The REDUCE Study: improving outcomes after hip fracture

Dr Celia Gregson is a Consultant Geriatrician in Bath and Consultant Senior Lecturer in Bristol. She is also a member of the National Osteoporosis Guideline Development Group. She tweets @celiagregson

Multiple hospital organisational factors are associated with adverse patient outcomes post hip fracture in England and Wales: the REDUCE record-linkage cohort study

How well patients recover after a hip fracture varies enormously between NHS hospitals in England and Wales. New 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 patients’ recovery during and after a hip fracture admission.

Researchers used anonymous, routinely collected hospital records, including data from The National Hip Fracture Database 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 to 30 days, how long patients needed to stay in hospital, and once home, how often patients needed to be readmitted to hospital because of a complication.

The team found that how well patients recovered after a hip fracture varied enormously between the 172 hospitals studied across England and Wales. The national average hospital (acute plus rehabilitation) length of stay was 21 days, but this ranged from 12 to 42 days across the country. Nationally, mortality within a month of hip fracture averaged 7.3%, but again this varied from 3.7% to 10.4% between hospitals. 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, with about 30 in 100 people needing to be readmitted to hospital; the national average was 15%.

The researchers used multiple national audits and reports to derive hospital-specific information about the way hip fracture services are organised and delivered. In all, 22 hospital organisational factors were independently associated with length of stay. For example, a hospital’s ability to mobilise ≥90% patients promptly after surgery predicted a two-day shorter length of stay. Ten hospital organisational factors were independently associated with 30-day mortality; for example, discussion of patient experience feedback at clinical governance meetings and provision of prompt surgery to ≥80% of patients were each associated with 10% lower mortality. Nine organisational factors were independently associated with hospital readmissions - for example, readmissions were 17% lower if hospitals were able to report how soon community therapy would start after discharge.

The aim is that 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 this 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. 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. 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 associated with the need for patients to come back into hospital appears to centre on 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. 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, service leads and senior doctors. ‘Tools’ 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 ROS’s website in 2023.

The full study findings can be read here: ‘Multiple hospital organisational factors are associated with adverse patient outcomes post hip fracture in England and Wales: the REDUCE record-linkage cohort study’ by Rita Patel, Celia L Gregson, et al. in Age and Ageing. And the study protocol paper ‘REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study’, is available here: REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study | BMJ Open