Elsevier

Injury

Volume 47, Issue 2, February 2016, Pages 444-447
Injury

Factors that affect fractured neck of femur outcome: Clinical commissioning groups influence length of stay and discharge destination

https://doi.org/10.1016/j.injury.2015.12.024Get rights and content

Abstract

Background

The average length of stay (LOS) following a hip fracture in hospitals around the UK has been approximately 20 days in recent years. This can vary between hospitals and there are numerous factors that can affect LOS. We had the impression that LOS varied by Clinical Commissioning Group (CCG) from which the patient originates. The aim of our study was to discover whether the concern was valid, and if so, what the reasons may be.

Methods

We analysed hip fracture data collected at our Trust between September 2008 and December 2014. LOS was compared for each of three CCGs in our Trust's catchment areas, and those patients admitted from outlying CCGs. Sub-analysis was performed by patient age, ASA grade, abbreviated mental test score, procedure type and discharge destination to determine which factors influence LOS.

Results

1847 patients were identified. After excluding deaths, missing data and extreme outliers, 1603 patients were included in the analysis. The median LOS varied from 14.9 to 23.4 days across CCGs. The major reason for this variation was discharge destination. CCGs associated with longer LOS had a significantly higher rate of discharge to the patient's own home, rather than institutional care. This was independent of patient age, mental status, ASA grade and promptness of surgery.

Conclusion

We have shown that CCGs vary in their performance to aid discharge. This directly influences a Trust's performance on the National Hip Fracture Database. Compared with other hospitals, our results show a poor outcome in terms of length of stay, but much better performance regarding home discharge. We recommend that more emphasis in future be placed on discharge destination than LOS.

Introduction

In England and Wales, the length of stay (LOS) after fractured neck of femur is recorded in the National Hip Fracture Database (NHFD) and as such is a hospital outcome measure. There may be competition between rapid discharge and the patient being discharged to their own home. Reasons for late discharge are multifactorial. It has been shown that patients who wait longer for their operation may deteriorate and spend longer as inpatients [1]. ASA grade, age and abbreviated mental test score (AMTS) may also be relevant [2]. Availability of home care and carers is important.

NICE guidelines advise that a multidisciplinary approach to rehabilitation should be utilised, involving physiotherapists and occupational therapists, as well as liaising with mental health, falls prevention, bone health, primary care and social services [3]. The Best Practice Tariff (BPT) is paid if certain criteria are met, such as surgery within 36 h of admission [4]. Regarding discharge, there are several options available. An early supported discharge can be considered as part of a Hip Fracture Programme, which allows the patient to be discharged to the community even when they have not yet achieved their full rehabilitation potential. Some hospitals have access to intermediate care that allows rehabilitation in a community hospital or residential care unit, with home discharge as independence improves. Patients admitted from residential care may be discharged back to their care home quickly unless their care needs increase. These variations affect LOS and there have been numerous descriptions of possible reasons [5], [6], [7]. The prolonged lengths of stay obviously incur excess cost which is not always reimbursed.

We have wondered over the years whether the role and efficiency of particular Primary Care Trusts (PCTs) and now Clinical Commissioning Groups (CCGs) are important. These organisations distribute funding for health and social care within discrete regions of England. Each is in charge of its own budget based on regional priorities and needs. Local variations between CCGs may mean that discharge policies vary owing to the availability of services within a particular postcode.

Our hypothesis was that there is regional variation in LOS, influenced by the patient's CCG. We also wished to determine whether patients in some CCGs had differential rates of discharge home versus institutional care.

Section snippets

Methods

A hip fracture database has been in place in our hospital since September 2008. It was initially for a local audit and now submits data to the NHFD. It has a comprehensive set of data and records patients’ discharge destinations with regards to our 3 main CCGs, and for those from outside our usual catchment area due to our proximity to an international airport. Data such as patient age, sex, post code (and therefore CCG), type of fracture, type of procedure, time between hospital admission and

Results

Our database contained 1847 patients between September 2008 and December 2014. We excluded patients who died in hospital (n = 211) and those with an incomplete data set (n = 12). This left 1624 patients. The median length of stay was 20.7 days. Our data for length of stay was not normally distributed (p < 0.0001) and to conduct meaningful statistical analysis, extreme outliers (whose lengths of stay exceeded 115.4 days) were excluded from the analysis. This left 1603 patients for the complete

Discussion

A simple analysis of NHFD data uncovers a disparity between LOS and successful home discharge. It can be seen from the graph in 2013s and 2014s NHFD report that the top 10 performing hospitals in terms of LOS only achieved a 29% home discharge rate. We note that the report considered it an improvement that the mean had shifted from 46.4% to 48% between 2013 and 2014 and a good rate of home discharge is commended. Our overall rate of home discharge is 68.4%. Even our worst-performing CCG in

Conclusion

Our study is the first to formally illustrate that length of hospital stay following a hip fracture is influenced by CCG. The reason for this was found to be discharge destination. With ongoing reforms in NHS structure and funding, we recommend that this metric be used to reflect the quality of regional social care services. A compromise must be made between the daily cost of occupying a hospital bed and the discharge destination.

Conflict of Interest

The authors have no conflicts of interest to declare.

References (21)

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  • Greater length of hospital stay for concurrent hip and upper limb fractures compared to isolated hip fractures: a systematic review of 13 studies including 210,289 patients and meta-analysis

    2022, Injury
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    Slow mobilisation following a hip fracture is associated with higher mortality, worse functional outcomes and delayed discharge [42–45]. Hence, the peri-operative period is pivotal in hip fracture patients and hospital mortality has been shown to occur early during the post-operative period [46]. Of the studies included in our analysis, only Morris et al. compared outcomes of operative versus non-operative management of the concurrent upper limb fracture [6].

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