nhfd national report 2011-summary:layout 1 national report 2011-summary.pdfbritish orthopaedic...

The National Hip Fracture DatabaseNational Report 2011 - Summary

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

The National HipFracture DatabaseNational Report 2011- Summary

The National Hip Fracture Database NationalReport 2011 was prepared by the members of theImplementation Group:Colin Currie, NHFD Geriatrician LeadMaggie Partridge, NHFD Project ManagerFay Plant, NHFD Project Coordinator (North)Jonathan Roberts, NHFD Web Developer, NHS ICRob Wakeman, NHFD Orthopaedic LeadAndy Williams, NHFD Project Coordinator (South)

Data analysis and chart production byQuantics Consulting Ltd,Roslin BioCentre,Roslin EH25 9TTTelephone +44 (0) 131 440 2781

Brief extracts from this publication may bereproduced provided the source is fullyacknowledged.

Enquiries and comments about the report wouldbe welcomed. Please contact:NHFD, British Geriatrics Society, Marjory WarrenHouse, 31 St. John’s Square, London EC1M 4DN

Both the full report and this summary are availableon line www.nhfd.co.uk

Copyright © The National Hip Fracture Database 2011. All rights reserved.

The National Hip Fracture DatabaseNational Report 2011

CONTENTS Pages

Introduction…………………………..…………………………………............……...………...4

Foreword……………...............................……………………………………..……...………..5

The National Hip Fracture Database………………..……………………….....................……6

The NHFD National Report 2011: Main Findings………………....................................……7

1. National-level improvements in care standards……………......……...………….8

2. Trend data in hospitals with established NHFD participation................................9

3. NHFD participation and the improvement of care – good practice examples........10

4. Achieving the Best Practice Tariff.........................................................................11

5. The Best Practice Tariff and its impact on care.......................................................12

Best Practice Tariff achievement by SHA………………………......................................…13-17

Casemix adjusted outcomes:……………………….........…………………………………….18

Funnel plot for return home from home at 30 days…………………....………………..18

Funnel plot for mortality at 30 days…………………………………….……….………19

Limitations of the Report…………………………….......……….........………………….........20

NHFD: the future……........................……….........................................................……....20

Appendix A - List of participating hospitals………………..…....………….................………21

Acknowledgements…………………………………………………………….......…..………23


Copyright © The National Hip Fracture Database 2011. All rights reserved.4

IntroductionThis brief summary of the National Hip FractureDatabase 2011 Report brings together the mainpoints from a much more detailed 123 page e-published full Report.

That Report, a public document which can bedownloaded in its entirety from the NHFDwebsite, provides a wealth of comparativeinformation on casemix, care and outcome on53,443 cases from 176 hospitals in the form of 58charts and 23 tables, together with considerabletechnical and statistical detail – and is therefore ofmost interest to clinicians and managers inparticipating hospitals, to regional healthauthorities, and to commissioners of care.

This summary document seeks only to provide aconcise and accessible overview that shows howthe National Hip Fracture Database seeks to fulfilits prime aim of improving hip fracture care; andhow clinical teams, supported by NHFD data andfeedback, have achieved measurableimprovements in the quality and cost-effectivenessof the care they provide.

Again, it is emphasised that much more detail –including that on fracture type and surgicalfixation; on individual hospital performance andcomparative performance at SHA level; and on thestatistical methods used in data analysis – can beaccessed in the e-version of the Report (availableat www.nhfd.co.uk )


Copyright © The National Hip Fracture Database 2011. All rights reserved. 5

ForewordHip fracture is a common, serious injury of older people that is likely tobecome more common as the population ages. For many patients, it canbring loss of mobility and independence, and for some the loss of acherished home. For society the costs, both in acute care and in providingfor subsequent dependency, are high – approaching £2 billion per yearfor the UK as a whole.

Since its launch in 2007 the National Hip Fracture Database has donemuch to draw attention to the status of hip fracture as the tracercondition for the current epidemic of fractures that result fromosteoporosis; and to mobilise professional enthusiasm for its care.

This publication, the third national report from the NHFD, is notable in anumber of respects. All eligible hospitals in England, Wales, NorthernIreland, and the Channel Islands are now registered with the NHFD, withthe vast majority regularly uploading data. In England, the NHFD hasmade possible the collaboration with the Department of Health toimplement the Best Practice Tariff (BPT) for hip fracture care withimpressive participation and steadily rising numbers of cases meeting thecriteria. With more than 53,000 cases from 176 hospitals, this report isthe most substantial so far, and provides further evidence that hipfracture care is improving, and that significant advances have been madein the provision of secondary prevention. We consider this is remarkableprogress and truly indicative of the influence of clinical audit.

Perhaps most importantly, the NHFD, together with the BPT initiative, hassucceeded in promoting the ideal of collaborative care, so thatorthopaedic surgeons, anaesthetists, orthogeriatricians and their teamsare working together in more and more hospitals providing safer, betterand more cost-effective care for their patients.

The NHFD, clinically led and focused on the improving clinical care, hasearned the trust of healthcare professionals – both clinicians andmanagers. We know they value the combination of audit, standards, andcontinuous feedback, and the support the NHFD offers as they worktogether to improve the services they provide for some of our mostvulnerable and frail patients.

This report, at a time of impending change and increasing cost pressuresin healthcare, is therefore most welcome, not least because it givesgrounds for optimism that, in hip fracture care, cost and quality are notin conflict, but can be achieved together. For the future, we look forwardto a key role for NICE Quality Standards in setting the standards forclinical audits.

Professor David OliverNational Clinical Director

for Older People

Professor Keith WillettNational Clinical Director

for Trauma Care


The National Hip Fracture Database (NHFD) is aclinically led, web-based audit of hip fracture careand secondary prevention in England, Wales, andNorthern Ireland. It was developed from 2004with industry funding and the support of theBritish Orthopaedic Association (BOA) and theBritish Geriatrics Society (BGS), and launched in2007. In 2009 it was recognised by the NationalClinical Audit Advisory Group for central fundingfor three years within the Healthcare QualityImprovement Partnership.

Hospitals registered with the NHFD participate byuploading in standard dataset format informationon cases of hip fracture admitted, and receivefrom the central database benchmarked feedbackon casemix, care and outcomes. This iscontinuously updated, and enables clinicians andmanagers to monitor and improve the clinical carethey provide; and can be used also to prompt andmonitor service developments aimed at raisingboth the quality and cost-effectiveness of suchcare.

In addition, the NHFD website offers support inthe form of case studies, good practice examples,model job descriptions, business plans and anextensive database of the medical literature on hipfracture care; and NHFD central staff – its projectmanager and two project coordinators – haveorganised a series of well-attended regionalmeetings. These bring together clinicians andmanagers to share expertise, and report on theuse of the NHFD in improving services for hipfracture patients. Together, these measures havesucceeded in creating a truly national clinicalaudit, and a critical mass of enthusiasm andexpertise in hip fracture care that is reflected inthe findings reported here.

All 191 eligible hospitals are now registered withthe NHFD, 98% participating by regularlyuploading case records. Around 76% of theestimated 70,000 cases occurring annually arenow documented by the NHFD. Cases recordedsince its launch in 2007 exceed 132,000, making

the NHFD the biggest national hip fracture auditin the world. Care is audited against six standardslaid out in the BOA/BGS Blue Book on the care ofpatients with fragility fracture (prompt admissionto orthopaedic care; surgery within 48 hours andwithin normal working hours; minimising pressureulcer incidence via good nursing care; routineaccess to orthogeriatric medical care; assessmentand treatment to promote bone health; and fallsassessment).

From April 2010 the NHFD has supported theimplementation of the Department of Health’sBest Practice Tariff for hip fracture care in England,which offers additional payment for cases wherecare meets agreed standards (surgery within 36hours; care by surgeon and geriatrician; careprotocol agreed by geriatrician, surgeon andanaesthetist; pre/perioperative assessment bygeriatrician; geriatrician-led multi-disciplinaryrehabilitation; secondary prevention including fallsand bone health assessment).

The 2011 NHFD National Report covers casemix,care and outcomes of 53,443 cases admittedbetween 1 April 2010 and 31st March 2011 by176 hospitals meeting the case threshold of 100(or high % submission rates in smaller hospitals).Appendix A provides a full list of NHFD-registeredhospitals and identifies those included in theReport.

When the findings of the current report arecompared with those of the reports of 2009 and2010, a clear picture emerges. The NHFD issucceeding in its aim of improving hip fracturecare by supplying reliable data, achievablestandards, continuous feedback, and know-howto clinical teams. This enables them to reviewpractice, identify problems, and work together tomake changes that deliver measurable benefits interms of both the quality and cost-effectivenessof the care they provide for their patients.

The National Hip Fracture Database


The NHFD 2011 National Report:Main FindingsData completeness

In terms of the cases included in this report,overall data completeness is high. The totalnumber of data fields documenting the 53,443cases is 1,081,670, of which 998,435 (92.3%)were completed. However, certain important datafields – including those for mental state, ASAgrade, and place of residence at 30 days – wereless well completed. Future efforts will addressthis.

Case ascertainment levels (the ratio of casesreported by hospitals to the NHFD as a proportionof their estimated total hip fracture admissions)vary considerably, thus accounting for the factthat only around 76% of the total incidence of hipfracture in England, Wales and Northern Ireland isknown to the NHFD. Again, further work isrequired.

Casemix

The NHFD dataset records casemix in terms ofage, sex-ratio, place of residence prior to fracture,ASA grade (a measure of prior fitness), cognitiveability (determined by a simple test of mentalfunction), walking ability, and fracture type. Suchpatient characteristics are a major determinant ofthe outcome after hip fracture – for example, theoldest and most confused patients have a pooreroutlook; and younger, previously mobile patientsare most likely to be able to return home early.

Such data also makes possible casemix-adjustedcomparisons between hospitals serving differentpopulations, in order to compare more fairly suchimportant outcomes as return home at 30 daysand mortality at 30 days.

Over the three NHFD National Reports publishedin 2009 (64 hospitals; 12,983 cases), in 2010 (129hospitals; 36,556 cases), and in 2011 (176hospitals; 53,443 cases), the casemix of patientsdocumented has remained remarkably constant.However, in the 2011 report, the proportion ofpatients admitted from care homes has risenslightly – indicating a frailer patient group.


1. National-level improvements in carestandards

The NHFD measures care against the six Blue BookStandards for hip fracture care and secondaryprevention briefly described above:

• Admission within four hours to an orthopaedic ward (Blue Book Standard 1) aims to ensure that hip fracture patients have immediate access to the skills and resources of a specialist trauma unit. This diminishes delay and anxiety, reassures patients and carers, and makes prompt surgery more likely.

• Surgery within 48 hours and within normal working hours (Blue Book Standard 2) reduces the likelihood of subsequent complications, facilitates early rehabilitation and has a favourable impact on length of stay. The great majority of patients can, withgood co-operation between anaesthetists, geriatricians and surgeons, safely undergo surgery within that time.

• Good nursing care can minimise the risk of patients developing pressure ulcers following admission with hip fracture (Blue Book Standard 3). Since pressure damage – which can cause persistent pain and disability – is largely avoidable, meeting this standard adds greatly to the quality of care.

• Pre-operative assessment by an orthogeriatrician (Blue Book Standard 4) ensures that medical problems are identifiedearly and treated, minimising preoperative delay and increasing patient safety.

• Assessment and, where appropriate, treatment for osteoporosis (Blue Book Standard 5) can improve bone strength and thus help to reduce the risk of future fracture.

• Similarly, a falls assessment (Blue Book Standard 6) can identify and treat remediable factors that might contribute to future falls, which, along with osteoporosis, are the main risk factor for hip fracture.

It is clear from the summary table below, whichuses available relevant data from the 2009, 2010and 2011 NHFD National Reports, that successiveimprovements in compliance with the standardshave been achieved at a national level.

Note: in order to ensure comparability between2010 and 2011 data, calculations for the tablebelow have been made – as for the 2010 report –with the exclusion of ‘unknown’ data.


1. Admission to orthopaedic ward within 4 hours

2. Surgery within 48 hours

3. Patients developing pressure ulcers

4. Pre-operation assessment by an ortho-geriatrician

5. Discharged on bone protection medication

6. Receiving a falls assessment prior to discharge

N/A

75%

N/A

24%

N/A

44%

57%

80%

6%

31%

57%

63%

58%

87%

3%

37%

66%

81%

Standard 2009 2010 2011

Audit and change



2. Trend data in hospitals withestablished NHFD participation

In order to assess the longer term impact ofinvolvement with the NHFD, a group of 28hospitals with established NHFD participation andsustained high levels of case-reporting and datacompleteness was identified. The graph belowshows trends in six care quality indicators – surgery within 36 hours; surgery within 48 hrs;

orthogeriatrician assessment; bone protectionassessment; falls assessment; and 30-day mortality– tracked for 30,022 patients (9,547 from April2008-March 2009; 10,075 from April 2009-March 2010 and 10,400 from April 2010-March2011).

Hip fracture treatment: trends over timeApril 2008 − March 2011

12 Month Average

April 2008 −March 2009



0

10

20

30

40

50

60

70

80

90

100

●

●

●

● ● ●

●

●

●

●

●

●

●

●

●

●

●

●Bone therapy or assessment

Falls assessment

Surgery within 48 hours

Surgery within 36 hours

Pre−operative assessment by geriatrician

Mortality at 30 days

Data taken from 30,022 patients from 28 hospitals with good data completion and case ascertainment over the period 1st April 2008− 31st March 2011

% o

f pat

ient

s

All six indicators show improvement over the three-year period. In statistical terms, these improvementswere highly statistically significant. (For further details, see the full report, p 51-56)

This analysis demonstrates clearly the value of committed audit participation to clinical teams seeking toimprove both process and outcome. It should also be noted that those hospitals in the group eligible forthe Best Practice Tariff (i.e. the 27 English hospitals) achieved BPT standards at an average level of 44%compared with the national figure of 31%.

3. NHFD participation and theimprovement of care – good practice examples

Most participating hospitals have set out to usetheir NHFD data and other NHFD resources toaddress a range of issues relating to hip fractureaudit and care. These range from audit datacollection and clinical topics relating to the BlueBook standards to ambitious service redesignprogrammes – often with a dramatic impact oncare and outcomes. Examples include:

Data collection

• When the Basingstoke and North HampshireHospital began participating in the NHFD in October 2009, the clinical team set out to ensure that the standards of data collection and follow-up were high. A&E staff supply reliable data on time of transfer. Theclerking pro-forma for hip fracture patients includes the NHFD dataset for acute care. ASA grades, routinely recorded in thetheatre IT system, are supplied by e-mail. 30-day follow-up achieving 90% return rates is based on a postal questionnaire, which offers also multidisciplinary clinic follow-up at around six weeks.

Pre-operative delay

• A multi-disciplinary, multi-specialty team atKingston Hospital, London, used NHFD dataon care process and outcomes to planservice developments. A full-time ortho-geriatrician service was introduced inFebruary 2010. This, together with closercollaboration between surgeons andanaesthetists, reduced time to surgery from41 to 30 hours.

• At Good Hope Hospital, Sutton Coldfield, NHFD data showed that waiting times forsurgery were higher for patients admittedon a Friday, Saturday or Sunday. The casewas made for an extra trauma list at theweekend, and when this was providedmean waiting times fell from 53 to 37 hours

Orthogeriatrician input

• Frenchay hospital, Bristol, used NHFD data to make the case for increased ortho-

geriatrician staffing and the appointment ofa trauma coordinator. A strongmultidisciplinary team provides both acutecare and rehabilitation in the trauma wards.Service changes resulted in a reduction in average time to theatre from 36 to 24hours, and a fall in average length of stay offive days. 30-day mortality has also beenreduced, from 12% to 8%.

Secondary prevention

• A Fracture Liaison Service (FLS) offers ‘systematic assessment of patientspresenting with fracture for osteoporosis toreduce their future fracture risk’. Building onthe work of the Glasgow FLS, whichsucceeded in reducing hip fractureadmissions by 7.3% over the period 1998-2008, Queen Elizabeth Hospital, Woolwich,introduced a FLS that offers a consultantosteoporosis clinic and – in addition to oralmedication – a nurse-led IV bisphosphonateservice. Hip fracture patients are recruitedvia FLS nurse visits to orthopaedic wards.The service has greatly improved therecognition and treatment of osteoporosis,and audit follow-up has demonstratedimpressively high levels of compliance withmedication – at 84%

Service redesign

• In a five-month project – beginning in November 2010 and using ‘Lean Thinking’problem-solving methodology – patients,carers and the whole clinical team in Torbayworked to redesign the entire hip fractureclinical pathway in order to deliver prompt,patient-focused, cost-effective care. Inresponse to an early alert from paramedics,a clinical trauma coordinator now escortsthe patient from ambulance to X-ray, thento the theatre complex for optimisation andpreparation for same-day or next-morningsurgery. Post-operative care has beenimproved by better pain control, earliermobilisation and coordinated dischargeplanning. Average time to theatre has been



reduced from 48 to 16 hrs; and acutelength of stay from 10 to 7 days. Paincontrol has improved, complications arefewer, substantial efficiency savings havebeen achieved through reduced length ofstay, and patient satisfaction is high.

• In Wansbeck and North Tyneside hospitals, Northumbria, a quality improvementprogramme for hip fracture care began inOctober 2009. A multidisciplinary steeringgroup, with support from the Kings Fund,has worked to improve care from admissionthrough to discharge. Pain control hasimproved, with 79% of patients receiving anerve block, on admission. 90% of patientsnow have surgery within 36 hours; 25% ofmedically fit patients are mobilised on theday of surgery, and 100% the following day.With the help of newly appointed nutritionassistants, 81% of patients now receiveadditional feeding. At Wansbeck GeneralHospital, 30-day mortality has improvedfrom 11.7% to 7.7%.

Achieving the Best Practice Tariff

• When the best practice tariff was introduced in April 2009, clinicians atIpswich hospital used NHFD data tobenchmark their performance against thatnecessary to achieve BPT standards and toidentify the changes needed in their service.Initially the optimisation of trauma lists andadditional care of elderly input resulted in a15% increase in patients having surgerywithin 36 hours; then a business case wasmade for the funding of joint protocols andcare, with daily care of elderly ward rounds.A three-month trial was agreed on the basisof potential BPT gains and length of stayreduction. NHFD data verified its success,and the funding was made permanent. In Ipswich 75% of hip fracture patients nowmeet the standards for the Best PracticeTariff.

• In a series of developments over several years clinicians and managers at DudleyHospitals have developed a specialisedservice for hip fracture patients that nowachieves high standards of care. UsingNHFD audit data and the clinical standards

set out in the Blue Book, the clinical teamhas delivered over the period 2004-2010both substantial reductions in acute lengthof stay (from 34 to 23 days) and a steadilyrising proportion of patients dischargeddirectly home (from 50% to 64%) Thesedevelopments ensured that the service waswell prepared to address the challenges ofBest Practice Tariff; within 10 months of itsintroduction in April 2010, the care of 82%of hip fracture patients treated in DudleyHospitals achieved all the BPT standards.


4. The Best Practice Tariff and itsimpact on care

The NHFD, with its care standards and its detaileddocumentation of casemix, care and outcomes,prompted the selection of hip fracture as a topicfor the Department of Health’s Best Practice Tariff(BPT) initiative, which offers additional paymentfor cases the care of which meets agreedstandards (surgery within 36 hours; joint care bysurgeon and geriatrician; care protocol agreed bygeriatrician, surgeon and anaesthetist;pre/perioperative assessment by geriatrician;geriatrician-led multi-disciplinary rehabilitation;secondary prevention including falls and bonehealth assessment) that are monitored by theNHFD.

From April 2010, when BPT – which applies onlyin England – began, participation has increasedquarter by quarter, with steadily rising numbers ofhospitals with cases meeting the tariff standards(from 92-118); and of the numbers of casesmeeting the tariff standards (from 2254 to 4645).

It appears that the implementation of BPT inEngland has served to promote interest, betterresourcing, service improvement, and betteroutcomes in hip fracture care.


Qtr 1

Qtr 2

Qtr 3

Qtr 4

158

160

161

161

92(58%)

103(64%)

112(69%)

118(73%)

9333

11751

13093

12672

2254(24%)

3247(28%)

4460(34%)

4645(37%)

0 – 81%

0 – 74%

0 – 82%

0 – 87%

Eligiblehospitals

Hospitalsachieving

BPT

Number ofpts

submitted

Number of ptsachieving

BPT Range



CHE DER KGH KMH LER LIN NTH PIL UHN

East Midlands

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

CHE DER KGH KMH LER LIN NTH PIL UHN

Hospital

Per

cent

age

020

4060

8010

0

ADD BAS BED BFH COL HIN IPS JPH LDH LIS NOR PAH PET QEW QKL SEH WAT WSH

East of England

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

ADD BAS BED BFH COL HIN IPS JPH LDH LIS NOR PAH PET QEW QKL SEH WAT WSH

Hospital

Per

cent

age

020

4060

8010

0

Best Practice Tariff – achievement by SHA


BNT BRO CCH CHS GEO GWH HIL HOM KCH KTH LEW LON MAY NMH NWG OLD RFH SHC STH STM WES WHC WHT WMU

London

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

BNT BRO CCH CHS GEO GWH HIL HOM KCH KTH LEW LON MAY NMH NWG OLD RFH SHC STH STM WES WHC WHT WMU

Hospital

Per

cent

age

020

4060

8010

0

ASH DAR DRY NTG NTY QEG RVN SCM STD SUN

North East

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

ASH DAR DRY NTG NTY QEG RVN SCM STD SUN

Hospital

Per

cent

age

020

4060

8010

0



AEI BLA BOL BRY CMI COC FAZ FGH LGH MAC MRI NOB RLI RLU RPH SHH SLF SOU TRA VIC WCI WIR WYT

North West

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

AEI BLA BOL BRY CMI COC FAZ FGH LGH MAC MRI NOB RLI RLU RPH SHH SLF SOU TRA VIC WCI WIR WYT

Hospital

Per

cent

age

020

4060

8010

0

HOR IOW MKH NHH QAP RAD RBE SGH SMV WEX

South Central

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

HOR IOW MKH NHH QAP RAD RBE SGH SMV WEX

Hospital

Per

cent

age

020

4060

8010

0


CGH DGE DVH ESU FRM KSX MAI MDW QEQ RSC RSU SPH STR WHH WRG

South East Coast

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

CGH DGE DVH ESU FRM KSX MAI MDW QEQ RSC RSU SPH STR WHH WRG

Hospital

Per

cent

age

020

4060

8010

0

BAT BRI CHG FRY GLO MPH NDD PGH PLY PMS RCH RDE SAL TOR WDH WGH YEO

South West

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

BAT BRI CHG FRY GLO MPH NDD PGH PLY PMS RCH RDE SAL TOR WDH WGH YEO

Hospital

Per

cent

age

020

4060

8010

0



BRT EBH GHS HCH NCR NUN QEB RED RSS RUS SAN SDG STO TLF UHC WAR WRC

West Midlands

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

BRT EBH GHS HCH NCR NUN QEB RED RSS RUS SAN SDG STO TLF UHC WAR WRC

Hospital

Per

cent

age

020

4060

8010

0

BAR BRD BSL DEW DID GGH HAR HRI HUD LGI NGS PIN ROT SCA SCU YDH

Yorkshire and the Humber

Hospital

Per

cent

age

020

4060

8010

0

Q1 Q2 Q3 Q4

BAR BRD BSL DEW DID GGH HAR HRI HUD LGI NGS PIN ROT SCA SCU YDH

Hospital

Per

cent

age

020

4060

8010

0


0 100 200 300 400 500 600 700

020

4060

80

Number of cases

Ret

urn

hom

e fr

om h

ome

at 3

0 da

ys (

%)

BLA

CMI

COLDID

EBH

FAZ

FRY

HUD

MAC MOR

NCR

NEV

NTG

NUN

PGH

PIL

PIN

PLY

QAP

QEG

SCM

SUN

VICWAR

WHH

WAT

BRDNHH

RSU

SMV

WRG

RawStandardisedAverage95% TI99.8% TI

Casemix adjusted outcomes:Funnel plot for return home from home at 30 days

This analysis shows the rate of return home by 30 days of patients admitted from home or shelteredhousing. Cases with unknown residential status at 30 days are excluded and, since only 74% of patientsare admitted from home or sheltered housing and 30-day follow-up reporting is generally poor, only16,592 cases are included.

The overall rate of return home by 30 days is 43.3%. The three most important predictors of returnhome are age, ASA grade, and walking ability; and these provide the basis for the casemix adjustmentshown here.

Determinants of rate of return home are clearly complex, and include: the effectiveness of in-hospitalrehabilitation; the availability of community rehabilitation; and the provision of specialist early supporteddischarge schemes – all of which vary greatly across the country. There is also some evidence that readyaccess to downstream beds may result in longer overall hospital stay, and hence lower the rate of returnhome by 30 days. Together, these factors may account for the high degree of variance displayed here.

Note: in order to include 30 day follow up, this and the mortality analysis are based on cases admittedbetween 1st March 2010 and 28th February 2011.

Please see Appendix C of the full report for list of excluded hospitals



0 200 400 600 800

05

1015

20

Number of cases

Mor

talit

y at

30

days

(%

)

BFH

BOL

DER

DVH

KTH

NORRDE

RED

RVB

SHH

STR

UHC

WRG

BAS SPH

WHC

RawStandardisedAverage95% TI99.8% TI

Funnel plot for mortality at 30 days

This analysis is based on 45,741 cases from hospitals with case ascertainment of 80% and above. Thelatter provision serves to minimise, but cannot entirely eliminate, the impact on the analysis of the under-reporting of cases with perhaps a high mortality; the possible effect of this in disadvantaging hospitalswith 100% case ascertainment must therefore be borne in mind.

Overall, 30-day mortality is 8.4%. The two most important predictors of mortality are ASA grade andage, and these, with others, provide the basis for the casemix adjustment displayed here.

As will be seen, standardisation for casemix may shift hospital mortality rates either way. Six hospitalshave standardised rates outside the upper 95% tolerance interval, with one of these outside the 99.8%tolerance interval. As noted in Appendix E on outlier management (Page 102 of the full report), furtherclose scrutiny of relevant data is necessary, and further analysis of casemix, care and mortality in thesehospitals is likely to provide information helpful in improving care.

Please see Appendix C of the full report for list of excluded hospitals


Limitations of the ReportThe 2011 NHFD National Report describes somesubstantial advances in the care of hip fracture,but – as frankly acknowledged – further work isrequired. Ideally, a national clinical audit wouldacquire complete data on all cases occurring, butthe NHFD is still some way from achieving this.The 53,443 cases included in this report representonly around 76% of the estimated total of c.70,000 cases presenting to the hospitalsregistered. Case ascertainment currently variesgreatly by hospital, from 19% upwards.

At case level, incomplete reporting persists, mostnotably in the reporting of ASA grades and AMTSscores (both of which are casemix factors stronglypredicting outcomes); and in 30-day follow-up,which varies by hospital from 0% to 100%missing. To acknowledge this, and for the firsttime in a NHFD National Report, the proportion ofmissing data in various fields is represented bywhite insertions in the horizontal bars in thecharts in the full Report.

As a result of the problem of missing data, thecasemix-adjusted reporting of two key outcomes –30 day mortality and particularly 30-day returnhome – must be regarded as indicative rather thanconclusive. In the case of return home, the datareported is frankly incomplete by reason of thecurrently limited 30-day follow-up data. In thecase of mortality – although deaths and thetiming of deaths are reliably reported from centralsources – incomplete case reporting by hospitalsmay under-report hospital mortality, thus skewingthe average; and hospitals submitting 100% ofcases may as a result appear to be performing lesswell.

The consequences of this for outlier identificationand management are obvious, and due cautionshould be exercised in the interpretation of thesecharts; and, while outlier identification andmanagement is described in Appendix E of the fullreport and is now being implemented, the NHFDwill continue to support and encourage higheroverall levels of data completeness.

NHFD: the futureAt a time of impending funding pressures for theNHS, the influence the NHFD demonstrates inimproving quality while reducing costs should bewelcomed; and the costs of NHFD – both centrallyand in the collection of data at hospital level – canbe fully justified. Both care and secondaryprevention are improving, with the cost of care –of which length of stay is the principal component– in a number of hospitals appearing to fall. Thehumane and economic benefits of secondaryprevention, potentially substantial, are still to befully realised.

To sustain and improve the role of the NHFD inimproving care, the goal of improving datacompleteness at hospital and case level will bepursued via NHFD regional meetings and dataworkshops for those directly involved in collectingdata.

The potential of using NHFD data to improve theevidence base for hip fracture care has beenrecognised, and the NHFD Scientific andPublications Committee is currently engaged inevaluating risks possibly associated with the use ofcemented arthroplasties; examining the problemof atypical fracture possibly associated withbisphosphonate use; and in using trend andcomparative data to evaluate the contribution ofortho-geriatrician input to care. An evaluation ofthe impact of the introduction of the Best PracticeTariff is currently at the planning stage.

The NHFD will continue in its present form until itscurrent funding ends in March 2012. Alreadyunder discussion is a continuation of its work inpartnership with the current RCP Falls and BoneHealth Audit. The new audit, covering both fallsand fragility fractures, would continue to developthe work of the NHFD, with possible broadeningof its scope to other fragility fractures, and anenhanced capacity to address through sprintaudits a closer scrutiny of process issues, includingthose relating to the important topic of secondaryprevention, which – as the Glasgow FractureLiaison Service has demonstrated – cansubstantially reduce the incidence of hip fracturein the target population.



Appendix A - Participating hospitals

Addenbrooke's Hospital, Cambridge ADDAirdale General HospitalAlexandra Hospital, Redditch REDAltnagelvin Area Hospital ALTArrowe Park Hospital, Wirral WIRBarnet Hospital BNTBarnsley Hospital BARBasildon University Hospital BASBassetlaw Hospital BSLBedford Hospital BEDBirmingham Heartlands EBHBradford Royal Infirmary BRDBristol Royal Infirmary BRIBronglais Hospital, Aberystwyth BRGBroomfield Hospital BFHCentral Middlesex Hospital, LondonCharing Cross Hospital CCHChase Farm Hospital CHSChelsea and Westminster Hospital WESCheltenham General Hospital CHGChesterfield Royal Hospital CHEColchester General Hospital COLConquest Hospital, Hastings CGHCountess of Chester Hospital COCCounty Hospital, Hereford HCHCraigavon Hospital, PortadownCumberland Infirmary, Carlisle CMIDarent Valley Hospital, Dartford DVHDarlington Memorial Hospital DARDerbyshire Royal Infirmary, Derby DERDerriford Hospital, Plymouth PLYDewsbury & District Hospital DEWDiana Princess of Wales Hospital, Grimbsy GGHDoncaster Royal Infirmary DIDDorset County Hospital, Dorchester WDHEaling HospitalEast Surrey Hospital, Redhill ESUEastbourne Hospital DGEFairfield Hospital, Bury BRYFrenchay Hospital, Bristol FRYFrimley Park, Camberley FRMFurness General Hospital, Barrow-in-Furness FGHGeorge Eliot Hospital, Nuneaton NUNGlan Clwyd Hospital, RhylGloucestershire Royal Hospital, Gloucester GLOGood Hope Hospital, Birmingham GHSGrantham and District HospitalGwynnedd Ysbyty, Bangor GWYHarrogate District Hospital HAR

Hillingdon Hospital HILHinchingbrooke Hospital HINHomerton Hospital, London HOMHope Hospital, Salford SLFHorton Hospital, Banbury HORHuddersfield Royal Infirmary HUDHull Royal Infirmary HRIIpswich Hospital IPSJames Cook University Hospital,Middlesbrough SCMJames Paget University Hospital,Great Yarmouth JPHJohn Radcliffe Hospital, Oxford RADKent and Sussex Hospital, Tunbridge Wells KSXKettering General Hospital KGHKing's College Hospital, London KCHKing's Mill Hospital, Sutton in Ashfield KMHKingston Hospital KTHLeeds General Infirmary LGILeicester Royal Infirmary LERLeighton Hospital, Crewe LGHLincoln County Hospital LINLister Hospital, Stevenage LISLuton and Dunstable Hospital LDHMacclesfield General Hospital MACMaelor Hospital, Wrexham WRXMaidstone Hospital MAIManchester Royal Infirmary MRIManor Hospital, Walsall Mayday University Hospital, London MAYMedway Maritime Hospital MDWMilton Keynes General Hospital MKHMorriston Hospital, Swansea MORMusgrove Park Hospital, Taunton MPHNevill Hall Hospital, Abergavenny NEVNew Cross Hospital, Wolverhampton NCRNewham General Hospital, London NWGNobles Hospital, Isle of Man NOBNorfolk and Norwich University Hospital NORNorth Devon District Hospital, Barnstaple NDDNorth Hampshire Hospital, Basingstoke NHHNorth Manchester General HospitalNorth Middlesex University Hospital NMHNorth Tyneside General Hospital,North Shields NTYNorthampton General Hospital NTHNorthern General Hospital, Sheffield NGSNorthwick Park Hospital, LondonPeterborough District Hospital PET

Indicates inclusion in this report n = 176; indicates participating in NHFD but not submittingsufficient data to be included in report n = 15.


Pilgrim Hospital, Boston PILPinderfields General Hospital, Wakefield PINPoole General Hospital PGHPrince Charles Hospital, Merthyr Tydfil PCHPrincess Elizabeth hospital, Guernsey PEHPrincess of Wales Hospital, BridgendPrincess Royal Hospital, Telford TLFPrincess Royal University Hospital, Bromley BROQueen Alexandra Hospital, Portsmouth QAPQueen Elizabeth Hospital, Birmingham QEBQueen Elizabeth Hospital, Gateshead QEGQueen Elizabeth Hospital, King's Lynn QKLQueen Elizabeth Hospital, Woolwich GWHQueen Elizabeth II Hospital, Welwyn QEWQueen Elizabeth the Queen Mother Hospital,Margate QEQQueens Hospital, Burton upon Trent BRTQueen's Hospital, Romford OLDRotherham District General Hospital ROTRoyal Albert Edward Infirmary, Wigan AEIRoyal Berkshire Hospital, Reading RBERoyal Blackburn Hospital BLARoyal Bolton Hospital BOLRoyal Devon & Exeter Hospital, Exeter RDERoyal Free Hospital, London RFHRoyal Glamorgan Hospital, Llantrisant RGHRoyal Gwent Hospital, NewportRoyal Hampshire County Hospital, WinchesterRoyal Lancaster Infirmary RLIRoyal Liverpool University Hospital RLURoyal Oldham Hospital OHMRoyal Preston Hospital RPHRoyal Shrewsbury Hospital RSSRoyal Surrey County Hospital, Guildford RSURoyal Sussex County Hospital, Brighton RSCRoyal United Hospital, Bath BATRoyal Victoria Hospital, Newcastle RVNRoyal Victoria Hospital.Belfast RVBRussells Hall Hospital, Dudley RUSSalisbury District Hospital SALSandwell General Hospital SANScarborough General Hospital SCAScunthorpe General Hospital SCUSouth Tyneside District Hospital,South Shields STDSouthampton General Hospital SGHSouthend Hospital SEHSouthport District General Hospital SOUSt George's Hospital, London GEOSt Helier Hospital, Carshalton SHCSt Peter's Hospital, Chertsey SPHSt Richard's Hospital, Chichester STRSt Thomas' Hospital, London STHSt. Hellier Hospital, Jersey SHJSt. Mary's Hospital, Isle of Wight IOW

St.Mary's Hospital, Paddington STMStafford Hospital SDGStepping Hill Hospital, Stockport SHHStoke Mandeville Hospital, Aylesbury SMVSunderland Royal Hospital SUNTameside General Hospital, Manchester TGAThe Great Western Hospital, Swindon PMSThe Princess Alexandra Hospital, Harlow PAHThe Royal Cornwall Hospital, Treliske RCHThe Royal London Hospital LONTorbay District General Hospital TORTrafford General Hospital, Manchester TRAUlster Hospital, Belfast NUHUniversity College Hospital LondonUniversity Hospital, Nottingham UHNUniversity Hospital Aintree FAZUniversity Hospital Coventry UHCUniversity Hospital of North Durham DRYUniversity Hosp. of North Staffordshire,Stoke-on Trent STOUniversity Hospital of North Tees,Stockton on Tees NTGUniversity Hospital of Wales, Cardiff UHWUniversity Hospital, Lewisham LEWVictoria Hospital, Blackpool VICWansbeck Hospital ASHWarrington Hospital Warwick Hospital WARWatford General Hospital WATWest Cumberland Hospital, Whitehaven WCIWest Middlesex University Hospital,Isleworth WMUWest Suffolk Hospital, Bury St. Edmunds WSHWest Wales General Hospital, Carmarthen WWGWeston General Hospital,Weston-Super-Mare WGHWexham Park Hospital, Slough WEXWhipps Cross University Hospital WHCWhiston Hospital, Prescot Whittington Hospital, London WHTWilliam Harvey Hospital, Ashford WHHWithybush Hospital, Haverford West WYBWorcestershire Royal Hospital, Worcester WRCWorthing Hospital WRGWythenshawe Hospital, Manchester WYTYeovil District Hospital YEOYork Hospital YDH



Acknowledgements:

NHFD participants: clinical and audit staff in all contributing hospitals

British Geriatrics Society


Department of Health

Dr. Richard Keen, Metabolic Bone Unit, Royal National Orthopaedic Hospital

Healthcare Quality Improvement Partnership

National Clinical Audit Advisory Group

NHS Information Centre

Quantics Consulting Ltd

Abacus Print Limited


The National HipFracture DatabaseNational Report 2011 - Summary

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

In partnership with:

Need to know more?Contact:NHFD Headquarters:British Geriatrics SocietyMarjory Warren House31 St. John’s SquareLondon EC1M 4DN

Tel: 020 7251 8868

Project Manager - Maggie PartridgeEmail: [email protected]: 07876 163 525

Project Coordinator (South) - Andy WilliamsEmail: [email protected]: 07818 065915

Project Coordinator (North) - Fay PlantEmail: [email protected]: 07792 213369


nhfd national report 2011-summary:layout 1 national report 2011-summary.pdfbritish orthopaedic...

Documents