REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study

Abstract

IntroductionSubstantial variation in the delivery of hip fracture care, and patient outcomes persists between hospitals, despite established UK national standards and guidelines. Patients’ outcomes are partly explained by patient-level risk factors, but it is hypothesised that organisational-level factors account for the persistence of unwarranted variation in outcomes. The mixed-methods REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE) study, aims to determine key organisational factors to target to improve patient care.Methods and analysisQuantitative analysis will assess the outcomes of patients treated at 172 hospitals in England and Wales (2016–2019) using National Hip Fracture Database data combined with English Hospital Episodes Statistics; Patient Episode Database for Wales; Civil Registration (deaths) and multiple organisational-level audits to characterise each service provider. Statistical analyses will identify which organisational factors explain variation in patient outcomes, and typify care pathways with high-quality consistent patient outcomes. Documentary analysis of 20 anonymised British Orthopaedic Association hospital-initiated peer-review reports, and qualitative interviews with staff from four diverse UK hospitals providing hip fracture care, will identify barriers and facilitators to care delivery. The COVID-19 pandemic has posed a major challenge to the resilience of services and interviews will explore strategies used to adapt and innovate. This system-wide understanding will inform the development, in partnership with key national stakeholders, of an ‘Implementation Toolkit’ to inform and improve commissioning and delivery of hip fracture services.Ethics and disseminationThis study was approved: quantitative study by London, City and East Research Ethics Committee (20/LO/0101); and qualitative study by Faculty of Health Sciences University of Bristol Research Ethics Committee (Ref: 108284), National Health Service (NHS) Health Research Authority (20/HRA/71) and each NHS Trust provided Research and Development approval. Findings will be disseminated through scientific conferences, peer-reviewed journals and online workshops.

Model of multidisciplinary teamwork in hip fracture care: a qualitative interview study

“…Purposive sampling was used to identify study sites,26 with variation in geography, number of hip fracture presentations per year, service configuration and audited hip fracture outcomes 27. Three hospitals were urban and one rural.…”

“…Purposive sampling was used to identify study sites, 26 with variation in geography, number of hip fracture presentations per year, service configuration and audited hip fracture outcomes. 27 Three hospitals were urban and one rural. One hospital admitted a large number (>75th percentile), and three moderate (between 25th and 75th percentiles) numbers of patients with hip fracture annually.…”

Multiple hospital organisational factors are associated with adverse patient outcomes post-hip fracture in England and Wales: the REDUCE record-linkage cohort study

“…Publicly available hospital/trust provider-level data were extracted from 18 national audits, data series or ratings [ 12 ], generating 231 organisational factors, characterising each stage of the hip fracture care pathway from admission to discharge ( Table S1 ). We used a systematic approach, as previously described [ 12 ], to categorise organisational factors that could potentially be associated with patient outcomes. Firstly, we mapped each factor to one or more of 14 a priori defined hip fracture care domains by stakeholder consensus (see Supplementary Methods) [ 12 ].…”

“…We used a systematic approach, as previously described [ 12 ], to categorise organisational factors that could potentially be associated with patient outcomes. Firstly, we mapped each factor to one or more of 14 a priori defined hip fracture care domains by stakeholder consensus (see Supplementary Methods) [ 12 ]. Each organisational-level factor was mapped as potentially relevant to one or more patient outcomes by expert consensus [ 12 ].…”

“…Firstly, we mapped each factor to one or more of 14 a priori defined hip fracture care domains by stakeholder consensus (see Supplementary Methods) [ 12 ]. Each organisational-level factor was mapped as potentially relevant to one or more patient outcomes by expert consensus [ 12 ]. Secondly, each factor was assigned to one overarching theme (pre-, peri-, post-op, governance or workload).…”