the national hip fracture database: uk experience in improving quality of care and outcomes
DESCRIPTION
Colin Currie, Clinical Lead (Geriatrics), The National Hip Fracture Database, UK delivered this presentation at the 2012 Hip Fracture Management conference in Australia. The only regional event to discuss practical innovations and improvement processes for the management of hip fractures in the hospital setting. For more information on the annual conference, please visit the website: http://bit.ly/14lcuVYTRANSCRIPT
Hip Fracture Management Conference
Novotel on Collins, Melbourne
3-4 December 2012
The National Hip Fracture DatabaseUK experience in improving care quality and outcomes
Colin Currie
Clinical Lead (Geriatric Medicine)
National Hip Fracture Database
Outline
• Hip fracture: the tracer condition for the current
epidemic of fragility fractures
• The National Hip Fracture Database: using the
synergy of standards, audit and feedback
• Impact of NHFD on care quality and outcomes
• The wider impact of a national clinical audit
Hip fracture
“The most common serious –
and the most serious
common – injury of older
people”
The tracer condition for the
current epidemic of fragility
fractures
Projected hip fractures worldwideProjected hip fractures worldwide
Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-9
Projected to reach 3.250 million in Asia by 2050
1990 2050
600
3250
1990 2050
668
400
1990 2050
742
378
1990 2050
10
0
629
Total number ofhip fractures:1990 = 1.66 million 2050 = 6.26 million
The fragility fracture careerThe fragility fracture career
Morbidity
50 60 70 80 90
Colles' fracture
Vertebral fracture
Hip fracture
Age
No fractures –increasing morbidity due to ageing alone
Added morbidity from fractures
AgeAdapted from Kanis JA, Johnell O; 1999
DH Falls & Bone Health Commissioning Toolkit 2009
19 December 2012
Objective 1: Improve outcomes and
improve efficiency of care after hip
fractures – by following the 6 “Blue Book” standards
Hip fracture patients
Objective 2: Respond to the first
fracture, prevent the second – through Fracture Liaison Services in acute and primary care
Non-hip fragility fracture patients
Objective 3: Early intervention to restore
independence – through falls care pathway linking acute and urgent care services to secondary falls prevention
Individuals at high risk of 1st fragility fracture or other injurious falls
Objective 4: Prevent frailty, preserve
bone health, reduce accidents –
through preserving physical activity, healthy lifestyles and reducing environmental hazards
Older people
Hip fracture – the patient experience
• A major life-event
• Recovery of mobility often limited
• Mortality high
• Loss of home much dreaded – and fairly common
Hip fracture – the patient experience
f r om
Hospital 16 (n= 444)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 11 21 31 41 51 61 71 81 91 101 111
120 days post admission
home
Residential Care
Long Term Care
other
ger rehab
Acute Ward
Orthopaedic Department
Died
Physiotherapy Primary Care
Nursing A&E Radiology
Supported Discharge OccupationalTherapy
Geriatric Medicine Anaesthetics
Social Management RehabilitationServices
G.P.Labs Portering
Orthopaedic SurgeryOrthopaedic Surgery
Hip fracture care – who’s involved?Hip fracture care – who’s involved?
CarersCarers
Hip fracture – service implications
• 30 years ago – an unwelcome and burdensome
caseload
• Now a major surgical, medical and rehabilitation
challenge
• Resource-intensive – amid growing service
pressures
• Service response much improved!
Hip fracture – a suitable case for audit?
• Common, serious, well-defined injury
• Good evidence base for care – and prevention
• Care is complex and costly
• Care, outcomes – and costs – vary
• Numbers rising as populations age
• Hip fracture care the central challenge of current global fragility fracture epidemic
Hip fracture audit: a brief history
• 1980’s onwards: ‘Rikshoft’ (Sweden)
– European bilaterals
– Scottish Hip Fracture Audit (1993-2010)
– Standardised Audit of Hip Fracture in Europe (SAHFE)
– Growing numbers of single-centre audits
• 2007 UK National Hip Fracture Database (NHFD)
– using the synergy of audit, standards and benchmarked feedback to improve care and outcomes
• 2011/12 International interest – and action! (Australia,
NZ, Ireland, Canada?)
National Clinical Governance for Hip Fracture Care: Scotland
The UK National Hip Fracture Database
• A clinically-led, web-based, continuous audit of hip fracture care and secondary prevention in England, Wales, and Northern Ireland
• Using the synergy of audit, standards and feedback to improve care and outcomes
• Valued by clinicians and managers, and by the Departments of Health
• Successive national reports show improvements in care and secondary prevention
www.nhfd.co.uk
Development: 2004-2007
• Strategic vision and ruthless acquisition/
plagiarism• Dataset from Rikshoft, SHFA, SAHFE etc
• IT from Myocardial Infarction National Audit Project (MINAP)
• Soft money and hard work• Industry funding (via national organisations) 2004-2009
• Committees large and small• To consult – and implement
• Making friends and influencing people• Media, meetings, lobbying, etc
Blue Book and NHFD: launched together in 2007
Progress: the NHFD 2007-2012
• NHFD launched – Sept. 2007
• Recognised by NCAAG in 2009 for funding by
HQIP as a national clinical audit
• Steady growth towards national coverage
• National reports: 2009, 2010, 2011, 2012
• Growing impact on care and outcomes
• International interest – and action!
Six Blue Book standards – monitored by NHFD
1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation
2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, during normal working hours
3. All patients with hip fracture should be assessed and cared for with a view to minimising the risk of developing a pressure ulcer
4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from the time of admission
5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures
6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls
Six Blue Book standards – why comply?
• Compliance with these standards
– raises quality in hip fracture care
– and reduces its costs!
• Cost and quality not in conflict
• ‘Looking after hip fracture patients well is cheaper than looking after them badly’
NHFD Reports: 2008-2011
12,983 records from 64 hospitals
36,556 records from 129 hospitals
NHFD National Report 2012
www.nhfd.co.uk
NHFD coverage: November 2012
• 188/188 (100%) of eligible hospitals registered
• 187/188 (99.5%) submitted data in the last three
months
• 228,000+ records submitted since launch
• c. 5000 records submitted per month (c. 95+%
of all eligible hip fractures – based on c. 65,000
p.a.)
The NHFD: audit and change
• Improving compliance with Blue Book standards
• Local use of audit for service change
• Trend data: 28 hospitals, 2008 – 2011
• Implementing Best Practice Tariff
Compliance with Blue Book standards: 2009-12
Standard 2009 2010 2011 2012
1. Admission to orthopaedic ward
within 4 hours
N/A 55% 56% 52%
2. Surgery within 48 hours and during
working hours
75% 80% 87% 83%
3. Patients developing pressure
ulcers
N/A 6% 3.7% 3.7%
4. Pre-operative assessment by an
orthogeriatrician
24% 31% 37% 43%
5. Discharged on bone protection
medication
N/A 57% 66% 69%
6. Received a falls assessment prior
to discharge
44% 63% 81% 92%
NHFD: audit and change locally
Hospital-level initiatives
• NHFD offers current, credible local data on workload and service performance
• Such data can prompt and monitor local initiativesagreed by clinicians and managers
• Many substantial improvements: e.g. reduced time to theatre, length of stay, mortality and service costs
Wansbeck and N. Tyneside
• Quality improvement programme: NHFD data; Kings Fund support – addressing whole care pathway
– Pain control improved (79% of patients get nerve block on admission)
– 95% have surgery within 36 hours
– 100% mobilise on first post-op day if medically fit
– Systematic feedback from patients and families consistently averages >9.3/10
St Peters Hospital, Chertsey
• Two orthogeriatricians appointed; quality initiative on hip
fracture care pathway (2010)
• In 2012, 60% of patients have surgery within 24 hours,
80% within 36 hours
• Length of stay reduced from 25 to 22 days, with
considerable efficiency savings
• 60% of patients discharged to original residence within
25 days, compared with 44% within 30 days in 2010
Chelsea and Westminster Hospital
• Meeting in May 2011 recognises hip fracture care as sub-optimal
• Changes include dedicated trauma theatre sessions, thrice-weekly ortho-geriatrician ward rounds, and weekly discharge planning rounds
• In-patient mortality reduced from 11% to 9%
• Average acute length of stay down from 24 to 19.5 days, with estimated savings of £91,000
Trend data: 2008-2011
• 28 hospitals– Early and sustained NHFD participation
– Good case ascertainment, data completeness
– 30,022 cases (1st April 2008 to 31stMarch 2011)
– Time to theatre, orthogeriatrician involvement, secondary prevention, mortality
Trend data: 2008-2011
Trend data: 2008-2011
Trend data: 2008-2011
Trend data: 2008-2011
Trend data: 2008-2011
Trend data: 2008-2011: the main points
• Overall mortality reduced by 15%!(binomial test p-value <0.001)
• Association with/impact of care process factors? – Ortho-geriatrician input? Time to theatre? Other?
• Further analysis pending
The Best Practice Tariff for hip fracture care
• A DoH initiative, based on NHFD participation
• Enhanced case-by-case payment if clinically
determined care standards met
– Surgery within 36 hours
– Joint care, joint protocol: surgeon, anaesthetist,
orthogeriatrician
– Early involvement of orthogeriatrician in care
– Multi-disciplinary rehabilitation
– Bone health, falls assessments
Best Practice Tariff: the first two years
Audit and change: how does it work?
• NHFD offers:
– the synergy of audit, standards and continuous feedback– a website providing key documents and literature database– helpdesk and supportive central staff – regional meetings – national reports
• ‘Together, these measures have succeeded in creating a critical mass of enthusiasm and expertise in hip fracture care…’*
*NHFD 2011 Summary Report on www.nhfd.co.uk
Progress in hip fracture care?
• NHFD and the Blue Book
– the synergy of audit, feedback and standards
• National-level evidence of:
– rising care standards
• Large-series evidence of:
– lower mortality
– associated with orthogeriatric care?
Progress in hip fracture care?
• Local evidence of:
– better care and outcomes
– lower costs too
• BPT a recent and effective incentive
– with double effect?
• ‘Looking after hip fracture patients well is
cheaper than looking after them badly’(Blue Book on the care of patients with fragility fracture)
Towards cost-effective care?
The length of acute + post-acute
Trust stay has fallen from 21.2 to
20.2 days over 2011-2012: a £14M
efficiency saving?
The length of acute + post-acute
Trust stay has fallen from 21.2 to
20.2 days over 2011-2012: a £14M
efficiency saving?
More effort required?
• Better documentation of longer-term care & outcomes– post-acute care
– mobility
– place of residence
• Sprint audits– ASAP in development
– other?
• Health economics– cost-effective care?
More progress in hip fracture care?
• Without audit, clinical standards are simply aspirational
• As a national clinical audit of hip fracture care, the NHFD has demonstrated the synergy of audit and standards in improving care
• NHFD has the potential to monitor compliance with the NICE Quality Standards
NHFD & the NICE Quality Standards for Hip Fracture
NHFD & the NICE Quality Standards for Hip Fracture
Monitoring compliance with NICE standards
The percentage of arthroplasties that are performed using a cemented prosthesis has risen from 63% in 2010 to 73% in 2012
The percentage of arthroplasties that are performed using a cemented prosthesis has risen from 63% in 2010 to 73% in 2012
NHFD & the NICE Quality Standards for Hip Fracture
NHFD & the NICE Quality Standards for Hip Fracture
• NHFD has the potential to monitor compliance with (some of) the NICE Quality Standards…
…and measure any impact on care and outcomes?
DH Falls & Bone Health Commissioning Toolkit 2009
19 December 2012
Objective 1: Improve outcomes and
improve efficiency of care after hip
fractures – by following the 6 “Blue Book” standards
Hip fracture patients
Objective 2: Respond to the first
fracture, prevent the second – through Fracture Liaison Services in acute and primary care
Non-hip fragility fracture patients
Objective 3: Early intervention to restore
independence – through falls care pathway linking acute and urgent care services to secondary falls prevention
Individuals at high risk of 1st fragility fracture or other injurious falls
Objective 4: Prevent frailty, preserve
bone health, reduce accidents –
through preserving physical activity, healthy lifestyles and reducing environmental hazards
Older people
The Falls and Fragility Fractures Audit Programme (FFFAP)
Element 1: continuation of the NHFD
(NHFD Workstream)
Element 2: feasibility study for a prospective database of non-hip fragility fractures (the FLSDB) in year 1
(FLSDB Workstream)
Element 4: audit of falls in care settings – pilot study in year 1
(Falls pathway Workstream)
Element 3: sprint audits – to be determined
(NHFD Workstream)
Element 5: intermittent spotlight audits – to be determined
(Falls pathway Workstream)
Hip fracture audit: an international opportunity?
• A common language for casemix, care and outcomes –to address the central challenge of current global fragility fracture epidemic?
• Now a mature technology – clinically led & user-friendly – that can improve quality and cost-effectiveness* in hip fracture care?
• A platform for regional, national and international research collaboration?
*Quality and cost-effectiveness not in conflict – because ‘looking after hip fracture patients well is cheaper than looking after them badly’.
International hip fracture audit: an emerging reality?
NHFD: a mature technology in a wired-up world
• Growing international interest – meetings etc: 2007 to date
• Emergent NHFD-based national hip fracture audits in 2012: – Australia
– New Zealand
– Ireland
– Canada?
• Further action via the international Fragility Fracture Network?
Acknowledgements
• Prof K-G Thorngren & Rikshoft
• SHFA colleagues
• Dave Marsh, Professor of Orthopaedic Surgery, RNOH, Chair/Co-chair, NHFD; Finbarr Martin, Co-chair, NHFD; Rob Wakeman, Lead Clinician, Orthopaedic Surgery, NHFD; Maggie Partridge, Project Manager, NHFD; NHFD Project Coordinators
• NHFD Steering Group, Dataset Sub-group, & Scientific and Publications Committee
• BOA & BGS
• Dept of Health and HQIP
• Blue Book Authorship Group
• Colleagues in NCASP/CCAD/NHS IC
• Quantics Consultancy
• Patients & staff in participating hospitals
www.nhfd.co.uk