A hip fracture is the most common serious injury for older people. For many people, it will bring to mind their experiences of an elderly relative who fractured their hip after a period of declining health and repeated falls. The average age of people who break their hip is 83 years old – three-quarters are women, one-in-five live in residential care and many have other health problems.
As a fracture nurse explained to me once, “a hip fracture is not about bones”.
A hip fracture is often linked to frailty: a consequence of declining strength and physical reserve as well as a major trauma that can itself cause further decline. People who fracture their hip require acute and rehabilitative care from a wide range of professionals across hospital and community services. Their experiences can tell us about how well emergency services provide care for older people, and how well care is coordinated inside and outside hospital.
How research can help improve hip fracture care
Some of the problems with care after hip fracture, such as limited access to help around the home, reflect the low political priority given to social care of older people. But there is also a role for research. There are many aspects of hip fracture care where evidence on effects of different treatment options is lacking or inconclusive. Similarly, research could help to identify more effective ways to coordinate care across teams and services.
The National Hip Fracture Database (NHFD) contains nearly half a million records with details of clinical care provided to people after hip fracture. As well as providing information to help teams understand and improve their care, this provides a valuable research resource that health professionals and researchers can apply to use. For example, a recent study using this database highlighted inequalities in access to total hip replacement surgery after hip fracture, raising concerns about inconsistent compliance with NICE recommendations.
Likewise, we have just published a paper focusing on one of the key drivers of local improvement: the involvement of geriatricians in hip fracture care. Orthogeriatricians have specialist medical knowledge of how to treat older people with fractures and work alongside orthopaedic surgeons, anaesthetists, nurses and physiotherapists, to provide prompt surgery and active rehabilitation and minimise risks and complications. Our research found that patients treated in departments with higher numbers of geriatrician hours tended to have lower mortality in the 30 days after arrival at hospital.
Many of the benefits of geriatrician involvement translate to acute care of frail older people with other conditions, an area of work that the Nuffield Trust is currently exploring.
Some problems are harder to solve
Providing good hip fracture care can be difficult and not all hospitals manage to do it well. For example, providing prompt and safe surgery as a routine standard of care is an organisational challenge. It requires coordination between A&E and orthopaedic departments, planning and flexibility in the scheduling of trauma and elective orthopaedic surgery and timely input from a mix of professionals.
Nationally, the proportion of patients who have surgery within 36 hours of arrival at hospital is 72.1 per cent. This compares to just over half of patients in 2007. Sharp improvements after 2007 suggest that the combination of national clinical standards, audit and financial incentives introduced since then have made a difference. But improvement has stalled since 2012 and the rate decreased slightly over 2016.
There is also persistent wide variation in adherence to this standard between hospitals in England – the proportion ranges from 29.1 per cent to 95.3 per cent. At the Nuffield Trust, we are currently carrying out analyses to try to identify organisational factors that influence performance against this and other clinical standards, which could inform efforts to improve and standardise care.
Community care poses another challenge. Around one in five people who fracture their hip are transferred from the acute hospital to a community hospital for a period of further rehabilitation. Of people who were living independently beforehand, many move into residential care after a hip fracture. However, the historic and persistent divides between health and social care often prevent the effective coordination of rehabilitative care. These are compounded by cuts to community health and social care budgets that contribute to delays in transfers and long waits for community physiotherapy.
The scarcity of data on community health and social care limit the scope for research to evaluate different ways of providing rehabilitative care.
In addition, the difficulty of capturing follow-up information on people’s mobility, wellbeing and independence can encourage a focus on more easily measured outcomes such as mortality and hospital readmission. This can result in undervaluation of services such as physiotherapy, volunteer support and befriending schemes that are designed to improve outcomes that are intangible or difficult to measure, but which are important to individuals.
To make further improvements to hip fracture care, there is a need for good quality data on care provided outside hospital and long-term outcomes. The NHFD are encouraging hospital teams to engage with rehabilitation and community services and monitor patients’ progress by collecting data at 120 days. The NHFD 2016 report gives examples of some local teams that are linking hospital and community services to help patients get home more quickly and continue their rehabilitation at home.
About our research
Our research is looking at improvements to hip fracture care in England by combining data from different sources to examine national policy, local improvement and individual care. This research is being carried out in collaboration with the London School of Hygiene & Tropical Medicine, the Royal College of Surgeons of England and the National Hip Fracture Database audit team. The work is funded by the National Institute for Health Research.
The full findings of Jenny’s latest study into the impact of orthogeriatricians in improving outcomes for hip fracture patients were published as a journal article in Age and Ageing.