Using data to improve care
Hip fracture is the most serious and costly fall-related injury suffered by older people; therefore, collecting patient- and facility-level data is important for improving outcomes in hip fracture management.
In 2016, there were approximately 22 000 hip fractures in Australia with a combined direct and indirect cost of $908 million. Projected figures for Australia have this number rising to 30 000 by 2022 and costing just over $1 billion.
The impact of a hip fracture on the individual is huge, with approximately five per cent dying in hospital, more than 10 per cent newly discharged to an aged care facility, more than half having ongoing issues with mobility over 12 months post-injury, and 15–20 per cent dying in the year after discharge.
Despite this massive cost to the individual, their families and society, research shows that provision of effective secondary care after fracture (eg, osteoporosis and falls assessment and management) is not routinely provided.
In September 2014, the Australian and New Zealand Hip Fracture Registry (ANZHFR) released the NHMRC-endorsed ANZ Guideline for Hip Fracture Care: Improving Outcomes in Hip Fracture Management of Adults. This guideline was designed to assist both clinicians and health managers to provide a high-level of care to people admitted with a fractured hip. Establishment of this guideline enabled the development of a bi-national Hip Fracture Care Clinical Care Standard, which was released in September 2016.
The ANZHFR collects individual patient- and facility-level data from hospitals across the two countries. Comparative reports highlight performance against the Australian Commission on Safety and Quality in Health Care and the Hip Fracture Care Clinical Care Standard, and provides opportunities for facilities to identify the areas of hip fracture care that they do well, and other areas that may need review and redesign.
In December 2016, the APA highlighted the role of the Hip Fracture Care Clinical Care Standard in an article in InMotion titled ‘A new standard of hip fracture care’. The standard aims to ensure that people admitted to hospital with a fracture of the femur neck are provided with high-quality and safe care throughout their hospital stay and during their transition from hospital to the community. The standard also aims to prevent further fractures by the implementing an individualised falls prevention program, and bone health assessment and management plan.
Many of the data that is needed for hospitals to assess their care are not readily collected through existing administrative datasets. The ANZHFR has been designed to align with both the guideline and the standard and enables hospitals that collect registry data to evaluate care against them.
The ANZHFR patient-level audit includes the following information:
- patient details—demographic information
- admission—where the patient has come from, time in the emergency department and the admission ward
- assessment—patients’ pre-admission walking ability, pain assessment and management, cognitive assessment, bone medications on admission, who conducted the preoperative medical assessment, fracture side, atypical fracture and fracture type
- treatment—information relating to surgery, use of a nerve block, pressure injuries, geriatric medicine assessment, specialist falls assessment and bone medication at discharge
- discharge—acute and overall hospital date, destination and length of stay
- follow up—date it occurred, survival, confirm discharge date, place of residence, weight bearing, walking ability, bone medication and reoperation within 30 days.
The ANZHFR website has a host of information, including resources for patients, their carer’s and healthcare professionals, and the registry annual reports. Also on the website is a demonstration site that allows you to explore the functions of the registry by signing up for a demonstration account.
ANZHFR’s 2018 annual report includes facility-level data from all 116 public hospitals in Australia and New Zealand that operate on people with hip fracture, as well as two private hospitals. There were also 56 hospitals contributing patient-level data, up from 34 the previous year. All New Zealand hospitals and 83 per cent of Australian hospitals are identified in the report.
In their foreword to the report, co-chairs of the ANZHFR Steering Group, Professor Jacqueline Close and Professor Ian Harris, identified the hope that this will allow clinicians from all professions to see their own data, be able to celebrate and share local successes, and use the data at a local level to drive change where required.
What can you do if you want to improve the care of patients with hip fracture?
- If you work in a facility that operates on patients with hip fracture, contact your site lead and ask how you can get involved (contact ANZHFR if you need to find out who that is).
- Log on to the website (anzhfr.org), obtain a demonstration account and check out the functions of the registry or look through the healthcare professional’s resources.
- Ensure your at-risk patients have a falls management plan and bone management plan in place.
- If you are interested in research in this area talk to the multidisciplinary team you work with about how you might use the data to improve care for older people who have broken their hip.
- If your hospital is not listed as participating in the ANZHFR, convene a multidisciplinary stakeholder group to investigate getting on-board. Based on experience from other countries, establishing a multidisciplinary stakeholder group at the outset helps achieve successful implementation of the ANZHFR at a hospital.
A stakeholder group may include representatives from medicine (eg, geriatrician or general physician), surgery (eg, orthopaedics), nursing and allied health, anaesthetists, emergency physicians, rehabilitation specialists and fracture liaison coordinators. At a site, a local clinical lead (principal investigator) and site coordinator (associate investigator) need to be identified. These two people will be responsible for data quality and governance, and implementation of the ANZHFR at the hospital. Additional associate investigators may be included, and these people may represent supporting departments within the hospital.
To contribute patient-level data to the ANZHFR, hospitals need to have both ethics and governance/locality approval. Data collection is ongoing from the date of governance/locality approval. To commence the approval process, contact the ANZHFR.
Brett Baxter, APAM, is the APA Representative on the ANZHFR Steering Group. He has been the clinical team leader in orthopaedic physiotherapy at the Princess Alexandra Hospital since 2000 specialising in orthopaedic trauma and elective physiotherapy.
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