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National audit shows improvements in hospital care of hip fracture patients

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4468 (Published 13 July 2011) Cite this as: BMJ 2011;343:d4468
  1. Ingrid Torjesen
  1. 1London

The care of elderly patients with hip fracture has improved over the past year as a government initiative giving financial incentives to trusts that meet quality standards begins to yield results, an audit has shown.

The national hip fracture database report, published this week, includes data on more than 53 000 cases of people admitted to hospitals in England, Wales, Northern Ireland, and the Channel Islands between April 2010 and March 2011—around 76% of the 70 000 estimated cases.

The audit, a collaboration of the British Geriatric Society and British Orthopaedic Association with funding from the Healthcare Quality Improvement Partnership, found that over the past year the quality of care of patients with hip fracture has continued to improve, in some areas markedly.

And in 2010-11 the Department of Health for England also introduced an added incentive to hospital trusts to improve care through the best practice tariff (BPT), whereby trusts are paid a higher fee for procedures that meet specified quality standards.

The 2011 audit shows that 58% of patients were admitted to orthopaedic wards within four hours, up from 57% in 2010, and the number assessed preoperatively by an orthogeriatrician rose from 31% to 37%.

Patients are also not waiting as long for their operation: 87% had surgery within 48 hours, compared with 80% last year. And over the past year the number of patients developing pressure ulcers has halved from 6% to 3%.

Before discharge, 71% of patients were given falls assessments and bone health assessments to try to prevent future fractures. In 2010 only 63% of patients received a falls assessment, but this has risen by almost a third to 81%. Meanwhile two thirds of patients (66%) are now discharged on bone protection drugs, up from 57% in 2010.

A separate analysis of data from a subgroup of 28 hospitals, which had submitted relatively complete and high quality data, showed major improvements in a number of process and outcome indicators over the past three years, demonstrating that the audit had been effective in improving care and reducing mortality.

The report also says: “It appears that the implementation of BPT in England has served to promote interest, better resourcing, service improvement, and better outcomes in hip fracture care.”

Under the BPT for hip fracture, hospital trusts are paid a higher fee for procedures if they meet certain quality standards, including surgery within 36 hours, preoperative or perioperative assessment by a geriatrician, and secondary prevention, including falls and bone health assessment. In the first year the number of cases qualifying for the enhanced tariff has more than doubled from 2254 to 4645.

Peter Kay, president of the British Orthopaedic Association, said, “The importance of this report cannot be overstated. 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.”

Colin Currie, consultant geriatrician and chairman of the hip fracture database report 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 knowhow 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.”

Although overall performance in hip fracture care has improved, the audit shows that variation still persists among hospitals, with some having much higher mortality rates. Two per cent of medically fit patients still wait more than four days for surgery, with serious implications for their recovery and survival, and documentation of length of stay, which is a major determinant of the overall cost of hip fracture care, remains poor.

From March 2012 the national hip fracture database audit is set to merge with the Royal College of Physicians’ wider falls audit and will be retitled the falls and fragility fractures audit.

Notes

Cite this as: BMJ 2011;343:d4468

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