1 Introduction

This chapter discusses the importance and utility of registry data to improve the care of fragility fracture patients. It focuses upon hip fracture because, as the most common serious fracture, it is the tracer condition for the current pandemic of osteoporotic fractures, and because the evidence base for care is good and hip fracture registries are now well established. The chapter aims to help the reader understand the importance of registry participation and the use of registry data at the hospital, national, and international levels to drive improvements in the quality, effectiveness, and cost-effectiveness of care.

2 Overview of registries for osteoporotic fracture care and their current and future impact

Hip fracture is the most common serious osteoporotic fracture. It is well defined anatomically. Its presentation is acute and normally results in hospital admission. Hip fracture care costs are high, and care quality and patient outcomes vary greatly. Hip fracture care is therefore an ideal subject for clinical audit and has been implemented at local, national, and international levels since the mid-1980s. Over time, an audit has often helped to raise the quality of care [1].

In contrast, nonhip osteoporotic fractures are less well defined, more variable in their presentation, and may, as in the case of vertebral fractures, be clinically silent. The evidence base for the care of such fractures is generally less robust than that for hip fracture. For these reasons, a large-scale audit of nonhip osteoporotic fractures is challenging, and no such audits could be identified in a recent literature search. For the purposes of this brief chapter, the focus is on hip fracture registries and hip fracture care; the terms audit, register, and registry are regarded as interchangeable.

Hip fracture is increasingly acknowledged as the tracer condition for the rapidly growing challenge of osteoporotic fracture care. As more orthopedic trauma units are able to deliver high-quality hip fracture care as a result of audit participation, they now deploy the skills, expertise, and systems that can meet the care and rehabilitation needs of frail older adults with the full range of nonhip osteoporotic fractures. This “halo effect” is a beneficial and welcome result of rising standards in hip fracture care.

Large-scale hip fracture audits began with the Swedish Rikshoft register [2], launched in 1989. Generously supported by Rikshoft expertise and technology, both the Scottish Hip Fracture Audit [3] and the multinational Standardized Audit of Hip Fracture in Europe (SAHFE) project [4] followed in the 1990s. A third national audit, the UK National Hip Fracture Database (NHFD) [1], drew on Swedish and Scottish experience and was developed from 2004 as a collaboration between the British Orthopaedic Association (BOA) and the British Geriatrics Society (BGS). The NHFD incorporated continuously reported feedback technology derived from a National Health Service (NHS) cardiac audit. This proved to be a considerable advance on the annual reports of the two national audits cited above. The NHFD was launched in 2007 alongside The Care of Patients with Fragility Fracture (ie, the Blue Book), also a BOA/BGS collaboration, with the NHFD monitoring compliance with the six consensus-derived clinical standards for hip fracture care set out in the Blue Book [5]. The following list shows the six standards monitored by NHFD. All patients:

1. 
   

   With hip fractures should be admitted to an acute orthopedic ward within 4 hours of presentation.

   
   
2. 
   

   With hip fractures that are medically fit should have surgery within 48 hours of admission, during normal working hours.

   
   
3. 
   

   With hip fractures should be assessed and cared for with a view to minimizing the risk of developing a pressure ulcer.

   
   
4. 
   

   Presenting with fragility fractures should be managed on an orthopedic ward with routine access to orthogeriatric medical support from the time of admission.

   
   
5. 
   

   Presenting with fragility fractures should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures.

   
   
6. 
   

   Presenting with fragility fractures following a fall should be offered multidisciplinary assessment and intervention to prevent future falls.

Since then, national hip fracture audits have been established successively in Norway [6], Denmark [7], Ireland [8], and Australia and New Zealand [9]—all essentially Rikshoft-derived, and incorporating datasets and clinical standards similar to those used in the NHFD. In Germany, an extensive national fragility fracture registry [10] includes key elements of hip fracture audit data compatible with NHFD standards 1–6 [11].

The rise of such large-scale hip fracture audits, and of similar local initiatives, can be seen as a rational response to the aging of populations and the consequent pressures on orthopedic services and healthcare delivery systems. In parallel, commendable surgical and industry interest in an injury once regarded as burdensome has led to the development of more reliable fixation methods and has also resulted in the rise of collaborative care, with geriatricians and other physicians becoming involved in nonsurgical aspects of the care of frail older adults [12, 13]. Importantly, major recent developments in information technology and internet communication have made data collection, transfer, and analysis all faster and cheaper, so that international collaboration has become easier and more cost-effective. Large-scale audits with high data quality and audit-based research with large prospective observational series and case-mix-adjusted outcomes, for example in anesthetic care, [14] are now possible.

Another major factor in the rise of effective hip fracture audits has been the increasing availability of guidelines. These have taken various forms. An early example is United They Stand: Coordinating care for elderly patients with hip fracture from 1995 [15]. The more formally evidence-based Scottish Intercollegiate Guideline Network guideline [16] Prevention and Management of hip fracture in older people followed in 2002 and was updated in 2009. More recently, the UK National Institute for Health and Care Excellence followed with Hip fracture: management (CG124) [17]. In the US, A Guide to Improving the Care of Patients with Fragility Fractures [18] covers both hip and nonhip fractures. Another recent US guideline adopted by the American Academy of Orthopaedic Surgeons Management of Hip Fractures in the Elderly focuses only on hip fracture care [19].

Clearly the nature of the gathered data greatly influences the effectiveness of a hip fracture audit. In general, the data must be sufficient in scope, volume, and quality to influence behavior and improve care. In most audits, the data need not, and will not, be of research quality, but it will serve its main purpose of quantifying and improving clinical care. The work of gathering, recording, and uploading audit data are a serious responsibility. Experience has shown that it is risky to rely on its casual delegation to voluntary or conscripted nursing staff or junior medical colleagues employed for other duties. Recruiting, training, and supporting competent and committed audit staff is essential.

A supportive approach pays dividends, and advancing technology, eg, offering drop-down definitions of data items, can contribute much. Regional data quality workshops, bringing together audit staff from a number of hospitals, have proved to be popular and effective in the case of the NHFD. Working alone or in pairs in participating units can be isolating, and for such staff peer support, exchanging views and troubles, and learning and lunching together serves to promote and maintain enthusiasm and to help people wanting to do a good job to do it better. The involvement of such staff, alongside clinicians, managers, and central audit staff, in the larger regional meetings described in the following topics serve to recognize their essential contribution to the wider effort.

Where nursing professionals are involved in data collection, professional standards apply inasmuch as to willfully enter false and misleading information about a patient could lead to a disciplinary process. Awareness of this might in itself deter such practice. In a few instances in the work of the NHFD, suspiciously low 30-day death rates prompted suspicions of the possible omission of poor prognosis patients, and these were checked by the use of nonaudit routine NHS data, ie, the Hospital Episode Statistics data, which records hospital admissions for hip fracture. Current NHFD advice on data quality assurance recommends that service lead clinicians check random monthly samples of records against data uploaded. Where sites have joint lead clinicians (eg, a surgeon and a geriatrician), data quality and performance standards are higher.

Issues arise in some jurisdictions where individual patient consent for inclusion in an audit is mandatory, and data completeness suffers accordingly. When it is accepted that a clinical audit is an integral part of good care, there are fewer problems. The cost of gathering specific data for audit at around GBP 80 per case, a negligible sum when compared to the price of care (“if you think information is expensive, try ignorance”), when routinely collected hospital data might suffice, has been raised as an objection to free-standing audits, although there is a broad counterview that the latter form of data are not fit for audit purposes. These and other questions have been helpfully addressed by Martyn Parker [20] in a guest editorial. In broader terms, and on the basis of experience, single-payer healthcare systems offer a more favorable environment for hip fracture audits than those that are less developed, or developed but commercially fragmented. If demographic and societal needs in coming decades dictate the development of hip fracture audits, the difficulties encountered in these varying environments must eventually be addressed.

Hip fracture audits are therefore now a mature web-based technology and an effective change agent, and also a platform for both quality improvement [1], research collaboration [14], and for the development of patient-reported outcome measures [21]. Given the current predictions for the worldwide rise in osteoporotic fractures, the status of hip fracture as its tracer condition, and the halo effect of audit-driven improvements in hip fracture for other fragility fracture cases, the potential international influence of hip fracture audits in developed and less well-developed healthcare economies is considerable. Over the next few decades standards of fragility fracture care could rise substantially, and audit-based research collaborations could drive forward evidence-based care in a range of national and international settings.

3 Using audits and feedback to improve patient care and outcomes

The purpose of hip fracture audits is to change behavior in ways that improve patient care and outcomes. Individual audits vary greatly in scope, methods, and impact. Access to the detailed information on hip fracture audits also varies greatly, and clearly a great many local audit initiatives fail to surface in the literature. Audits may range from single-hospital efforts that are transient or more enduring and largely unreported to established national audits, currently few in number, though with other national initiatives emerging in Japan, the Netherlands, and Spain. Such audits can document thousands of cases annually, deliver measurable improvements in care, and are now making substantial contributions to the hip fracture literature.

What matters most for any hip fracture audit is its impact on care teams, which is best addressed in terms of hearts and minds. So it is worth considering audit characteristics likely to achieve this. Reporting methods matter. Annual reports of multicenter audits seem to have relatively little impact on meaningful individual program improvement. Units in the top percentiles may enjoy temporary satisfaction while those at the bottom of the league table may temper remorse with a vague intention, or a hope, that things might improve in time for the next report.

Conversely, regular feedback, ideally continuous, confers on clinical teams the benefits of what production engineers call statistical process control. At regular meetings clinical teams can look at their data and ask, for instance, what happened the previous month that resulted in longer preoperative delay: more cases, lack of operating room time, poor management of operating room time, an unenthusiastic anesthetist, or unnecessary preoperative investigations? In this way local teams can use data to address local problems and find local solutions. In effect they are empowered by information, which produces a mindset different from that of an annual league-table.

A successful audit is likely to be supportive not only via regular feedback, but by making available examples of good practice, providing practical online support with a regularly updated “key papers” literature library, model business cases for funding, and even job descriptions for various audit and clinical roles. A regular web-based newsletter featuring relevant meetings and news from teams and from the audit′s leadership will supplement the above measures in creating a hip fracture audit community with the real sense of itself and its purpose.

Meetings matter. Within a large national audit, regional meetings bring people together. Such meetings with 100 or more clinicians, audit staff, managers, and a program of presentations, lunch, and coffee breaks can promote and maintain enthusiasm. And they may have a competitive edge too, and successive local presentations often reflect this, adding to the enjoyment and effectiveness of the meetings. Of course there are other approaches quite different from the above, such as an audit as a top-down bureaucratic exercise, departmentally controlled, and lacking in central clinical leadership, judgmental rather than supportive, and communicating only via annual reports. However, they are less likely to create “a critical mass of enthusiasm and expertise in hip fracture care” with a demonstrable and sustained impact achieved by overall quality improvement and resulting in improved survival [1].

An early and interesting example of a regional audit was carried out in East Anglia, England, in 1992 and repeated in 1997 [22]. The 1992 findings showed no significant differences in case-mix across the eight participating hospitals, meaning that differences in outcome were likely to be attributable to variance in care. There were significant differences in 90-day mortality. Results showed that only around half of the survivors regained their prefracture physical function, with a marked decrease in physical function (for 31%) being associated with postoperative complications. Key measures for improvement identified for scrutiny in the 1997 audit were processes likely to reduce postoperative complications and improve outcomes at 90 days.

The 1997 findings showed reduced pneumonia, wound and hip joint infections, pressure sores, and fatal pulmonary embolism. Two relevant interventions were more widely applied, leading to a rise in thromboembolic prophylaxis from 45% to 81% and early mobilization from 56% to 70%. However, 90-day functional outcomes and mortality were unchanged. The 1997 population sample was older, but again there were no significant differences across the hospitals. In 1992, one hospital had impressively low mortality, but by 1997 this hospital “had lost its … preeminence, perhaps partly because of the improvement of some other hospitals, but primarily because of failure to maintain and improve its overall package of care … We therefore recommend that hospitals continue to audit the care of patients with hip fractures.” [22].

National hip fracture audits remain few in number, and where they exist, their relationships with their respective health departments will vary by context. Some audits may have developed with independent funding and subsequently been recognized as innovative and effective and therefore meriting funding from national sources, as was the case with the UK NHFD. Others may have had to negotiate the complexities of a federal system, together with predetermined national processes and conditions for audit development, as was the case in Australia. In smaller nations, such as Scotland, Ireland, and New Zealand, tighter networks may make things easier. But once established, effective nationwide clinically-led audits may find themselves in a position to influence policy. In this respect the UK NHFD was fortunate, with various NHFD activists working within the White-hall village where the profiles of hip fracture care and fragility fractures generally rose quite markedly [23]. The political element of hip fracture audit work should be openly recognized, and is essential if the goal of influencing policy is to be achieved.