Title: REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study
Funder: Versus Arthritis

Abstract: Each year in the UK approximately 80,000 older adults fracture a hip, incurring £1.2 billion in direct medical costs alone and conveying a 30% 1-year mortality and a 22% reduction in quality-of-life. Fracture services are provided through complex multidisciplinary organisational structures. Despite UK standards and guidelines, we and others have shown substantial variation in hospital delivery of hip fracture care, potentially reflecting local organisational legacies and lack of commissioning expertise. Nationally we see wide variation in hip fracture outcomes between hospitals (e.g. mortality, functional recovery, requirement for institutionalised care); whilst in part explained by patient-level risk factors, we hypothesize that organisational factors are responsible for unwarranted variation in fracture care pathways and hence patient outcomes. Understanding sources of variation in care delivery (i.e. healthcare access), its effects on patient outcomes (i.e. inequity), permits service-level interventions to reduce unwarranted variation, maximise health equity and ultimately improve patient experience. Across 173 hospitals in England and Wales (2011-18), we will analyse National Hip Fracture Database (NHFD), Hospital Episodes Statistics (HES) and Office for National Statistics (ONS) mortality data, all linked at the patient-level, together with multiple organisational-level audits which characterise each service providing care to patients with hip fractures. We will quantify organisational capacity to manage fragility fractures, including delivering of emergency, orthopaedic, orthogeriatric, anaesthetic, nursing, and rehabilitation services. Statistical analyses, using multi-level models, we will identify which organisational factors are responsible for the greatest variation in patient outcomes (e.g. death, length of hospital stay, osteoporosis treatment, hospital readmissions) and which typify care pathways with high-quality consistent outcomes. Health Cost analyses will calculate NHS resource, in the year following hip fracture, attributable to organisational factors. Qualitative Interviews with staff from hospitals providing high and low levels of quality fracture care will identify barriers and facilitators to fracture care delivery, as will Documentary Analysis of British Orthopaedic Association hospital-initiated peer-review reports. Our system-wide understanding will then inform development of an Implementation Toolkit in partnership with key national stakeholders, to overcome organisational barriers when commissioning and implementing sustainable high-quality fracture services. Findings will empower hospital managers and healthcare providers to make the changes needed in health services commissioning by: 1. Identifying sources of unwarranted variation in the quality of hip fracture care 2. Quantifying the costs of service delivery of high quality care 3. Developing a new step-by-step guide (‘Implementation Toolkit’) This proposal is novel in terms of its scale and the unique datasets which gives us a rare opportunity to robustly assess what is a complex system of care and the very real impacts this system has on patients. Findings will inform future commissioning/ service planning priorities for hip fracture care, provide reports for every hospital in England and Wales outlining their strengths and vulnerabilities, inform national review processes for hip fracture services and together with a new Toolkit, which will be maintained by the National Osteoporosis Society beyond the duration of this grant, this programme will minimize avoidable variation in fracture care and improve the quality of care for patients across the UK.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: INJURIES AND ACCIDENTS;MUSCULOSKELETAL