Intended for healthcare professionals

Dr Foster's Case Notes

Some way to go for consistent implementation of guidance on hip fracture

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:1097
  1. Alex Bottle,
  2. Brian Jarman,
  3. Paul Aylin,
  4. Roger Taylor
  1. Dr Foster Unit, Imperial College

    Fractured hips are a common cause of hospitalisation among elderly people, and in the year after treatment the mortality rate may be as much as 30%. For many years medical bodies throughout the world have issued consistent evidence based guidelines for the management of broken hips, but 2002-3 data from the United Kingdom show that implementation of this guidance is patchy. In addition, the data show that the percentage of patients managed conservatively varies considerably between hospitals. These patients have a considerably higher mortality. Further guidance on when to manage conservatively may be appropriate.

    The bottom line

    • In-hospital mortality after admission for fractured neckof femur is 13% in England. For patients aged 65 and over who do not have surgery, mortality is 28%

    • On average, hospitals operate on 89% of patients admitted with fractured neck of femur, but this varies between units from 63% to 97%

    • Management of fractured neck of femur varies considerably: 17% of patients are not operated on within 48 hours after admission, and almost one in four hospitals do not have multidisciplinary teamworkbetween surgeons and medics

    In line with recommendations internationally, the Scottish Intercollegiate Guidelines Network (SIGN) recommends that patients with fractured neck of femur are operated on as soon as possible, and ideally within 48 hours after admission; that patients are helped to be mobile again within 24 hours of surgery; and that surgeons and medics work together in multidisciplinary teams.

    Dr Foster collected data by questionnaire on hospital treatment of patients admitted with fractured neck of femur from 176 NHS acute trusts between October and December 2003. Questionnaires were completed by a communications contact designated specifically for the Dr Foster project by each hospital. This was often the communications manager or medical director, who collected the information from relevant staff members.

    Hospital responses to management of hip patients

    View this table:

    Questionnaires were completed either on paper and returned in the post, or online. On receipt of the completed questionnaire, a DrFoster representative spoke with the designated contact by phone to verify the data and clarify any discrepancies. For all paper copies, the responses were manually entered into a SQL database by a Dr Foster representative and again verified against the paper copy. Analysis of the data was performed using Excel.

    Analysis of this data showed that, on average, 17% of patients did not reach the operating theatre within 48 hours of admission and that in some cases the figure was much higher, up to 46%. On average, 85% of patients saw a physiotherapist within 24 hours after the operation, but the rate varied from 33% to 100%; 72% of hospitals said they held regular meetings of orthopaedic surgeons and medical teams, and 77% said that all hip fracture patients were reviewed by a medic during their stay in hospital.

    Hospitals varied greatly in the percentage of patients who were managed without surgery. SIGN guidelines say that conservative treatment may be appropriate for patients who are chairbound or bedbound. Analysis of the collected data shows that on average in England 11% of patients are managed conservatively; however, in some units this figures rises above 25%. The in-hospital mortality rate among this group of patients, who may be frailer than average, is three times that of patients treated surgically.

    The basic figures

    • 12% of women and 5% of men fracture a hip before the age of85

    • About 60 000 people a year in England and Wales are treated for fractured neck of femur

    • 86% of patients with fractured neck of femur are aged 65

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    This month's Dr Foster's Case Notes were compiled by Alex Bottle, Brian Jarman, Paul Aylin, and Roger Taylor of the Dr Foster Unit at Imperial College. Dr Foster is an independent research and publishing organisation created to examine measures of clinical performance.

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