Update on the National hip fracture database in the UK

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Update on the National hip fracture database in
the UK
ExMex Fragility Fractures EFORT 2009 - Vienna

• David Marsh
• Professor of Clinical Orthopaedics, University
  College LondonRoyal National Orthopaedic
  Hospital
• Co-chair, NHFD Executive
• International Ambassador for the Bone and Joint
  Decade

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Outline

• The NHFD
• Purpose and origins
• Progress in implementation
• Influence on government strategy
• Commissioning guidance to improve fragility
  fracture services

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Hip fracture challenge

• Dramatic increases in
• Numbers of geriatric patients with hip fractures
• Age of these patients (older old people)
• Medical complexity and mortality rates
• Demand for more cost-effectiveness

Geriatric co-management can reduce mortality,
delay to surgery, length of stay and improve
functional outcome
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Two linked initiatives

• BOA BGS Blue Book on the Care of Patients with
  Fragility Fractures
• National Hip Fracture Database

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Four big messages Multidisciplinary approach to
the management of fragility fracture
patients Reliable secondary prevention
osteoporosis falls Chronic disease model
Quality assurance the NHFD
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BOA-BGS Blue Booksix standards for hip fracture
care

• All patients with hip fracture should be admitted
  to an acute orthopaedic ward within 4 hours of
  presentation
• All patients with hip fracture who are medically
  fit should have surgery within 48 hours of
  admission, during normal working hours
• All patients with hip fracture should be assessed
  and cared for with a view to minimising their
  risk of developing a pressure ulcer
• 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
• All patients presenting with fragility fracture
  should be assessed to determine their need for
  antiresorptive therapy to prevent future
  osteoporotic fractures
• All patients presenting with a fragility fracture
  following a fall should be offered
  multidisciplinary assessment and intervention to
  prevent future falls

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The NHFD Project- jointly led by BOA and BGS

• Measures compliance with Blue Book standards
• A web-based national database, aiming to include
  every UK fracture unit
• Rikshoft ? Scottish Hip Fracture Audit ? NHFD
• Includes secondary prevention
• Feed back to units their performance compared to
  national diagnosis of limiting factors
• Extensile for research

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Implementation so far

• 150 fracture units registered on NHFD(out of 200
  in England, Wales and Northern Ireland)
• 96 currently entering data
• 31,000 records so far
• First annual report released
• Adopted by UK Dept of Health for fundingas a
  national clinical audit

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NHFD Goals

• To change the behaviour of health workers who
  look after patients with fragility fractures
• Prompt multidisciplinary care
• Reliable secondary prevention
• To change the attitude of healthcare providers
  and commissioners to musculoskeletal
  medicine/surgery
• Raise fragility fractures, especially hip
  fractures, up the agenda
• To provide a platform for clinical research
• to improve surgical methods, medical care,
  rehabilitation, models of care

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The NHFD dataset

• Casemix
• Age distribution
• Gender distribution
• ASA
• Domicile
• Process
• The six standards
• Outcome
• 30-day mortality
• 30-day home from home
• Secondary prevention

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Determinants of 30-day mortality (order of effect
in this dataset) Age group Gender Domicile P
recise age Walking ability Precise
age Gender
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Casemix-adjustment

• For each fracture unit, expected outcome
  calculated
• by multiplying the number of patients in each
  category by the national mortality rate for the
  category and summing across all the categories
• Adjusted outcome for each hospital
• calculated by multiplying the national rate by
  the ratio of observed to expected outcome for the
  hospital

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30-day mortality
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Process time to theatre
Direct comparison with data from the Audit
Commission report of 2000, applying the same
criteria - percentage of patients having their
operations within 48hrs has fallen from 82 to
69. Operations on dedicated trauma lists
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First Annual Report, May 2009

• Well-received by clinicians and managers
• Acknowledged limitations in completeness and
  quality of the data
• Now government funded to tackle these properly

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DoH falls and fractures commissioning toolkit

• Co-chairs
• Finbarr Martin, President-Elect of BGSActing
  National Clinical Director for Older Peopleand
  co-chair of NHFD
• Keith Willett, Professor of Trauma,
  OxfordNational Clinical Director for Trauma
• Standards-dependent commissioning
• To be launched end of June, as major part of
  drive to improved services to the elderly

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UK Department of Health commissioning guidance
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Political progresscatalysed by the NHFDTop-down
and bottom-up

• Commissioning guidance top-down
• Regional advocacy
• NHFD, NOS, Help the Aged
• British Orthopaedic Directors Society
• Various local initiatives
• Regional teams built on orthopaedic and geriatric
  champions

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Regional goals

• 1. Universal participation in the National Hip
  Fracture Database
• 2. Establishment of a Fracture Liaison Service in
  every UK hospital
• 3. Pro-active case-finding of unassessed
  fragility fracture patients across primary care
• 4. Links to falls services

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Extended role of NHFD

• Feedback to drive up standards
• Website providing tools for change
• examples of best practice
• templates for systems, job descriptions etc
• Platform for clinical research
• thromboprophylaxis

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Summary

• Alliance between orthopaedics and geriatrics is
  powerful - clinically and politically
• Hip fracture management is the best area in which
  to build the alliance and get the ear of
  government
• The NHFD is designed to drive
• Clinical improvement prompt surgery, secondary
  prevention
• Smart commissioning, with mandatory standards,
  linked to remuneration
• Innovative, multidisciplinary thinking is
  essential to survive the pressures we now face