England has highest hip fracture death rates in western world, highlighting urgent need to invest in post-hospital care

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England has the highest death rates of older people hospitalised with a hip fracture or heart failure in the western world, a landmark study has found, suggesting an urgent need to invest in preventative care in the community.  

The International Collaborative on Costs, Outcomes and Needs in Care (ICCONIC) study, led by Harvard University and the London School of Economics (LSE), used electronic medical records to compare the cost and quality of care between health care systems in 11 OECD countries. 

The data for England – compiled and analysed by the Health Foundation – focused on two groups of high-need older patients which represent priority areas for the NHS and other health systems – those hospitalised with a hip fracture and those hospitalised with heart failure who also have diabetes.  

Looking at pre-pandemic data from 2014/15 to 2017/18, the study found that, for both groups of patients, England had the highest mortality rates of any country, despite performing relatively well on several other measures of quality of hospital care.

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One year after hip fracture surgery, almost a third (31%) of patients in England had died of any cause compared with less than a quarter of patients in in Canada (23%), Australia (22%) and France (20%).  

Another key area where England stands out from other countries included in the analysis is the length of time that hip fracture patients spend in hospital. Patients in England spent an average of 21.7 days in hospital after their surgery – the highest of all 11 countries evaluated.  

High mortality among hip fracture patients is occurring despite England performing well on other care quality measures – for example, over 82% of hip fracture patients in England received hip surgery within 48 hours of admission, second only to 85% of patients in Sweden.

This is recommended as a key component of high-quality care. However, one year after their initial admission, 31% of English patients had died, compared with only 25% of Swedish patients. 

The Health Foundation said the study highlights a need to invest in post-hospital care, in order to free up capacity and reduce the time patients remain in hospital after hip fracture surgery, the most common reason for emergency surgery.

“There is broad agreement that hospital is not the best place for a frail older patient to stay following surgery as it is not conducive to rehabilitation. By investing in post-hospital care, there may be scope to reduce the length of hospital stays for hip fracture patients and free up additional capacity to deal with the backlog of care,” the charity said.

The Health Foundation noted that the findings warrant further investigation, explaining that it is notoriously difficult to draw comparisons between health care systems that serve different populations and collect information about patients in different ways, and that doing so often raises more questions than it answers.

The charity believes the results ultimately highlight major gaps in the available data in England and the need for investment to better understand what is happening to patient care across acute hospitals, rehabilitation services, support in the community and social care. 

However, by using patient-level data and enabling comparisons across primary, secondary and post-acute care, the ICCONIC study provides health care policymakers with vital information on how current care strategies are influencing the quality of care in the NHS in England, while also highlighting opportunities to significantly improve productivity, the Health Foundation said.

Dr Jennifer Dixon, chief executive of the Health Foundation, commented: “The findings of the ICCONIC study warrant urgent further investigation, particularly the finding of higher mortality among patients with hip fracture in the year after their admission for emergency treatment. The study suggests there is a significant opportunity to achieve higher quality care for patients, in part by learning from how other health systems deliver care and the investment it takes to do so.  

“That patients in England with hip fracture spend far longer in hospital after surgery than they would in other countries also highlights an opportunity to improve efficiency by reducing the avoidable use of hospital care. Less avoidably long stays would mean existing capacity could be better used to address the backlogs in hospital care as a result of the pandemic. This could contribute to both better outcomes for patients and – as hip fracture is the most common reason for emergency surgery – significantly improved productivity for hospitals across the country.”

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Sarah Clarke

The author Sarah Clarke