1531 multiple modifiable components of hospital service delivery predict hip fracture: a national record-linkage study

Abstract Introduction Substantial variations remain in hip fracture care delivery across the UK despite established standards and guidelines. We aimed to predict adverse patient outcomes following hip fracture from modifiable hospital-level organisational factors and develop implementation tools to improve national service delivery. Method We used a national record-linkage cohort of 178,757 patients (≥60 years) with a hip fracture in England and Wales (2016–19). We linked patient-level hospital admissions, National Hip Fracture Database and mortality data with 231 metrics from 18 hospital-level organisational-level audits and reports. Multilevel models identified organisational factors, independent of patient case-mix, associated with patient outcomes: length of hospital stay, emergency 30-day readmission, 120-day mobility recovery, days in hospital and health costs over 365-days, and mortality (30- and 365-day) in 172 hospitals across England and Wales. Results Over one-year patients with mean (SD) age 83 (8.6) years, spent 31.7 (32.1) days in hospital, costing £14,642 (£9,017), and 50,354 (28.2%) died. We identified 46 key organisational factors independently associated with one or more patient outcome, of which 14 were (a) associated with cost and/or bed-day savings over one year, (b) consistently associated with other positive patient outcomes, and (c) potentially modifiable. Factors included weekend physiotherapy provision (mean saving per patient/year: £676 [95%CI:£67-1285]), orthogeriatrician assessment (£529 [£148-910]), direct admission to a hip fracture ward (3.4 [-0.36-7.07]days), regular dissemination of audit data to staff (0.85 [0.30-1.39]days). These data have informed the development of a hospital-specific cost-benefit calculator, with a model business case for service improvement, specialty checklists, audit and ‘how to’ guides for complex care delivery. Conclusion All hospitals should try to provide the best available hip fracture care equally across England and Wales. We identified multiple, potentially modifiable, organisational factors associated with important patient outcomes following hip fracture. Our practical and freely-available toolkit should help reduce variation in service delivery.