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

Abstract

Objectives Despite established standards and guidelines, substantial variation remains in the delivery of hip fracture care across the United Kingdom. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the months following hip fracture. Methods We examined a national record-linkage cohort of 178,757 patients aged ≥60 years who sustained a hip fracture in England and Wales in 2016–19. Patient-level hospital admissions datasets, National Hip Fracture Database and mortality data were linked to metrics from 18 hospital-level organisational-level audits and reports. Multilevel models identified organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality and emergency 30-day readmission. Results Across hospitals mean LOS ranged from 12 to 41.9 days, mean 30-day mortality from 3.7 to 10.4% and mean readmission rates from 3.7 to 30.3%, overall means were 21.4 days, 7.3% and 15.3%, respectively. In all, 22 organisational factors were independently associated with LOS; e.g. a hospital’s ability to mobilise >90% of patients promptly after surgery predicted a 2-day shorter LOS (95% confidence interval [CI]: 1.2–2.6). Ten organisational factors were independently associated with 30-day mortality; e.g. 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 (95%CI: 5–15%). Nine organisational factors were independently associated with readmissions; e.g. readmissions were 17% lower if hospitals reported how soon community therapy would start after discharge (95%CI: 9–24%). Conclusions Receipt of hip fracture care should be reliable and equitable across the country. We have identified multiple, potentially modifiable, organisational factors associated with important patient outcomes following hip fracture.

Complex organisational factors influence multidisciplinary care for patients with hip fractures: a qualitative study of barriers and facilitators to service delivery

“…This study examined organisational processes that help or hinder the implementation of key components of hip fracture services. It echoes evidence of the multiple organisational factors affecting patient outcomes [ 27 ] and complements existing guidelines, providing information about strategies to achieve effective hip fracture care in daily clinical practice. Based on these findings, a set of recommendations have been generated on how to deliver effective hip fracture care (Table 5 ), which may help hospitals to design and implement effective services to improve patient care.…”

“…Our findings highlight strategies to ensure their consistent use in the ED. This is timely, given recent evidence indicating nerve block use pre-surgery is associated with reduced length of hospital stay [ 27 ]. The value of coordinated, multidisciplinary discharge planning, daily discharge reviews and shared information systems between hospital and community settings is also emphasised.…”

Patients’ recovery of mobility and return to original residence after hip fracture are associated with multiple modifiable components of hospital service organisation: the REDUCE record-linkage cohort study in England and Wales

“…Individuals who feel they are informed members of a multidisciplinary team are motivated to provide higher quality patient care [28]. We have previously shown greater provision of pre-operative nerve blocks (usually femoral or fascia-iliaca) -which reduces opiate analgesic use and associated side effects [29] -is associated with shorter lengths of hospital stay [30]; here we add an increased likelihood of patients being back home at 120 days to the associated benefits. These findings support the NHFD key performance indicator (KPI-0) encouraging the prompt provision of local anaesthetic nerve blocks during admission [31].…”

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

“…Furthermore, there are currently national FLS registries at various stages of development in Australia and New Zealand ( 391 , 392 ), Ireland ( 393 ), the UK ( 394 ), and USA ( 395 ). Several “real-world” evidence from the UK National Hip Fracture Database and Best Practice Tariff for hip fracture care have provided valuable insights ( 396 – 398 ). In Italy, the “real-world” monitoring changes and assessing impact of the new guidelines will be made possible by the “Italian Fragility Fracture Observatory,” a structure recently founded for bridging the gap between health institution and academy in generating knowledge ( 399 ) in the field of fragility fractures.…”