Optimising the In-Hospital Management of Hip Fracture Using the Irish Hip Fracture Database

Abstract

Hip fracture can have a devastating impact on older adults as it is associated with reduced life expectancy, loss of independence and poorer quality of life. Each year in Ireland approximately 3,600 patients experience a hip fracture, most commonly due to a low-impact fall in their own home. These are a vulnerable cohort of patients with a mean age of 81 years and a high degree of comorbidity and frailty. Not only is hip fracture costly in terms of the human cost involved, but with a mean length of stay of 17 days in the acute hospital, it has a considerable impact on healthcare utilisation. Our challenge is to optimise the management of hip fracture so patients can rehabilitate to their pre-fracture state and live independently.

We are fortunate in Ireland to have the Irish Hip Fracture Database, a high-quality database that captures hip fracture cases in adults over 60 years of age across all 16 trauma units in the Republic of Ireland. Currently, over 25,000 hip fracture cases are recorded and this rich data source allows the most influential points of care in the patient journey to be identified. The Irish Hip Fracture Standards are the evidenced-based gold standards of care against which Irish services are benchmarked. In turn, these standards are linked to a Best Practice Tariff system, which rewards hospitals financially for each case that is managed in keeping with all 9 standards.

The research in this thesis centred on three core aspects of hip fracture care; mortality, discharge destination and financial costs. The first paper sought to identify the determinants of in-hospital mortality and demonstrated that older males with poor pre-fracture mobility who were not mobilised on the day of/after surgery had the highest risk of in-hospital mortality. This finding led to the addition of a new formal standard of care to the Irish Hip Fracture Standards with an associated best practice tariff, in keeping with international best practice.

The second paper identified inherent differences between those discharged directly home following hip fracture as opposed to discharged to an alternative location, both in terms of patient characteristics and care pathway. The results of the analysis demonstrated that younger patients independently mobile prior to fracture, who received timely surgery and early post-operative mobilisation were more likely to be discharged home directly. The Irish Hip Fracture Standards incorporate 2 out of the 3 modifiable factors identified, which reinforces the importance of these National standards in improving patient outcomes. The third paper quantified the cost of hospitalisation for hip fracture in Ireland in terms of bed days and direct hospital costs. For the time period 2014-2020, the total cost of hospitalisation for 23,494 cases in the Irish Hip Fracture Database was approximately €296 million, equating to €11,700 per episode of care. In 2020, the mean length of stay for hip fracture was 17 days, which accounted for >62,600 acute hospital bed days. This paper provided up-to-date robust data on the impact of hip fracture on healthcare utilisation, which will facilitate efficient health service planning and aid the delivery of cost-effective patient care.

The most important take-home message from the research presented is that early post-operative mobilisation is one of the most influential modifiable factors for improving patient outcomes. Not only does it reduce the risk of dying in-hospital but it also increases the likelihood of being discharged home directly from hospital. Furthermore, early mobilisation confers a cost benefit as patients mobilised early in the post-operative period are more likely to have a shorter length of stay in the acute hospital, which is a key driver of the costs of hip fracture care. Looking to the future, the Irish Hip Fracture Database will expand to include long-term outcomes such as survival at 1 year and health related quality of life. Internationally, the Irish Hip Fracture Database will continue to collaborate with the global Fragility Fracture Network to develop a minimum common dataset for hip fracture registries. This will serve as an accepted framework for monitoring and improving hip fracture services worldwide.