Introduction. The Best Practice Tariff (BpT) for primary THR / TKR was established in 2014 and rewards good clinical practice with a £550 uplift on the £5000 basic reimbursement. For an ‘average unit’ performing 220 primary THR and 260 eligible knee surgeries (NJR data) this equates to £265,000 per year or over £1million since its inception. The aim of this study was to investigate why Chelsea & Westminster Hospital NHS Trust was not receiving this reimbursement. Materials & Methods. BpT is dependent on four factors (NHS England, PROMS): (i) the provider not having an average health gain significantly below the national average, (ii) a minimum National Joint Registry compliance rate of 85%, (iii) an NJR unknown consent rate below 15%, and (iv) a PROMs participation rate of 50%. Results. Data from NHS Digital confirmed that the Trust's health gains were not significantly below average. Our NJR data was exemplary with 95% compliance rate and an unknown consent rate of only 3%. Based on HES data our PROMS returns were found to be considerably below the 50% target each month (Table 1). The HES data being compared against (269 hip replacement, 334 knee replacement) was far greater than our hospital NJR figures (165 hips, 151 knees). NHS England (PROMs) confirmed that BpT was collated on a Trust not hospital level. Our investigation established that PROMs data for the other hospital within our Trust was not being submitted under the correct ‘ODS’ code and was therefore not contributing to the Trust totals. Discussion. This investigation has precipitated resubmission of all data to NHS Digital under the correct Trust code. This will ensure compliance with the 50% target for PROMs Q1 submission, overall conformity with the BpT standards and a reimbursement of £370,000 to the Trust. For any figures and tables, please contact the authors directly

Introduction. A fractured hip is the commonest cause of injury related death in the UK. Prompt surgery has been found to improve pain scores and reduce the length of hospital stay, risk of decubitus ulcer formation and mortality rates. The hip fracture Best Practice Tariff (BPT) aims to improve these outcomes by financially compensating services, which deliver hip fracture surgery within 36 hours of admission. Ensuring that delays are reserved for patients with conditions which compromise survival, but are responsive to medical optimisation, would facilitate enhanced outcomes and help to achieve the 36-hour target. We aimed to identify medical conditions associated with patients failing to achieve the 36-hour cut off, and evaluated whether these were justified by calculating their associated mortality risk. Methods. Prospectively collected data from the National Hip Fracture Database (NHFD) and inpatient hospital records and blood results from a single major trauma centre were obtained. Complete data sets from 1361 patients were available for analysis. Medical conditions contributing to surgical delay beyond the BPPT (Best Practice Tariff Target) 36-hour cut off, were identified and analysed using univariate and multivariate regression analyses, whilst adjusting for covariates. The mortality risk associated with each factor contributing to surgical delay was then calculated using univariate and hierarchical regression techniques. Results. A total 1,361 patients underwent hip fracture surgery, of which 537 patients (39.5%) received surgery within 36- hours of admission. The overall median time to surgery from presentation was 23 hours (range 3–36) in patients who did (group 1) and 72 hours (range 36–774) in those who did not (group 2) receive timely surgery. There was no difference between the two groups with respect to age, gender, walking ability, fracture pattern and ASA grade. Following univariate analysis, seven variables including admission source, history of dementia, ischaemic heart disease, MI, cerebrovascular accidents (CVA), urinary tract infections and hyponatraemia met criteria for inclusion into the Cox regression model. The model thereafter revealed only hyponatraemia to be a significant determinant of delay to surgery beyond 36 hours with a covariate adjusted relative risk (RR) 1.24 (95% CI 1.06 – 1.44, p=0.006). The overall 30- day mortality in our cohort of hip fracture patients was 9.0%. The commonest cause of death was pneumonia (37%). A second stage hierarchical cox model failed to demonstrate hyponatraemia as being a predictor of 30- day mortality after adjusting for significant co-variants (RR=0.944, CI 95% 0.616–1.447, p=0.793). Conclusions. Hip fracture surgery should not be delayed in the presence of non-severe and isolated hyponatraemia. Instead surgical delay should be reserved for medical conditions, which contribute to mortality and are optimisable

The ‘Best Practice Tariff‘ (BPT) was developed to improve hip fracture care by incentivising hospitals to provide timely multidisciplinary care to patients sustaining these injuries. The current literature examining the association between BPT and patient outcomes is conflicting and underpowered. We aimed to determine if achieving BPT has an impact on 30-day mortality and postoperative length of stay.

A retrospective analysis for patients admitted to a major trauma centre (MTC) was performed between 01/01/2013 to 31/12/2020. Data were extracted from the National Hip Fracture Database. The study population was divided into two groups: those who achieved all BPT criteria (BPT-passed) and those who did not (BPT-failed). The primary outcomes of interest included the 30-day mortality rate and postoperative length of stay (LOS). As a secondary objective, we aimed to assess factors that predict perioperative mortality by utilising a logistic regression model.

4397 cases were included for analysis. 3422 (78%) met the BPT criteria, whereas 973 (22%) did not. The mean LOS in the BPT-achieving group was 17.2 days compared with 18.6 in the BPT-failed group, p<0.001. 30-day mortality was significantly lower in the BPT-achieving group i.e., 4.3% in BPT-achieved vs. 12.1% in BPT-failed, p<0.001. Logistic regression modelling demonstrated that attainment of BPT was associated with significantly lower 30-day mortality (OR: 0.32; 95% CI:0.24–0.41; p<0.001).

To our knowledge, this is the largest study to investigate the association between BPT attainment and 30-day mortality as well as the length of stay. The present study demonstrates that achieving BPT in hip fracture patients is associated with a significant reduction in the average length of stay and 30-day mortality rates. Our crude calculations revealed that achieving BPT for 3422 patients earned our hospital trust >£4 million over 8 years. Findings from this study suggest that achieving BPT not only improves 30-day survival in patients with hip fractures but also aids cost-effectiveness by reducing LOS and helps generate NHS Trusts a significant amount of financial reward.

Aims

The aim of this study was to determine whether national standards of best practice are associated with improved health-related quality of life (HRQoL) outcomes in hip fracture patients.

Within an ageing population, the morbidity and mortality burden of neck of femur fractures will only worsen. Financially incentivising acute Trusts via the Best Practice Tariff for inpatient care has yielded good results(1,2,3,4) but post-discharge care is still variable. Most importantly, restoring patients to their pre-fracture mobility is key to their quality of life(5,6) and reducing both readmissions to hospital(7,8) and expensive local authority residential care. Unfortunately, physiotherapist vacancies are in their thousands(9,10) leading to waiting times of around three months once discharged(11). In 2019, the Royal Derby Hospital created a novel Hip Fracture Patient Advocate (HFPA) to observe those who have fallen through gaps in community services. It involves monitoring patients’ progression, signposting to appropriate services, flagging issues to the responsible consultant and assisting in physical mobilisation. A retrospective review examined data from patients discharged to their own homes. This included demographics, residential status and mobility, both pre-fracture and at 120 days post-fracture. Mobility was classified into five categories, in line with the national hip fracture database. In 2018, of 238 patients, 41.2% returned to their baseline or increased mobility, and, after the introduction of the HFPA in 2019, this figure increased to 48.2%. In one year, there was a 7% increase in patients recovering their baseline mobility. This is a cost-effective intervention that can successfully improve mobility, leading to improved long-term outcomes. This includes the potential to reduce acute readmissions and the need for residential care, appealing to Integrated Care Boards. It also bridges the gap to primary care to optimise medical management and after further development, could be financially-incentivised via the Best Practice Tariff. Rather than thinking more expensive clinicians are required, this study proposes that a HFPA can garner better outcomes for both the patient and the wider system

Hip fracture is a common injury with a high associated mortality. Many recommendations regarding timing of operative intervention exist for patients with such injuries. The Best Practice Tariff was introduced in England and Wales in 2010, offering financial incentives for surgery undertaken within 36 hours of admission. The England and Wales National Institute for Health and Clinical Excellence (NICE) Guidance states that surgery should be performed on the day or day after admission. Due to lack of clear evidence, this recommendation is based on Humanitarian grounds. NICE have called for further research into the effect of surgical timing on mortality. We utilised data from the National Hip Fracture database prospectively collected between 2007 and 2015, comprising 413,063 hip fractures. Using 11 variables, both Cox and Logistic regression analysis was used to establish the effect on mortality of each 12 hour interval from admission to surgery. For each 12 hour time frame from admission to surgery a trend for improved 30 day survival was demonstrated the earlier the surgery was performed. However, this did not reach significance until beyond 48 hours (Hazard ratio of 1.12, 95% CI: 1.04–1.20). Surgery after 48 hours suffered significantly higher chance of mortality compared to surgery done within 12 hours. This is the largest analysis undertaken to date. Lowest mortality rates are found within the 0–12 hour window. After 48 hours there is a significant increased risk of mortality compared to the 0–12 hour time frame. As such, expeditious surgery within 48 hours can be justified both on humanitarian and survivorship grounds. Hip fracture surgery performed within 48 hours is associated with reduced mortality when compared to that beyond this time. This is in agreement with Blue Book recommendations and extends the currently recommended NICE and Best Practice Tariff targets of 36 hours

Aims. Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common surgical complications. In the UK, the Best Practice Tariff incentivizes the screening of delirium in patients with hip fracture. Further, a National Hip Fracture Database (NHFD) performance indicator is the reduction in the incidence of POD. To aid in its recognition, we sought to determine factors associated with POD and POCD in patients with hip fractures. Methods. We interrogated the NHFD data on patients presenting with hip fractures to our institution from 2016 to 2018. POD was determined using the 4AT score, as recommended by the NHFD and UK Department of Health. POCD was defined as a decline in Abbreviated Mental Test Score (AMTS) of two or greater. Using logistic regression, we adjusted for covariates to identify factors associated with POD and POCD. Results. Of the 1,224 patients presenting in the study period, 1,023 had complete datasets for final analysis. POD was observed in 242 patients (25%). On multivariate analysis only preoperative AMTS and American Society of Anesthesiologists grade (ASA) were independent predictors of POD. Every point increase in AMTS was associated with a fall in the odds of POD by a factor of 0.60 (95% confidence interval (CI) 0.56 to 0.63, p < 0.001). Every grade increase in ASA led to a 1.7-fold increase in the odds of POD (95% CI 1.13 to 2.50, p = 0.009). A preoperative AMTS of less than 8 was strongly predictive of POD with area under the receiver operating characteristic of 0.86 (95% CI 0.84 to 0.89). Only ASA was predictive of POCD—every grade increase in ASA led to a 2.6-fold increase in the odds of POCD (95% CI 1.7 to 4.0, p < 0.001). Conclusion. POD and POCD are common in the hip fracture patients. Preoperative AMTS and ASA are strong predictors of POD, and ASA predictive of POCD. This may aid in the earlier identification of those most at risk and suited for the patient consent and decision-making process. Cite this article: Bone Joint J 2020;102-B(12):1675–1681

Aims. This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year. Methods. A single-centre retrospective cohort study was performed at an acute NHS Trust. Hip and distal femur fracture patients admitted within the first month from each of the three starting dates of each national lockdown were included and compared to a control group in March 2019. Data were collected as per the best practice tariff outcomes including additional outcomes as required. Data collection included COVID-19 status, time to theatre, 30-day mortality, presence of acute kidney injury (AKI) and pneumonia, and do not attempt cardiopulmonary resuscitation (DNACPR) status. Data were analyzed using an independent-samples t-test or chi-squared test with Fisher’s exact test where applicable. A p-value of < 0.05 was considered statistically significant. Results. A total of 95 patients during the pandemic were included and 20 were COVID-positive. Patients experienced a statistically significant increase in time to theatre in Lockdown 1 compared to 2019 (p = 0.039) with a decrease with successive lockdown periods by Lockdown 3. The 30-day mortality increased from 8.8% in 2019 to 10.0% to 14.8% in all lockdown periods. COVID-positive patient mortality was 30.0% (p = 0.063, odds ratio (OR) = 4.43 vs 2019). The rates of AKI and pneumonia experienced were higher for patients during the pandemic. The highest rates were experienced in COVID-positive patients, with 45.0% of patients with AKI versus 27.0% in 2019 (p = 0.38, OR = 1.80), and 50.0% of patients diagnosed with pneumonia versus 16.2% in 2019 (p = 0.0012, OR = 5.17). The percentage of patients with a DNACPR increased from 30.0% in 2019 to 60.7% by Lockdown 3 (p = 0.034, OR = 3.61). Conclusion. COVID-positive hip and distal femur fracture patients are at a higher risk of mortality due to AKI and pneumonia. Patient outcomes have improved with successive lockdowns to pre-pandemic levels. Cite this article: Bone Jt Open 2021;2(12):1017–1026

Following the establishment of regional Major Trauma Networks in England in 2012, there were concerns that pressures regarding resource allocation in Major Trauma Centres (MTCs) may have a detrimental impact on the care of patients with hip fractures in these hospitals. This study aimed to compare outcomes in hip fracture care between MTCs and trauma units (TUs). National Hip Fracture Database data was extracted from 01/01/2015 to 31/12/2022 for all hospitals in England. Outcome measures included perioperative medical and physiotherapy assessments, time to surgery, consultant supervision in theatre, Best Practice Tariff (BPT) compliance, discharge to original residence, and mortality. Data was pooled and weighted for MTCs and remaining hospitals (TUs). A total of 487,089 patients with hip fractures were included from 167 hospitals (23 MTCs and 144 TUs). MTCs achieved marginally higher rates of orthogeriatrician assessment within 72 hours of admission (91.1% vs 90.4%, p<0.001) and mobilisation out of bed by first postoperative day (81.9% vs 79.7%, p<0.001). A lower proportion of patients underwent surgery by the day after admission in MTCs (65.2% vs 69.7%, p<0.001). However, there was significantly higher consultant surgeon and anaesthetist supervision rates during surgery in MTCs (71.8% vs 61.6%, p<0.001). There was poorer compliance with BPT criteria in MTCs (57.3% vs 60.4%, p<0.001), and proportionately fewer MTC patients were discharged to their original residence (63.5% vs 60.4%, p<0.001). There was no difference between MTCs and TUs in 30-day mortality (6.8% vs 6.8%, p=0.825). This study demonstrates that MTCs have greater difficulty in providing prompt surgery to hip fracture patients. However, their marginally superior perioperative care outcomes appear to compensate for this, as their mortality rates are similar to TUs. These findings suggest that the regionalisation of major trauma in England has not significantly compromised the overall care of hip fracture patients

Aims. “Get It Right First Time” (GIRFT) and NHS England’s Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a ‘paradox’. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs. Methods. This study compares THA outcomes for over 1,000 uncemented Corail/Pinnacle constructs used in all age groups/patient frailty, under one surgeon, with identical pre- and postoperative pathways over a nine-year period with mean follow-up of five years and two months (range: nine months to nine years and nine months). Implant information, survivorship, and regular postoperative Oxford Hip Scores (OHS) were collected and two comparisons undertaken: a comparison of those aged over 65 years with those 65 and under and a second comparison of those aged 70 years and over with those aged under 70. Results. Overall revision rate was 1.3% (13/1,004). A greater number of revisions were undertaken in those aged over 65 years, but numbers were small and did not reach significance. The majority of revisions were implant-independent. Single component analysis revealed a 99.9% and 99.6% survival for the uncemented cup and femoral component, respectively. Mean patient-reported outcome measures (PROMs) improvement for all ages outperformed the national PROMs and a significantly greater proportion of those aged over 65/69 years reached and maintained a meaningful improvement in their OHS earlier than their younger counterparts (p < 0.05/0.01 respectively). Conclusion. This study confirms that this uncemented THA system can be used safely and effectively in patient groups aged over 65 years and those over 69 years, with low complication and revision rates. Cite this article: Bone Jt Open 2021;2(5):293–300

Background. In a number of disciplines, positive correlations have been reported between volume and clinical outcome. This has helped drive the evolution of specialist centres to deal with complex or high risk medical conditions. Hip fractures are a common injury associated with high morbidity and mortality. Aim. To assess whether volume of hip fracture cases attended to by individual hospitals is associated with the quality of care provided and clinical outcomes. Methods. Utilising 19 quality of care measures espoused by NICE and available on the National Hip Fracture Database website, we examined whether there was a correlation between Volume of hip fractures per institution and each outcome measure for 2016 and 2018. Outcomes were assessed for normality of distribution and correlated using either Spearman rank or Pearson Correlation as appropriate. Results. Over 170 institutions were available for analysis. The average number of procedures per institution was 371 (sd 154) in 2016 and 378 (sd 158) in 2018. 9 units attended to in excess of 700 cases per annum. There was a positive correlation between volume of cases and a number of quality of care indices; notably survivorship, length of stay, ortho-geriatric consultation, pressure ulcer prevention, post-operative mobilisation, delirium prevention, bone health assessment and the proportion of patients satisfying the Best Practice Tariff (BPT) criteria. 5 of the measures had no correlation. The worst performances were observed for measures that were not financially incentivised. Discussion. Our analysis of a large synchronous national dataset show weak but favourable correlations with unit volume and important outcomes including mortality and length of stay. Our results do not invariably justify the centralisation of hip fracture services. Hip fracture care may be more convincingly improved by promoting compliance to the guidance that already exists via financial incentivisation or otherwise

Aims

The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA).

Aims

This study investigates the use of the metabolic equivalent of task (MET) score in a young hip arthroplasty population, and its ability to capture additional benefit beyond the ceiling effect of conventional patient-reported outcome measures.

Aims

Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost.

Aims

This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time.

Aims

The coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks.

Aims

Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants are available which may yield superior clinical outcomes. This study compared the clinical effectiveness of the novel X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures.

Aims

The aim of this study was to describe temporal trends and survivorship of total hip arthroplasty (THA) in very young patients, aged ≤ 20 years.