Towards a ANZ Hip Fracture Registry“Quality Care Costs Less”

Hip fractures due to fallsMales and females, Australia 1999-2007

0100200300400500600700800900

1999–00 2000–01 2001–02 2002–03 2003–04 2004–05 2005–06 2006–07

Year of separation

Age-standardised rate

Males Females

Source: Bradley C. 2011. Hospitalisations due to falls by older people, Australia 2006–07. Injury research and statistics series no. 56. Cat. no. INJCAT 132. Australian Institute of Health and Welfare, Canberra.

Fragility hip fracture rates by year, WA, 1999-2009

Average yearly change: Indigenous, +6.9% (95%CI 2-12%) vs non-Indigenous, -3.6% (95%CI 3-4%)

Falls and fracture care and preventionA road map for a systematic approach

Hip fracture patients

Objective 1: Improve outcomes and improve efficiency of care after hip fractures

Non-hip fragility fracture patients

Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care

Individuals at high risk of 1st fragility fracture or other

injurious falls

Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention

Older peopleObjective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards

Stepwise implementation - based on sizeof impact

1. DH Prevention Package for Older People

Falls and fracture care and preventionA road map for a systematic approach

Hip fracture patients

Objective 1: Improve outcomes and improve efficiency of care after hip fractures

Non-hip fragility fracture patients

Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care

Individuals at high risk of 1st fragility fracture or other

injurious falls

Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention

Older peopleObjective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards

Stepwise implementation - based on sizeof impact

1. DH Prevention Package for Older People

High volume, high costEvidence around model/s of care

Evidence of clinical variation in practiceEvidence of sub-optimal care

Evidence that data can be used to drive change

Inter-professional collaboration 2004-2007

Six Blue Book standards – monitored by NHFD

1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation

2. All patients with hip fracture if medically fit should have surgery within 48 hours of admission, during normal working hours

3. All patients with hip fracture should be assessed and cared for to minimise risk of a pressure ulcer

4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from admission

5. All fragility fracture patients should be assessed for need of antiresorptive therapy to prevent future osteoporotic fractures

6. All fragility fracture patients should be offered multidisciplinary assessment and intervention to prevent future falls

UK NHFD Reports: 2008-2011

Individual reports for 26 hospitals

Analysis on 12,983 records from 64 hospitals

Analysis on 36,556 records from 129 hospitals

Analysis on 53,443 records from 176 hospitals

2011 - ALL eligible hospitals registered 191/191

2011 National Hip Fracture Database ReportKey metrics

NHFD 2011 National Report. Available from www.nhfd.co.uk

Surgery within 36 hours Pre-op medical assessment Acute Length of Stay

Three-year trend data: 30,022 patients from 28 hospitals

Binomial test p-value <0.001 for all trends; average mortality at 30 days fell from 9.4% to 8%.

Registry

National Guidelines

Quality Indicators

PolicyModels of CareSafety & QualitySystem Redesign

Training / Education

Resourcing models of careLocal training /

support

Consumer Manifesto

Implementing best practiceMeasuring

performance

National Steering Group

States and Territories LHDs Hospitals

National Hip Fracture Database• Employs 4 people and now funded by DOH• Now has got 189 of 191 hospitals sending data

(England, Wales, Northern Ireland)• Annual reporting since 2008

– 2008: ? patients from 26 hospitals– 2009: 12,983 patients from 64 hospitals– 2010: 36,556 patients from 129 hospitals– 2011: 56,000 patients from 176 hospitals

82% of predicted hip fractures

National Hip Fracture Database

• Total hip fracture records = 137,933

– Reports process indicators and case-mix adjusted outcomes (e.g. 30 day mortality)

– All hospitals identified in reports

Best Practice Tariff

Best Practice Tariff• Aims

– To reduce unexplained variation in quality– To universalise best practice

• Key indicators– Surgery within 36 hours– Involvement of Geriatricians

• Balanced Scorecard for Hip Fractures

BPT - Payment

• All criteria must be met• Tariff

– Reduced previous average payment by 10%– If criteria met – get old payment + extra– Extra = £445

• If doing 300 / yr = £134,000 = $270,000 per yr• From 2011: £890 = £267,000 = $530,000 per yr• Enough to allow investment in change, improvement

and data collection

How System Works

Local Hospital

National Hip Fracture Database

Commissioners

Pay additional funds quarterly

Provide NHI and individual patient data

Notify BPT compliance

Importance of “trust” in each segment of system

So why have a registry?

• Improve patient outcomes– Death, dependency and institutionalisation

• Safety and quality– e.g. timely and appropriate interventions

• Reduce inequalities– Local organisational, rural remote

• Driver for organisational change• Use the data to shape practice• Undertake additional research

Australia and New Zealand Hip Fracture Database

• Inaugural Meeting October 2011• Working Group Established• Strong support from HQSC – NZ & Aust• Professional Societies• OA NZ & Aust

Progress with a National Registry

• Auditing at facility level – NSW, NZ, WA• Piloting at patient level in NSW• WA/CMDHB have started electronic database• Guidelines and quality indicators to be

completed in 2012• Consumer manifesto – 2012• Conversations re build and operation of a

national database

Progress

• NZ Workshop planned May 2012 led by HQSC, NZ with NZ stakeholders participating

• (ACC, MOH, NHB, IT board, CNBU)

Discussion

• Thank you