHS Strategic HealthAuthority (South West) has included in its strategicvision a commitment to meet Blue Book standards;and the NHS Institute for Innovation andImprovement has adopted participation in NHFD as a requirement for Trusts participating in its 2008-2010 programme of improvement in hipfracture care.

In addition, hip fracture care has been selected as acondition for which service improvements are to besought through Payment by Results� as part of theBest Practice Tariffs� initiative in England. Thisbrings with it the need for specific and reliableinformation on quality and cost-effectiveness ofcare – a need that NHFD can readily meet if reliabledata collection is assured. And from the point ofview of the Primary Care Trusts that commission hipfracture care, the ability of NHFD to provideinformation on case volume, quality of care andoutcomes is in itself an argument for includingNHFD participation – including, adequately fundeddata collection – in the contract through which hipfracture care is commissioned.

Future developments

With growing participation, a steadily enlargingnational database, improving data quality, andcasemix-adjusted reporting of outcomes such asreturn home and mortality, NHFD will in futuremake a powerful and robust contribution to theclinical governance of an important and costlyinjury. In addition, its research potential should berecognized. Important and unresolved issues in hipfracture care - relating to anaesthesia, surgery,thromboprophylaxis, and rehabilitation – can andshould be addressed via large observational studiesand specifically organised and funded large-scaleclinical trials.

This first NHFD Preliminary National Reportdemonstrates both the progress and furtherpotential of NHFD; and shows how – together withthe Blue Book on fragility fracture care – it canutilise the synergy of audit, standards and feedbackin the improvement of the care and prevention ofhip fracture.

This will benefit patients and the NHS alike, sincequality and cost-effectiveness are not in conflict. Inthe words of the Blue Book: ‘Looking after hipfracture patients well is cheaper than looking afterthem badly’.1



9

The National Hip Fracture Database was establishedin 2007 to provide health communities with themeans of auditing the care given to hip fracturepatients against recognised professional standards,with the aim of improving the provision of care tofragility fracture patients across the United Kingdom.

It is twenty years since the Royal College ofPhysicians produced their seminal report, FracturedNeck of Femur: Prevention and Management5,which set out the then ‘best practice’ in hip fracturecare. Since 1989 there have been considerableadvances in fragility fracture management,particularly in the realm of osteoporosis diagnosisand treatment. The intervening years have also seenreports from The Audit Commission6,7, the NationalConfidential Enquiry into Perioperative Deaths8 andthe National Health Service Institute for Innovationand Improvement9, and the publication ofPerformance Indicators10, all recognising theimportance of hip fracture as a tracer condition forthe care of the frail elderly surgical patient. In 2003and 2007 the British Orthopaedic Association andBritish Geriatrics Society produced guidelines on thecare of the patient with fragility fracture – the ‘BlueBooks’1,11. However, the current report documentswidespread shortcomings in the provision of acutecare and the availability of the resources needed toinitiate the secondary prevention of fragility fractures.

Main findings

1. The time from presentation to A&E to surgery isthe best documented part of the hip fracturepathway. There is a consensus that this shouldtake less than 24 hours for the majority ofpatients and that beyond 48 hours there isevidence to show that there is an increase inmorbidity and mortality. In 1995 the AuditCommission showed that half of patientswaited for more than 24 hours and 18%waited for more than 48 hours6. The currentreport shows a significant deterioration in thesetimes with only 35% having surgery within 24hours and 69% having their operation within48 hours.

2. Preoperative assessment by a geriatrician is seenas an important step in the multidisciplinarycare of the frail elderly patient1, and yet thisonly happens for 58% of patients, and 12% ofhospitals have no geriatrician specialising in thecare of orthopaedic patients.

3. A fragility fracture should trigger an assessmentof risk of further falls, and an assessment ofbone health1, to reduce the possibility of futureinjury. 40% of patients left hospital without anadequate assessment of their osteoporosis and56% did not have a falls assessment.

Main findings andrecommendations

10

Recommendations

All hospitals treating hip fractures:

1. Should enter the details of ALL their patients onthe National Hip Fracture Database. Accuratedata will allow for broader comparison andincreasingly useful output.

2. Should work with their commissioners toreduce medically unnecessary waits for surgery.Aiming to deliver a service that treats 95% ofall fit trauma patients within 24 hours, willensure that the frailest patients do not become‘fillers’, waiting for theatre capacity to becomeavailable once paediatric injuries, high energyfractures and ‘complex cases’ have beenoperated on. Experience shows that a traumaservice that aims to treat its hip fracture patientswell, will treat ALL of its patients well.

3. Should provide sufficient senior (middle gradeor consultant) orthogeriatric care to ensure theroutine preoperative assessment of elderly hipfracture patients, five days a week. Formalarrangements for the preoperative assessmentof patients at weekends and on holidays by the‘on call’ medical team should be in place.

4. Should develop protocols to ensure that allpatients sustaining fragility fractures have a fullevaluation of their bone health, either throughthe fracture liaison service or by theorthogeriatrician. Access to DXA scanningshould be readily available.

5. Should ensure that all patients who sustain afracture as a result of a fall are properlyassessed for falls prevention.

Hospitals that provide ‘tertiary’ orthopaedic careshould ensure that such care is properly resourcedand organised so that the high caseload associatedwith tertiary care does not detrimentally affect thecare given to patients with fragility fractures.

Much has been written on the care of patients withhip fractures. Now is the time to act. Thepublication of hospital identifiable data that can bebenchmarked nationally will allow for a fullyinformed development of local services with anational impact on standards.



11

Hospital identification; inclusionIn all of the following charts hospitals have a unique identifying number. This is available to the hospital’s NHFD clinicallead via the NHFD help desk. Not all hospitals contributing data appear in all of the following charts. This is becausethose submitting case numbers at or only slightly above the threshold of 60 will have very small and unrepresentativenumbers of cases of individual fracture types and surgical interventions. In addition, where serious doubts arose aboutdata quality (e.g. hospitals reporting almost all intracapsular fractures as undisplaced) such data was omitted.

Participating Hospitals(*indicates inclusion in 1st Preliminary National Report)

Addenbrooke's Hospital, CambridgeAiredale General Hospital, KeighleyBarnet General Hospital*Barnsley District General Hospital*Basildon University Hospital*Bradford Royal Infirmary*Bronglais General HospitalChelsea & Westminster HospitalCheltenham General Hospital*Countess of Chester Hospital*County Hospital HerefordCumberland Infirmary*Derby Royal Infirmary*Dewsbury District HospitalDiana, Princess of Wales Hospital,Grimsby*Doncaster Royal InfirmaryFrenchay Hospital, Bristol*Friarage Hospital, Northallerton*Gloucestershire Royal HospitalGood Hope General Hospital, Sutton Coldfield*Great Western Hospital, SwindonHillingdon Hospital, London*Hope Hospital, Salford*Hull Royal Infirmary*Ipswich Hospital*James Cook University Hospital,Middlesborough*John Radcliffe Hospital, Oxford*Kent & Sussex HospitalKing's College Hospital, London*Luton & Dunstable HospitalLeicester Royal Infirmary*Leighton Hospital*Leeds General InfirmaryMaelor Hospital, Wrexham*Maidstone General Hospital*Manchester Royal Infirmary*

Medway Maritime Hospital,Gillingham*Milton Keynes General Hospital*Musgrove Park Hospital, Taunton*New Cross Hospital, WolverhamptonNoble's Hospital, Isle of Man*Norfolk and Norwich Hospital*North Middlesex Hospital*Northampton General Hospital*North Tyneside HospitalPilgrim Hospital, Boston*Pindersfield General HospitalPrincess Royal Hospital, Haywards Heath Princess Royal Hospital, Telford*Queen Alexandra Hospital,Portsmouth*Queen Elizabeth Hospital,Gateshead*Queen Elizabeth Hospital King'sLynn*Queen Elizabeth Hospital,Woolwich*Queen Elizabeth the Queen MotherHospital, MargateQueens Hospital, Romford*Queens Medical Centre,Nottingham*Royal Albert Edward Infirmary,Wigan*Royal Berkshire Hospital*Royal Bolton Hospital*Royal Devon & Exeter HospitalRoyal Free Hospital, LondonRoyal Hampshire County HospitalRoyal Lancaster InfirmaryRoyal Shrewsbury Hospital*Royal Surrey County Hospital*Royal United Hospital Bath*Royal Victoria Hospital, Belfast*

Russells Hall Hospital, DudleySt Mary’s Hospital, Paddington*St Peter's Hospital, ChertseySt Richards Hospital, ChichesterSt Thomas Hospital, London*Scarborough General HospitalScunthorpe General Hospital*Selly Oak Hospital, BirminghamSouthend HospitalSouthport and Formby District GeneralStepping Hill Hospital, Stockport*Stoke Mandeville Hospital*Sunderland Royal Hospital*Tameside General Hospital*Trafford General HospitalUniversity Hospital Aintree, MerseyUniversity College Hospital, LondonUniversity Hospital of North DurhamUniversity Hospital of NorthStaffordshire*University Hospital of North Tees*University Hospital of Wales*University Hospital Lewisham*Victoria Hospital, Blackpool*Walsgrave Hospital, Coventry*Warwick Hospital*Watford General Hospital*West Cumberland InfirmaryWeston General Hospital, WestonSuper MareWhipps Cross Hospital, London*Whittington Hospital, London*William Harvey Hospital, AshfordWorthing HospitalWythenshawe HospitalYork District Hospital*Ysbyty Gwynedd Hospital, Bangor

12

Data completenessChart 1This chart shows that there is variation in average field

completion from 52% to 98%. This is calculated by consideringall the fields used in compilingthis document.Appendix B

All



13

CasemixThe following charts show five casemix factors�

namely: age at admission, sex, place of residence,ASA grade and type of fracture.

Age at admission and sex (Charts 2 & 3)

Both age and sex are important casemix factors,with significant influence on outcomes. In generalterms, older and oldest patients have pooreroutcomes in terms of return home if admitted from home, and of survival. Male patients, thoughgenerally presenting younger (average age Male: 83.1, Female: 83.5) tend to have greater co-morbidity� and hence poorer outcomes.12

75% of our cases were female.

Place of residence (Chart 4)

Seventy six percent of patients were admitted fromtheir own homes (this term is taken to includesheltered housing). Outcomes for such patients are generally better than those at admitted fromother settings.

Patients admitted to orthopaedic care from otherforms of hospital care, and patients from nursingand residential care homes, are as a rule all to someextent already disadvantaged, e.g. by comorbidities,dependency, frailty, and cognitive impairment.Mortality for such patients is higher, and many willhave little potential for rehabilitation (mainlybecause of previous disability and/or cognitiveimpairment). Care needs may increase: e.g. patientsfrom residential care may subsequently requirenursing care.

ASA grades�

(Chart 5)

ASA grades13 are a widely used means ofcategorising pre-operative risk. They range from 1(healthy) to 5 (moribund, unlikely to survive 24hours). It is noteworthy that 66% of hip fracturepatients present with grades of 3 (severe systemicdisease with functional limitation) or higher. Notsurprisingly, mortality is most likely in patients in thehigher risk grades. As noted in the introduction,concerns about completeness of current NHFD dataare recognised. ASA grades are among the morecommonly missed data items.

Walking ability (Chart 6)

Forty three percent of patients presenting with hipfracture were previously mobile without a walkingaid (e.g. walking stick). Loss of mobility – and henceindependence – is an outcome greatly feared bypatients. Maximum restoration of mobility istherefore a major goal of rehabilitation. However,around half of all hip fracture patients do notregain their previous level of mobility: e.g. willrequire to use a walking stick having previouslywalked independently, or will graduate from usinga stick to using a walking frame.

14

Age at admission

Chart 2A

ll



15

Sex

Chart 3A

ll

16

Place of residence

Chart 4

All



17

ASA Grade

Chart 5

All

18

Walking ability

Chart 6A

ll



19

Fracture type

In general, the term ‘hip fracture’ is used todescribe a number of fracture types involving theupper or proximal femur. The term excludesfractures of the pelvic side of the hip joint andfractures of the surface of the head of the femuror isolated fractures the muscular attachments(trochanteric avulsion). Although the differentfracture types are generally treated by differentsurgical techniques, the generic term ‘hipfracture’ is well defined and widely recognised.Hip fracture patients have usually suffered a fall,commonly have previous frailty and oftencomplex rehabilitation needs. Interestingly,casemix-adjusted outcome analysis shows thatfracture type is a relatively unimportantdeterminant of outcome (e.g when compared toage, sex, or ASA grade)

Those fractures that occur within the joint itselfare termed intracapsular (54% of total). Theseare divided into those in which the bones remainin their correct place – undisplaced (13% oftotal), and those which have moved to an extentthat the blood supply to the bone is disrupted –displaced (41% of total). Fractures outside thejoint are divided into those that occur betweenthe major muscle insertions (the trochanters)which are termed intertrochanteric (35% oftotal), and those that occur further down thefemur at the junction with the femoral shaft.These are termed subtrochanteric (6% of total).(see Fig 1.)

Within these categories, fracture patterns showconsiderable variation and there is likely to be adegree of disagreement in classification betweenobservers, particularly in terms of fracturedisplacement and in the subtrochanteric region.

Fig 1

20

Fracture Type

Chart 7A

ll



21

Surgery within 48 hours and duringnormal working hours (Chart 8)

The following chart shows the percentage ofpatients having surgery within 48hrs ofpresentation to the Accident and EmergencyDepartment. This excludes the small number ofpatients – varying markedly across participatinghospitals – regarded as unfit for surgery at 48hrsand patients operated on out of hours, in line withthe Blue Book standard.

Early surgery (within 48 hours of arrival at Accidentand Emergency) for hip fracture not only minimisesavoidable discomfort and dependency but has beenshown to improve rehabilitation prospects andhence diminish the length of stay.16 Extended delayis associated with preventable morbidity andmortality, and should be avoided accordingly.16,17

Ideally, patients should be operated on as soon as itis safe to do so. It is now twenty years since theRoyal College of Physicians first recommended thathip fracture operations should be carried out‘within 24hrs’5 and ten years since NCEPOD statedthat ‘There should be sufficient, fully staffed,daytime theatre and recovery facilities to ensurethat no patient requiring an urgent operation waitsfor more than 24 hours once fit for surgery. Thisincludes weekends’.15 However, if we make a directcomparison with data from the Audit Commissionreport of 20007, applying the same criteria, we seethat the percentage of patients having theiroperations within 24 hours has fallen from a half

to 35% and those having surgery with 48hrs hasfallen from 82% to 69%. Since out of hourssurgery has been shown to carry higher risks18, andsince hip fracture surgery is an urgent rather thanan emergency procedure, operating within ‘normalworking hours’� is recommended. Our data shows a reduction in out of hours operating from 14% to 4% (using the NCEPOD definition 18.01-07.59)15

It may be that there has been an improvement inpatient safety, but this has resulted in adeterioration of service delivery.

Pre-operative delay appears to vary with caresetting. NHFD data shows that there is a significantdifference between the percentage of patientstreated in ‘district’ hospitals having their operationwithin 48hrs (71.6%) and those treated at a‘tertiary’ hospital (60.1%, P < 0.0001). The highercaseloads encountered in the latter may make extrademands on the resourcing and/or organisation ofpre-operative and operative care, and these issuesshould be addressed if patients treated in largercentres are not to be disadvantaged

In more general terms, measures that have beenshown to decrease pre-operative delay include:dedicated hip fracture lists; orthogeriatrician input;the close involvement of senior anaesthetic staff;and the organisational contribution of an elderlytrauma nurse specialist . Since minimising delayimproves both the experience of the patient andthe overall costs of care, here – as elsewhere in hipfracture care – cost and quality are not in conflict.

Process

22

Reason for no operation within 48hours (Chart 9)

Delay to surgery is relatively simple to measure.However, the reasons for delay may be complex,multiple and cumulative (e.g. when delay awaitinginvestigation or theatre time leads to medicalproblems such as pneumonia or electrolytedisturbance, with further resultant ‘medical’ delay).

The categories used here to document delay arenecessarily somewhat simplistic, and in practice notmutually exclusive; but can be used locally tohighlight problems (e.g. inadequate – orinefficiently used – theatre time; the need fororthogeriatrician input; the absence of assessmentprotocols, etc).

In pre-operative care, the real value of NHFDparticipation lies in using information locally toassess and address the main causes of delay, andnot to perfect the documentation of these causes.If effective action is taken, avoidable delay will beminimised, care will be improved, and feedbackdata will show this.

Patients treated without surgery(Chart 10)

Very occasionally patients present late with afracture - most commonly an undisplacedintracapsular fracture - that is already healing.

Apart from such cases, almost all patients with hipfracture should undergo surgery, which relievespain, stabilises the joint and - even in frail patientsnearing the end of life - can be justified because itreduces suffering and facilitates nursing care. For avery small group of patients where an operation isconsidered futile, an end of life care pathwayshould be instituted.

Hospitals that have a high percentage of patientstreated non-operatively should review theirpreoperative assessment process. Furtherinformation regarding the preoperative optimisationof patients is available from the NHFD website.



23

Surgery within 48 hours and duringnormal working hours Blue Book Standard 2

Chart 8

All

24

Reasons for no operation within 48hrs

Chart 9

All



25

Patients treated without surgery

Chart 10A

ll

26

The following charts show the variation in surgicalpractice. Since this report has included hospitalsthat have submitted small numbers of records –inevitably not as representative of casemix andmanagement as larger samples – the numbers ofoperations included in each fracture category havebeen included on the right.

Undisplaced intracapsular(Chart 11)This chart shows that 41% of patients have an internalfixation while almost 57% have some form ofarthroplasty�. This finding is surprising as undisplacedintracapsular fractures that are treated surgically shouldgenerally be treated by internal fixation.1 Data qualityissues, perhaps arising from the use of non-clinical oruntrained audit staff, may explain this anomaly.

Hospitals that report a high percentage ofundisplaced fractures tend to have an increased use of rate of hemiarthroplasty�.

Displaced intracapsular (Chart 12)In contrast, 90.5% of displaced intracapsularfractures are treated with some form of arthroplasty,while 6.5% have a reduction and internal fixation.Because of the likely disruption of the blood supplyto the femoral head patients older than 70 years aregenerally treated with an arthroplasty. In youngerpatients, internal fixation may be attempted in orderto avoid the longer term problems of arthroplasty.These patients may require more revision operationsin the short term.

Intertrochanteric (Chart 13)For the majority of fracture configurations thetreatment of choice is a sliding hip screw (SHS)�, ascomplication rates are generally lower than occur inintramedullary fixation. In this group of patients 81%has a SHS while 10% had an intramedullary nail�.

SubtrochantericIntramedullary nailing� (53.5%) produces a more stablefixation for early mobilisation than a sliding hip screwand should result in a lower incidence of non-union.Screw fixation (5.9%) is an improbable treatment,perhaps reflecting poor data quality rather than reality.

Data quality issues may have arisen in relation tofracture type also, with the possibility that subcapitalfractures are wrongly coded as subtrochanteric.Hospitals that have a high proportion of intracapsularfractures that are undisplaced or a high proportion ofsubtrochanteric fractures treated by screws, shouldincrease the level of orthopaedic involvement in thetraining of their data collectors.

Subtrochanteric fractures amount to less than tenpercent of hip fractures and individual hospitals operateon low numbers. No chart has been included as thereappears to be some difficulty in recognising andreporting the fracture type and reporting on thesurgical technique used. Again this emphasises theimportance of audit staff selection and training, and of data validation.

Cementing of arthroplasties (Chart 14)Fifty six percent of arthroplasties are cemented inplace (Range 0 – 100%). The available evidencesuggests that there is a marginal advantage tocementing arthroplasties in hip fracture surgery, witha reduction in pain and an increase in mobility19.This is based on evidence from the use of oldertypes of hemiarthroplasty and more recentlydeveloped devices need careful evaluation as bettersizing and coating� of the implants may improveoutcomes. While there are concerns regarding bonecement� implantation syndrome, which have lead tothe National Patient Safety Agency issued a directivethat all perioperative death or harm in patientstreated with a hip hemiarthroplasty should bereported to the Agency, the risk or perioperativemortality may be reduced by appropriate measuresin cementation.20, 21, 22

Operations performed by fracture type



27

Operations performed for undisplaced intracapsular fractures

Chart 11

All

28

Operations performed for displaced intracapsular fractures

Chart 12

All



29

Operations performed for intertrochanteric fractures

Chart 13

All

30

Cementing of arthroplasties

Chart 14A

ll



31

Development of pressure ulcers

(Chart 15)Expert nursing care is a crucial component of theoverall care of hip fracture patients. Good practiceincludes assessing patient risk to pressure areas atthe time of admission and thereafter, combinedwith a meticulous and proactive approach topressure area care. The rate of pressure ulcer�

development is seen as a useful measure of nursingcare.23

The development of a new pressure ulcer (grade 2 or above)� appears from the available data to be a relatively infrequent occurrence (3.6%).

However, there are some concerns about thequality of the data on pressure ulcers, perhaps withparadoxical results: reporting of ulcer developmentmay be less likely where pressure area care andawareness is poor.

Pre-operative medical assessment

(Chart 16)The RCP (London) report of 1989 describes a modelof hip fracture care that included “medical advicevia a geriatrician” prior to surgery.5 This chartdemonstrates the extent to which this has becomeroutine practice. It is disappointing that only 24%of patients have a routine assessment by ageriatrician and that only 42% of patients have anypreoperative medical assessment.

32

Development of pressure ulcersBlue Book Standard 3

Chart 15A

ll



33

Preoperative medical assessmentBlue Book Standard 4

Chart 16

All

34

Anti-resorptive therapy (Charts 17,18 & 19)

NHFD seeks not only to improve the care of hipfracture but to diminish its incidence. Boneprotection therapy – usually in the form ofantiresorptive medication� that increases bonemineral density – has been shown to be botheffective and cost effective in the prevention offuture fractures

It is encouraging that two thirds of hip fracturepatients are discharged from acute care withprescribed antiresorptive therapy.

However, since good compliance – continuing withregular treatment – is essential, further work byNHFD is required to assess this.

Specialist falls assessment (Chart 20)

Following a fracture all frail elderly patients should beassessed for secondary prevention. Currently 42% ofpatients have an assessment during their admissionand a further 3% are referred to a falls clinic. Fiftyfive percent have no documented assessment.

Specialist falls assessment� – followed byappropriate interventions such as exercise, homemodifications, and simplification of medication –has been shown to reduce the subsequentincidence of falls.

Together with antiresorptive therapy it is an effectivecomponent of the prevention of future fractures.

Ideally, comprehensive secondary preventionfollowing hip fracture would be readily accessibleand patient-focused, with bone protection and fallsassessment provided within a single service. TheFracture Liaison Service model achieves these goalsfar more effectively than other relevant UKinitiatives24, and should be more widely adopted.



35

Antiresorptive therapy at admission

Chart 17

All

36

Bone health assessment and treatment at dischargeBlue Book Standard 5

Chart 18

All



37

Patients discharged on anti-resorptivetreatment continuing treatment at 120 daysChart 19

All

38

Falls assessmentBlue Book Standard 6

Chart 20

All



39

Secondary prevention overview

Chart 21

This chart shows allpatients in hospital 61receive falls assessmentand bone healthassessment with otherhospitals providingvarying proportions ofthese, or none.

All

40

Length of stay and discharge destination (Charts 22 & 23)

Length of stay is calculated from the day ofadmission to the hospital to the day of dischargefrom the hospital (23 days, range 12 - 58) in linewith DoH length of ‘spell’. As yet we cannot dividethis into ‘acute ward’ v ‘rehabilitation ward’ due topoor completion of these fields. ‘Superspell’, theentire length of the NHS treatment includingrehabilitation in other NHS hospitals, is moredifficult to measure as it requires data collectionfrom two sites. This may become possible once allhospitals undertake regular patient follow up.Alternatively, future data linkage with the HealthEpisode Statistics (HES – data submitted by everyhospital in England for each admission) – alreadyunder discussion – may allow reliable capture of‘superspell’ data on a large scale.

Access to down-stream multi-disciplinaryrehabilitation� - which is of value for frailer patientsfrom home requiring sustained rehabilitation tomaximise chances of return home – varies greatlybetween hospitals. Where it is limited, much of thenecessary rehabilitation will be carried out in theacute setting, resulting in longer stay there.However, this is not the case due to variations inthe structure of care locally. Early rehabilitation in

the acute setting, backed up by ready access toEarly Supported Discharge Schemes� offering careand continuing rehabilitation at home, will offershorter overall stay and a prompt return home.

It should be noted that an over-zealous focus onthe reduction of acute care stay - driven by acutesector bed pressures and achieved by transfer of alarge proportion of patients to post-acute careelsewhere – is likely to add to overall length of stayand hence costs, and also fails to meet patients’wish to get home quickly.

Effective early rehabilitation in acute care togetherwith early supported discharge schemes provide acost-effective model of care that also meets theaspiration of patients to return home as soon aspossible. Such care should be much more widelyavailable.

However rehabilitation is structured and provided inthe local care system, what matters most topatients – and what mainly determines overall costof care – is the total length of inpatient stayfollowing hip fracture.

NHFD coverage of this should improve in future,with better access to linked ‘superspell’ data. This,and the contribution of NHFD audit and feedback,together with the recommendations of the BlueBook, should assist in promoting care that is notonly of higher quality but also more cost effective.



41

Length of acute Trust stay

Chart 22

42

Discharge destination from Trust

Chart 23

All



43

Casemix Adjusted OutcomesCasemix adjusting of outcomes allows for a fair comparison of individual units.Appendix C

Casemix methodology developed by Quantics Consulting Ltd.

Funnel plot for return home from home at 30 daysChart 24

Return home from home

This chart shows the percentage of patients admitted from home who are discharged to their own homein less than 30 days. It does not include patients who have returned home after attending anotherprovider for rehabilitation.

The dominant case-mix factors determining early return home are age and walking ability.

While Office of National Statistics (ONS)25 mortality data is robust, NHFD follow-up data on return home by30 days is less so, with fewer hospitals contributing the necessary data.

However, the spread of this important outcome is even more striking – with implications for cost andquality of care that participating units may wish to address.

44

Funnel plot for mortality at 30 days

Chart 25

Mortality

The dominant case-mix factors determining mortality are ASA grade, walking ability prior to injury, andplace of residence prior to injury. For this analysis, linked data on mortality was obtained by NHFD fromthe ONS.

As will be seen from the funnel plot, there is a considerable spread around the average figure of 8.3%,but the vast majority of adjusted and unadjusted mortality falls within the 95% confidence limits shown as dotted lines.

Case-mix adjustment of rates from individual hospitals shows varying impact: with a poorly-performingunit brought within the 95% confidence limits; and another – a well-performing unit – also broughtwithin the 95% confidence limits.



45

Facilities Audit

Acute Care:Population

Hospitals with similar catchment areas may facegreater demands on their hip fracture services as aresult of variation in the demographics of the localpopulation. The rate of hip fractures is lowest insome inner city areas while the highest rate is seenin a coastal resort.

Trauma theatres

Over a third of delays to operation are directlyattributable to a lack of theatre time. While all ofthe hospitals have introduced dedicated daytime(08:00 – 20:00) trauma sessions as a response tothe NCEPOD report Who operates when?15, theprovision of such theatre time in district hospitalsvaries by a factor of ten. It may be that hospitalsuse vacant elective lists and ‘emergency’ lists toaccommodate fracture patients, but hospitals witha high proportion of patients not receiving surgerywithin 48hrs of presentation should assess theirneed for additional lists.

Orthogeriatric care

The need for input from physicians trained in thecare of the frail elderly patient has been established.However, despite the National Service Frameworkfor Older People 200126 statement: ‘specialistattention is particularly relevant for older peopleundergoing surgery’, of the 64 hospitals submittingrecords for this report, 8 (12.2%) have noorthogeriatrician, and 40 (62.5%) have two or lessorthogeriatric ward rounds a week. Hospitalsshould ensure that sufficient orthogeriatric cover isavailable to allow for daily review of patients.

Some units may find that the link betweenorthopaedic surgeons and the geriatric departmentis enhanced by the development of elderly traumanurse specialists. Further details are available on the website.

All hospitals participating in the National Hip Fracture Database are asked to complete a Facilities Audit atthe time of registration and yearly thereafter. This allows for the identification of special circumstancesfaced by a particular hospital and shows something of the variation in the provision of services nationally.

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48

Fracture liaison nurses

These nurses have a special interest in finding allpatients with fragility fractures and ensuring thatthey are assessed by the osteoporosis service andreferred into the local falls service if appropriate.Thirty eight hospitals (59%) have no fracture liaisonnurse. Since six of these have no elderly traumanurse specialist or orthogeriatrician, secondaryprevention is presumably left to the juniororthopaedic surgeons, who may have had little orno training in this field.

Falls clinics

Despite the National Service Framework for OlderPeople 2001 requirement for an integrated fallsservice to be in place by 2005, thirteen hospitalsreport that they do not have a falls clinic to referpatient to.

DXA scanners

Dual energy X-ray absorptiometry is the mostwidely used means of measuring bone density todetermine the need for osteoporosis treatment inthe younger patient i.e. below the age of 75. Thisservice is frequently provided by a hospital butcould be provided by the PCT or a private provider.Axial scanners are more sensitive than peripheralones, although the latter have the advantage ofbeing portable. Although the National ServiceFramework for Older People 2001 states that allhospitals should have access to bone mineraldensitometry, 36% of hospitals did not have accessto on-site scanning.

The facilities audit shows a number of structuralfailings in the provision of services to ensuresecondary prevention of fractures, which shouldhave been addressed with the implementation ofthe recommendations of the National ServiceFramework for Older People 2001. It is no wonderthat almost 40% of patients leave hospital withoutevidence of an assessment for antiresorptivetreatment. Implementation of the fracture liaisonservice model, as advocated by the BOA/BGS BlueBook would provide a proven mechanism to closethis healthcare delivery gap.

Secondary prevention of fractures:



49

Barnet General Hospital 1 cons none

Barnsley District General 0 nurse peripheral

Basildon University Hospital 1 cons axial

Bradford Royal Infirmary 0 cons axial

Cheltenham General Hospital 0 cons none

Countess of Chester Hospital 0 cons none

Cumberland Infirmary 0 nurse none

Derby Royal Infirmary 1 cons axial

Diana, Princess of Wales Hospital, Grimsby 1 none axial

Frenchay Hospital, Bristol* 0 cons axial

Friarage Hospital, Northallerton 0 none none

Good Hope General Hospital, Sutton Coldfield 0 cons axial

Hillingdon Hospital, London 0 none none

Hope Hospital, Salford* 0.5 cons none

Hull Royal Infirmary 0 none axial

Ipswich Hospital 1 cons axial

James Cook University Hospital, Middlesbrough* 0 none axial

John Radcliffe Hospital, Oxford* 2 cons none

King's College Hospital, London* 1 cons axial

Leicester Royal Infirmary* 0 cons axial

Leighton Hospital 1 none axial

Maelor Hospital, Wrexham 1 none none

Maidstone General Hospital 1 cons none

Manchester Royal Infirmary 0 cons axial

Medway Maritime Hospital, Gillingham 0 cons axial

Milton Keynes General Hospital 0 cons none

Musgrove Park Hospital, Taunton 0 cons axial

Noble's Hospital, Isle of Man 0 nurse axial

Norfolk and Norwich Hospital* 0 cons axial

North Middlesex Hospital 0 cons none

Northampton General Hospital 0 none axial

Pilgrim Hospital, Boston 0 cons axial

Princess Royal Hospital, Telford 1 cons none

Queen Alexandra Hospital, Portsmouth 0 cons axial

Queen Elizabeth Hospital, Gateshead 0.6 nurse axial

Fracture LiaisonNurse Falls Clinic DXA Scanner

Hospital*hospitals providing ‘tertiary’ trauma services

such as pelvic and limb reconstruction

50

Queen Elizabeth Hospital, King's Lynn 0 none none

Queen Elizabeth Hospital, Woolwich 1.6 cons axial

Queen's Hospital, Romford 0 nurse axial

Queen's Medical Centre, Nottingham 0.5 cons axial

Royal Albert Edward Infirmary, Wigan 0 cons axial

Royal Berkshire Hospital 1 cons none

Royal Bolton Hospital 1 cons none

Royal Shrewsbury Hospital 0 nurse none

Royal Surrey County Hospital 0 cons none

Royal United Hospital Bath 1 cons peripheral

Royal Victoria Hospital, Belfast* 1 cons none

St Mary's Hospital, Paddington 1 cons axial

St Thomas Hospital, London* 0 cons axial

Scunthorpe General Hospital 0 cons axial

Stepping Hill Hospital, Stockport 0 cons axial

Stoke Mandeville Hospital 1 cons peripheral

Sunderland Royal Hospital 1 cons peripheral

Tameside General Hospital 0.2 cons none

University Hospital of North Staffordshire* 0.5 cons axial

University Hospital of North Tees 0.5 cons axial

University Hospital of Wales* 0 none axial

University Hospital, Lewisham 0 cons none

Victoria Hospital, Blackpool 0 none peripheral

Walsgrave Hospital, Coventry* 0 none none

Warwick Hospital 0 none none

Watford General Hospital 0 cons none

Whipps Cross Hospital, London 1 cons axial

Whittington Hospital, London 0 cons axial

York District Hospital 0 cons none

Fracture LiaisonNurse Falls Clinic DXA Scanner

Hospital*hospitals providing ‘tertiary’ trauma services

such as pelvic and limb reconstruction



51

GlossaryTerm Definitions

Arthroplasty Any replacement of the upper femur including hemiarthroplasties, bipolarhemiarthroplasties and total hip replacements

ASA grades American Society of Anesthesiologists' (ASA) physical status classification :-

1. A normal healthy patient

2. A patient with a mild systemic disease

3. A patient with a severe systemic disease that limits activity, but is not incapacitating

4. A patient with an incapacitating systemic disease that is a constant threat to life

5. A moribund patient not expected to survive 24 hours with or without operation

This grading does not take into account acute illness, hence a patient can be ASA 1 and ‘unfit’.

Best practice These are to be introduced so that the NHS will pay for best practice rather thantariffs average cost, meaning NHS organisations will have to make constant improvements

in care to reduce costs.3

Bone cement Polymethyl methacrylate is a plastic that may be used to hold hip replacements inplace. A mixture of powder and fluid are introduced into the bone before the replacement is put in place. The ‘cement’ sets in a few minutes.

Bone Protection 1. BisphosphonatesMedication Oral

EtidronateAlendronateRisedronateIbandronateCombined treatment (Bisphosphonate + vitamin D)IntravenousIbandronateZoledronatePamidronate-Aredia and generic

2. HRT and SERMSHRT (various)TiboloneRaloxifene

3. Parathyroid hormonePTH 1-34 (Teriparatide)PTH 1-84

52

Term Definitions

Bone Protection 4. StrontiumMedication Strontium ranelate

5. Calcium and vitamin D6. Calcitonin

Case mix factors Demographic and functional information about patient. E.g. Age, sex, mobility, deprivation status , ASA and previous living circumstances (for mortality data only)

Co-morbidity The presence of one or more disorders (or diseases) in addition to the hip fracture at the time of admission.

Early supported Supported discharge and early supported discharge (ESD) schemes comprise an discharge identified team of staff (schemes vary but the teams tend to include designatedschemes medical, nursing, physiotherapy, occupational therapy and social work personnel)

whose role is to assess patients on admission, to identify those suitable for supporteddischarge, to facilitate early mobilisation and rehabilitation and arrange appropriatesupport on discharge and follow up.

Elderly trauma A nurse with specialist training in the assessment and care of elderly patients nurse specialist with fractures.

Fracture liaison A nurse is based in fracture clinic whose primary purpose is liaison with orthopaedicnurse / service and trauma services to ensure in and outpatients with low impact fractures after falls

are screened for falls and osteoporosis

Coating Hydroxyapatite (HA) is a chemical found in bone. Coating metal hip replacements (of inplants) with HA at the time of manufacture may produce a bond between the patient’s bone

and the metal of the replacement, increasing the chance of the hip functioning well.

Hemiarthroplasty A replacement of the upper end of the femur. This can be made of a single piece /Bipolar of metal (monoblock), or it can be made of a separate stem and head (modular). Hemiarthroplasty Some have a ball and socket joint between the head and stem (bipolar). Initially

designed to reduce wear in the hip joint, bipolar design makes revision to a total hip replacement easier.

Intramedullary A metal rod that goes down the centre of the femur.nail

Multidisciplinary A multidisciplinary approach incorporates staff from different medical disciplines rehabilitation and professions allied to medicine who are engaged in working together as

equal stakeholders.

NCEPOD The National Confidential Enquiry into Perioperative Deaths. A Department of Health funded independent organisation that makes recommendations on the safe management of surgical cases.



53

Term Definitions

Normal 08:00 – 19:59hrsworking hours The NCEPOD reports of 1997 and 2003 Ref define “out of hours” as any time outside

08:00 to 17:59 on weekdays, and any time on a Saturday or Sunday. The 1999 reportstates that “There should be sufficient, fully-staffed, daytime theatre and recoveryfacilities to ensure that no patient requiring an urgent operation waits for more than24 hours once fit for surgery. This includes weekends.” The NCEPOD websiteincludes a section on ‘urban myths’ acknowledging that patterns of work will vary,dependent upon local arrangements, and for these reasons along with the fact thatthis definition is currently in use in Scotland27, we have adopted 08:00 to 19:59 sevendays a week as being ‘normal working hours’

Payment by Under this process, instead of being commissioned through block agreements asResults previously, hospitals (and other providers) are paid for the activity that they undertake.

Payment will be linked to activity and adjusted for casemix.28

Pressure ulcer A pressure ulcer is an area of localised damage to the skin and underlying tissuecaused by pressure, shear, friction and or a combination of these.

Pressure ulcer Grade 1 = skin inflammationgrades Grade 2 = Skin blistering/superficial damage

Grade 3 = Skin broken/serous dischargeGrade 4 = Deep ulcer, underlying fascia, bone, muscle affected

Sliding hip screw A sliding hip screw is frequently used for intertrochanteric fractures. It consists (SHS) of a large screw which is inserted into the head of the femur; this is assembled

into the barrel at the end of a plate which is screwed onto the upper femur, allowing the two parts of the fracture to press together as they heal.

Specialist falls A systematic assessment by a suitably trained person e.g. Geriatrician or a specialistassessment trained nurse which must cover the following domains:- Falls history (noting previous

falls), cause of index fall (including medication review), risk factors for falling and injury(including fracture) and from this information formulate and document a plan ofaction to prevent further falls.

Total hip The prosthetic replacement of both surfaces of the hip jointreplacement

54

References1. British Orthopaedic Association. The Care of patients with fragility fracture. Br Orthop Ass 2007.

Available from: http://www.boa.ac.uk

2. Lawrence TM, White CT, Wenn R, et al. The current hospital costs of treating hip fractures. Injury 2005;36:88–91

3. High Quality Care for All: NHS Next Stage Review final report 2008 Available from:http://www.cabinetoffice.gov.uk/media/cabinetoffice/strategy/assets/publications/nhs_next_stage_review.pdf

4. NHS Constitution 2009 Available from: http://www.dh.gov.uk/en/Healthcare/NHSConstitution/index.htm

5. The Royal College of Physicians (London). 1989. Fractured Neck of Femur: Prevention and Management.ISBN 0 900596 81 3

6. The Audit Commission. 1995. United they stand. ISBN 011 886 434 3

7. The Audit Commission. 2000. United they stand Update. Available from: http://www.audit-commission.gov.uk/Products/NATIONAL-REPORT/251D3429-93AE-4F4A-B912-8D89E87F749F/hipvfmi.pdf

8. The National Confidential Enquiry into Peri-operative Deaths Report 2001.Changing the way we operate.Available from: http://www.ncepod.org.uk/2001htm

9. Delivering Quality and Value. Focus on: Fractured Neck of Femur 2006. The National Health Service Institutefor Innovation and Improvement. Available from:http://www.institute.nhs.uk/option,com_joomcart/Itemid,26/main_page,document_product_info/products_id,188.html

10. Department of Health. 2002. Quality and performance in the NHS: clinical indicators. Available from:http://www.performance.doh.gov.uk/performanceratings/2002/index.html

11. British Orthopaedic Association. The Care of Fragility Fracture Patients. Br Orthop Ass 2003

12. Holt G, Smith R, Duncan K, Hutchison JD, Gregori A. Gender differences in epidemiology and outcomeafter hip fracture: evidence from the Scottish Hip Fracture Audit. J Bone Joint Surg (Br) 2008;90:4:480-483.PubMed Id18378923

13. American Society of Anaesthesiologists. New classification of physical status. Anaesthesiology 1963;24:111.

14. The National Confidential Enquiry into Peri-operative Deaths. 1999. Extremes of age ISBN 0 9522069 6 XAvailable from: www.nceopd.org.uk

15. The National Confidential Enquiry into Peri-operative Deaths 1997 Who Operates When? NCEPOD ISBN 0 9522069 4 3 Available from: www.nceopd.org.uk

16. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures ofthe proximal femur. J Bone Joint Surg (Br) 2005; 87-B(8):1123-1126.

17. Moran, CG Wenn RT, Sikand M and Taylor AM. Early mortality after hip fracture: Is delay before surgeryimportant? JBJS (AM) 2005: 87A(3): 483-489.

18. Pearce M, Woolf A. Care of elderly patients with a fractured neck of femur. Health trends 1992; 24 (4): 134-5



55

19. Parker MJ, Gurusamy KS. Arthroplasties (with and without bone cement) for proximalfemoral fractures in adults. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001706. DOI:10.1002/14651858.CD001706.pub3.

20. Department of Health. 2007. On the State of Public Health: Annual Report of the Chief Medical Officerpage 30 Available from: http://www.dh.gov.uk/en/publicationsandstatistics/publications/annualreports/dh_086176

21. PA-PSRS Patient Safety Advisory. 2006. Vol. 3, No. 4 Available from http://www.ecri.org/Documents/PA_PSRS/2006.12_Advisory.pdf

22. National Patient Safety Agency Mitigating surgical risk in patients undergoing hip arthroplasty for fracturesof the proximal femur March 2009 http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/mitigating-risks-when-using-bone-cement-in-hip-surgery/

23. Fairbank J, Goldacre M, Mason A, Wilkinson E, Fletcher J, Amess M, Eastwood A, Cleary R (eds.) HealthOutcome Indicators: Fractured Proximal Femur. Report of a working group to the Department of Health.Oxford: National Centre for Health Outcomes Development, 1999. Available from:http://nchod.uhce.ox.ac.uk/fracturedfemur.pdf

24. McLellan A, Fraser M. Fracture liaison services In: Lanham-New S, O’Neill T, Morris R, Skelton D, Sutcliffe A,editors. Managing Osteoporosis. Oxford: Clinical Publishing, 2007 pp219-34.

25. Office of National Statistics: http://www.statistics.gov.uk

26. Department of Health. National Service Framework for Older People. March 2001. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 4003066

27. Scottish Hip Fracture Audit Report 2008 Available from: http://www.shfa.scot.nhs.uk/AnnualReport/SHFA_Report_2008.pdf

28. Payment by results. Available from: http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHSFinancialReforms/DH_4065236

29. Breiman L, Friedman J, Ohlshen R, Stone S. Classification and regression trees Pacific Grove: Wadsworth, 1984

56

Appendix AFunding

Sponsorship through the Association of British Pharmaceutical Industries (ABPI) and Association of BritishHealthcare Industries (ABHI)

Amgen

DePuy International

Kyphon (now Medtronics)

Nycomed

Novartis Pharmaceuticals

Procter & Gamble

Roche Pharmaceuticals

Sanofi-Aventis UK

Servier Laboratories

Shire Pharmaceuticals Group plc

Smith & Nephew

The Furlong Research Charitable Foundation

The Department of Health, Healthcare Quality Directorate

ARMA (Arthritis and Musculoskeletal Alliance)

Acknowledgements:

The BOA and BGS

NHFD participants: clinical and audit staff in all contributing hospitals

Quantics Consulting Ltd

We wish to acknowledge our colleagues in the NHS Institute for Innovation and Improvement. Hip fracturecare has been selected as one of 2 orthopaedic key areas for the current National Rapid ImprovementProgramme.

Selected Secondary Care Trusts from all regions in England have been invited to participate in a 12-weekintensive programme for hip fracture pathway and quality improvement. Support visits have beenundertaken by the NHS Institute Management and Clinical Team. Pathways are adapted to local needsand expertise, but are integrated with the BOA / BGS Blue Book and NHFD guidelines. NHFD datacollection will validate objective improvement.

It is anticipated that initial quality improvements achieved by the 12 week rapid Improvement Programmewill be followed by a later delayed phase of improvement over a 2 year time-frame. This will be achievedfrom analysis of evidence base data from NHFD.

NHS Institute and NHFD therefore complement each other in achieving long-term sustainable qualityimprovement in hip fracture care.



57

NHFD Executive

Co-Chairs

David MarshProfessor of Clinical Orthopaedics, UCL, Royal National Orthopaedic Hospital

Finbarr MartinConsultant Physician, Guy’s and St. Thomas’ Hospital, London. Specialist Clinical Adviser (Older People)Social Care Policy and Innovation Division, Department of Health

Guy Broome Consultant Orthopaedic Surgeon, Cumberland Infirmary, Carlisle

Nick Carter Mandate Communications

David CunninghamTechnical Project Manager, NHS Information Centre*

Colin Currie Consultant Geriatrician, NHS Lothian

James Elliott Consultant Orthopaedic Surgeon, Belfast

Colin EslerConsultant Orthopaedic Surgeon, Leicester

Stewart FlemingSoftware Developer, NHS Information Centre*

Karen HertzAdvanced Nurse Practitioner, University Hospital ofNorth Staffordshire NHS Trust

Pamela Holmes Head of Healthy Ageing, Help the Aged

Antony JohansenConsultant Orthogeriatrician and Senior Lecturer inPublic Health, Cardiff & Vale NHS Trust

Paul MitchellAssociate Lecturer, Derby University

Chris MoranProfessor of Orthopaedic Trauma Surgery, Queen’s Medical Centre, Nottingham

Maggie Partridge NHFD Project Manager

Mike PearsonProfessor of Clinical Evaluation, University of Liverpool

Jonathan PotterConsultant Physician Director Clinical Effectiveness, Royal College of Physicians

Opinder Sahota Consultant Geriatrician, Queen’s Medical Centre,Nottingham

Robert WakemanConsultant Orthopaedic Surgeon, Basildon University Hospital*

Keith WillettProfessor of Orthopaedic Trauma Surgery, John Radcliffe Infirmary, OxfordNational Clinical Director for Trauma Care,Department of Health

* NHFD Implementation Group

58

NHFD Data sub group

Chair

Colin Currie, Consultant Geriatrician, NHS Lothian

Gary Cook, Consultant in Public Health Medicine, Stockport

David CunninghamTechnical Project Manager, NHS Information Centre

James ElliottConsultant Orthopaedic Surgeon, Royal Victoria Hospital, Belfast

Antony JohansenConsultant Orthogeriatrician and Senior Lecture in Public Health, Cardiff & Vale NHS Trus

Rob WakemanConsultant Orthopaedic Surgeon, Basildon University Hospital

NHFD Stakeholders

National Osteoporosis Society

University of Derby

Royal College of Nursing

Age Anaesthesia

NHS Institute for Innovation and Improvement



59

Appendix B: Data CompletenessThe percentage of data completed was calculated by considering all draft and completed records forincluded hospitals.

Seventeen fields were considered and the points for each record were added and dividing by the totalnumber of records for a hospital to give the percentage data completeness.

Fields used:

Age at Event (based on DOB); Sex; Admitted From; ASA Grade; Walking Ability Preadmission; FractureType; Operation Performed; Surgery; Reason 48 hours; Reason 24 Hours; Pressure Ulcers; PreoperativeMedical Assessment; Antiresorptive Therapy; Discharge Ward Destination; Discharge Trust Destination;Antiresorptive Therapy at 120 days; Specialist Falls Assessment.

60

Appendix C:Casemix AdjustingThe case mix factors were used to develop separate classification trees29 for 30 day mortality and 30 dayreturn home from home. Note that ASA Grade and Walking Ability Outdoors were both excluded fromthe case mix factors because they were poorly recorded. The trees categorised patients in such a way thatwithin a category the outcome was similar, and between categories the outcome differed.

The case mix adjusted outcomes were then derived as follows. For each hospital, the expected outcomewas calculated. For mortality at 30 days this was the expected number of deaths – calculated bymultiplying the number of patients in each category by the national mortality rate for the category andsumming across all the categories. The adjusted outcome for the hospital was then calculated bymultiplying the national rate by the ratio of observed to expected outcome for the hospital. This methodis known as indirect standardization.



61

Classification tree for mortality at 30 days

113128.3%

251915.1%

87936.4%

Age 60 - 88 Age 89+

Number in node% mortality

Key to nodes:

Terminal nodes areshades to indicate therelative risk of death

Female Male

205212.8%

46725.5%

Age 98+Age 94-97Age 89-93

13509.3%

55316.5%

14930.2%

Admitted from hospital,rehab unit, residentialcare, nursing home or

LTC hospital

Admitted from ownhome, sheltered housing

or other

68365.0%

195711.0%

Regularly walkedindoors without aids

Regularly walked indoors with one or two aids or frame or

wheelchair or bed bound

37953.4%

30417.1%

Age 60-77 Age 78-88 Female Male

85110.5%

21905.8%

21854.6%

16101.8%

62

Notes



In partnership with:

Copyright © 2009. The Information Centre, NationalHip Fracture Database. All Rights Reserved.

The National HipFracture DatabasePreliminary NationalReport 2009

F O R H E A L T H A N D S O C I A L C A R E

Need to know more?Visit our demonstration website:www.nhfd.co.ukEnter Username: nhfd demouserEnter Password: password

0207 251 8868

Email: [email protected]

NHFD Headquarters, British Geriatrics Society, Marjory Warren House, 31 St. John's Square, London EC1M 4DN

British Orthopaedic Association

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