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Broken hips - measuring performance

Fracture of the hip is an important cause of morbidity and mortality. Demographic change will lead to an increasing demand for services. The recent Audit Commission report [4] suggests that care for this condition may be sub-optimal. There is a need, therefore, for health authorities to closely examine this area of care. How might purchasers monitor and address this topic?

Mortality statistics

Comparative mortality statistics for hip fracture could be used by health authorities to measure the health experience of their population, or the performance of local provider units. Studies have shown that certification habits surrounding the certification of fractured neck of femur can vary, however. A study of cases of hip fracture within four weeks of death has shown that the percentage of death certificates on which the condition was mentioned at all was only 25%, and as an underlying cause of death in 17% of cases [6].

Hence there may be a general under-reporting of this condition as a cause of death. Pemberton [7] noted that hip fracture may be underestimated by comparing death rates based on Hospital Activity Analysis with OPCS mortality statistics. Local variations in certification practice, combined with the under-reporting of this condition as an underlying cause of death may make comparative mortality statistics difficult to interpret.

Where are we now? - Common themes of good quality care in the management of elderly patients with fractured hip

  1. Spending less than one hour in casualty
  2. Receiving prophylactic antibiotics
  3. Receiving pharmaceutical thromboembolic prophylaxis
  4. Having surgery within 24 hours
  5. Recording the grade of surgeon and anaesthetist performing the operation
  6. Number of days after surgery by which 50% of patients were mobilised
  7. Occurrence of pressure sores, urinary tract infection and pneumonia
  8. Provision of a thorough medical and social assessment
  9. Degree and effectiveness of joint working between orthopaedic surgeons and consultants in medicine for the elderly
  10. Adequacy of discharge planning and implementation

Comparative hospital data

Analysis of information supplied to health authorities in the hospital minimum data set could provide an insight into local management. For example, there is general agreement that pre-operative length of stay should be as short as possible, and that fractures should ideally be operated on within 24 hours [2]. This information could be identified for local providers which would allow a comparison either with other units, or with agreed standards.

Other measures may be more difficult to interpret. Overall length of stay is a common measure used by purchasers to measure performance. Problems arise in interpreting this measure due to case mix, and it has been noted that setting targets in length of stay could reduce the quality, and impair the outcome of patient care [8].

It is possible to calculate a local case-fatality ratio for providers, say by looking at what percentage of admissions with fractured neck of femur have a discharge cause of death. Whilst this measure might allow comparisons to be made without the problem of certification practice, interpretation problems still arise. Firstly, individual providers may have small numbers of deaths, so that chance effects need to be considered. Secondly, and perhaps most important, is the issue of case mix. If mortality is used as an outcome measure factors affecting prognosis - age, sex, intracapsular or extracapsular fracture and pre-existing conditions like dementia, stroke or cardiac failure - would have to be taken into account.

How to address this

Three influential reports, those of the Royal College of Physicians [2], the East Anglian Audit [5] and most recently the Audit Commission report [4] have identified a range of process measures and markers of good quality care in the management of elderly patients with fractured hip. It has been noted that disease-specific mortality may be an insensitive tool with which to compare the quality of care between hospitals. Health authorities might find measuring providers' performance against locally agreed process measures and criteria of good practice a better way to address this topic, rather than measuring performance against provider or population-based mortality statistics which may be difficult to interpret.

Dr Mike Bedford, University of Sheffield


  1. W Hollingworth, CJ Todd, MJ Parker. The cost of treating hip fractures in the twenty first century. Journal of Public Health Medicine 1995 17:269-76.
  2. Royal College of Physicians. Fractured neck of femur, prevention and management: Summary and recommendations of a report of the Royal College of Physicians. Journal of the Royal College of Physicians 1989 23:8-12.
  3. AJ McColl, MC Gulliford. Population Health Outcome Indicators for the NHS: a feasibility study. London: Faculty of Public Health Medicine, 1993.
  4. Audit Commission. United they stand: co-ordinating care for elderly patients with hip fracture. London: HMSO, 1995.
  5. CJ Todd, CJ Freeman, C Camilleri-Ferrante et al. Differences in mortality after fracture of the hip: the East Anglian audit. British Medical Journal 1995 310:904-8.
  6. MJ Goldacre. Cause-specific mortality: understanding uncertain tips of the disease iceberg. Journal of Epidemiology and Community Health 1993 47:491-6.
  7. J Pemberton. Are hip fractures underestimated as a cause of death? The influence of coroners and pathologists on the death rate. Community Medicine 1988 10:117-23.
  8. R Beech, C Withey, M Morris. Understanding variations in lengths of stay between hospitals for fractured neck of femur patients and the potential consequences of reduced stay targets. Journal of Public Health Medicine 1995 17:77-84.

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