Outcomes after hip fracture by duration, frequency and type of rehabilitation

King’s College London (KCL) requires HES data from NHS Digital for the purpose of research which will use the National Hip Fracture Database (NHFD) linked to Hospital Episode Statistics (HES) and the Patient Episode Database for Wales (PEDW) to determine whether poor outcomes after hip fracture surgery were less frequent among patients exposed to more frequent, longer duration, and more comprehensive rehabilitation controlling for characteristics of patients, their injuries and healthcare.

More specifically, the aims are to:

1. estimate the odds of return to preadmission residence, readmission and survival at 30-days post-discharge, and recovery of mobility at 120-days, overall and by duration, frequency, and type of rehabilitation after adjustment for potential confounders;

2. estimate the probability of discharge by time after surgery overall and by duration, frequency, and type of rehabilitation after adjustment for potential confounders and the competing risk of death;

3. determine whether estimates vary across subgroups defined by patient and care factors;

The purpose and aims are justified under Article 6 (1) (e) and Article 9 (2) (i). This project will address an evidence gap with a view to complete analysis performed in the public interest of informing quality improvement in rehabilitative care for patients with hip fracture (Article 6 (1) (e)). This project will also help to reduce unwarranted variation in current rehabilitative care to ensure high standards of quality and safety of rehabilitative health care (Article 9 (2) (i)).

KCL has determined that there are no moral or ethical issues raised by the proposed dissemination and there is no risk of potential harm to the public by the dissemination.

UK hospitals admit 75,000 men and women with hip fracture annually. Patients with hip fracture and their carers describe rehabilitation as key to their recovery. Yet, the optimal rehabilitation remains unclear. This is highlighted by: the detail in the NICE guidance being limited to daily mobilisation and regular physiotherapy review; the absence of recent Cochrane systematic reviews; the conclusion that there is insufficient evidence to recommend practice change from earlier Cochrane reviews, and uncertainty among physiotherapists with respect to the appropriate management of patient subgroups.

The National Hip Fracture Database (NHFD) is a clinically led, web-based quality improvement initiative commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the Royal College of Physicians (RCP). The NHFD audit demonstrated marked national variation in the duration, frequency, and type of acute rehabilitation delivered by physiotherapists during a fixed period in 2017. The audit recommended longer, more frequent, and more comprehensive rehabilitation. The audit was not resourced to evaluate the association between duration, frequency, and type of rehabilitation with outcomes, or possible variation in associations for different patient subgroups.

The requested data will provide essential outcome data (readmission and survival at 30-days) as well as rich information on ethnic category, deprivation, comorbidities and complications for regression adjustment and subgroups in the proposed analyses. The aims will inform quality improvement initiatives to reduce unwarranted variation in rehabilitation after hip fracture.

The data subjects will consist of all patients 60 years of age or older who underwent hip fracture surgery in England or Wales between May 1st and June 30th 2017. KCL requires HES Admitted Patient Care data for the years 2015/16 to 2017/18 linked to this cohort. KCL also requires the survival status at 30 days post discharge from care.

KCL require pseudonymised data to address the aims outlined above which allows ‘the processing of personal data in such a way that the data can no longer be attributed to a specific data subject without the use of additional information’ (GDPR 2018). The additional information required to identify an individual will not be available at King’s College London.

The NHFD collected data related to rehabilitation duration, frequency, and type for patients admitted with hip fracture between May 1st and June 30th, 2017. KCL require data for 2017/18 to capture the care spell related to hip fracture and any readmission within 30-days of discharge from the care spell. KCL also require data for care spells in the years prior to the hip fracture care spell (2015/16 & 2016/17) to identify comorbidities not coded in the hip fracture care spell for regression adjustment.

KCL require data for England and Wales. KCL require this geographical spread to capture patients who underwent surgery at a NHFD site participating in data collection related to rehabilitation duration, frequency, and type which is required to address our study aims.

KCL has determined that there are no alternative, less intrusive ways of achieving the purpose.

The data is minimised to the cohort of patients whose care spell related to hip fracture between May 1st and June 30th, 2017. Care spells in the year prior to the care spell related to hip fracture, and Readmission within 30 days of discharge from the care spell related to the hip fracture. Survival status at 30-days derived from the civil registration mortality dataset will be the only mortality information requested.

Kings College London is the data controller and also processes the data for this study. No other organisations process the data for this purpose.

NHS Wales Informatic Service (NWIS) is a public service organisation which manages requests for access to administrative data including the PEDW. KCL will request similar data fields from NWIS as from NHS Digital to enable similar data fields for the analysis for patients in both England and Wales.

The NHFD is a clinically led, web-based quality improvement initiative commissioned by the HQIP and managed by the Royal College of Physicians (RCP). Crown Informatics are RCP's data processor who will be sending in the cohort to both NHS Digital and NWIS for linkage. The Healthcare Quality Improvement Partnership (HQIP) is a joint Data Controller for the NHFD data but not for the HES data being released by NHS Digital or PEDW data being released by NWIS. RCP and HQIP will have no access to the data and will play no part in the processing of the data for this study.

Researchers at the University of Oxford, University Hospital of Wales and University of Bristol will contribute to the interpretation of results, and preparation of materials for dissemination. They will have no access to the data and will play no part in the processing of the data for this study.

This research is funded by the Chartered Society of Physiotherapy Charitable Trust. The funder has no role in the design of this study, execution, analyses, data interpretation, or overall dissemination plan. The applicants are required to present the results of the study at the annual Chartered Society of Physiotherapy conference as a condition of the funding award.

Crown Informatics (RCP’s data processor) will send the following identifying details for the cohort to NHS Digital:

- Study ID

- NHS number

- Date of Birth

- Surname

- Forename

- Postcode

- Date of Admission

NHS Digital will receive the cohort identifiers detailed above. NHS Digital will identify the relevant care spells for patients in HES data and will extract the data for the care spell related to hip fracture and any readmission within 30-days of discharge from the care spell. They will also extract the same data for care spells in the year prior to the hip fracture care spell. Fact of Death sourced from the Civil Registration Mortality dataset will also be extracted for the cohort and will only be used to indicate the survival status at 30 days following discharge from the care spell.

NHS Digital will send the following pseudonymised fields to King’s College London:

- Study ID

- [ADMIDATE] Date of admission,

- [ADMISORC] Source of admission,

- [DIAG_NN] All Diagnosis codes,

- [DISDEST] Destination on discharge,

- [ETHNOS] Ethnic category,

- [IMD04 IMD] Index of Multiple Deprivation,

- [IMD04HD IMD] Health and Disability Domain,

- [IMD04RK] IMD Overall Rank,

- [STUDY_ID] STUDY_ID

- [DISDATE] Date of discharge

- Survival status at 30-days (Calculated from Date of Discharge)

- Indicator of readmission within 30-days

There are no subsequent flows of data.

The flow of data from Crown Informatics into NHS Digital will include personal data with identifying details. The flow of data from NHS Digital to KCL will not contain identifying details.

Kings College London will process data from NHS Digital, as well as data received from NWIS and Crown Informatics. This data is personal data and will not contain identifying details.

Crown Informatics is processing data that will flow to NHS Digital, NWIS, and Kings College London.

Crown Informatics will identify the study cohort as all patients 60 years of age or older who underwent hip fracture surgery in England or Wales between May 1st and June 30th, 2017. Crown Informatics will then extract the cohort data detailed in this purpose statement and send to NHS Digital for England, and NWIS for Wales. Crown Informatics will then remove the identifying data except for the Study ID. Crown Informatics will also minimise the audit data requested to variables relevant to the stated purpose. Crown Informatics will send pseudonymised audit data including the Study ID to KCL.

NWIS will also receive the cohort details from Crown Informatics. NWIS will identify the relevant care spells for patients in PEDW data. NWIS will extract the data for the care spell related to hip fracture and any readmission within 30-days of discharge from the care spell, including survival status at 30 days. They will also extract the same data for care spells in the year prior to the hip fracture care spell. NWIS will send pseudonymised audit data including the Study ID to KCL.

KCL will link the data received from NHS Digital and NWIS to the data received from Crown Informatics using the Study ID. KCL will then process the pseudonymised data to meet the purpose and aims outlined above while enabling ‘the processing of personal data in such a way that the data can no longer be attributed to a specific data subject without the use of additional information’ (GDPR 2018). The additional information required to identify an individual will not be available at KCL. There will be no requirement/attempt to re-identify individuals.

The data processing at KCL will only be carried out by substantive employees of KCL who have completed KCL’s GDPR training and NHS Level 1 Data Security Awareness Training and who have confirmed in writing they have read and understood the protocols outlined and referred to in the Data Security and Protection Toolkit.

The data will be held as an encrypted file on KCL’s secure network drive. The encrypted file will be held in an access-controlled area of the network drive and the data will be accessible to authorised study personnel only, by means of a password or a recovery key. All users have their own username and password, and these will never be shared. Access to the data for the study will be cancelled as soon as a user leaves the study, KCL, or if they are absent for a long period.

Data will be stored on servers owned and managed by KCL, within the JISC Southern Data Centre. Only individuals with the administrative rights to those servers will be able to access data stored on them. The only individuals with those administrative rights are KCL’s IT Computer & Storage team. JISC is a United Kingdom not-for-profit company whose role is to support post-16 and higher education, and research, by providing relevant and useful advice, digital resources and network and technology services, while researching and developing new technologies and ways of working.

Project timeline was extended due to maternity leave of the project PI.

Interim reports on the progress of the research was sent to the funding body (Chartered Society of Physiotherapy Charitable Trust) in October 2020 and November 2021. A final report to the Chartered Society of Physiotherapy Charitable Trust will follow in 2022. This will cover results to address all aims outlined above.

KCL will publish outputs in peer-reviewed open-access journal articles and in reports for the Chartered Society of Physiotherapy Charitable Trust.

Published academic papers:

1. Goubar A, Ayis S, Beaupre L, Cameron ID, Milton-Cole R, Gregson CL, Johansen A, Kristensen MT, Magaziner J, Martin FC, Sackley C. The impact of the frequency, duration and type of physiotherapy on discharge after hip fracture surgery: a secondary analysis of UK national linked audit data. Osteoporosis International. 2021 Nov 8:1-2. Available at: https://link.springer.com/article/10.1007/s00198-021-06195-9

This manuscript captures the following,

- the probability of discharge by time after surgery overall and by duration, frequency, and type of rehabilitation after adjustment for potential confounders and the competing risk of death;

- variation in the probability of discharge by time after surgery overall and by duration, frequency, and type of rehabilitation after adjustment for potential confounders and the competing risk of death across subgroups defined by patient and care factors;

Planned academic papers submitted to open-access peer reviewed journals:

1. Probability of discharge home, readmission, survival and recovery following additional in-hospital physiotherapy after hip fracture surgery. Secondary analysis of the National Physiotherapy Hip Fracture Sprint Audit (March 2022).

This manuscript will capture the following,

- the odds of return to preadmission residence, readmission and survival at 30-days post-discharge, and recovery of mobility at 120-days, overall and by duration, frequency, and type of rehabilitation after adjustment for potential confounders;

2. Probability of discharge home, readmission, survival and recovery following additional in-hospital physiotherapy after hip fracture surgery by patient and care factors. Secondary analysis of the National Physiotherapy Hip Fracture Sprint Audit (July 2022).

This manuscript will capture the following,

- variation in the odds of return to preadmission residence, readmission and survival at 30-days post-discharge, and recovery of mobility at 120-days, overall and by duration, frequency, and type of rehabilitation after adjustment for potential confounders across subgroups defined by patient and care factors;

All outputs will contain only aggregate level data with small numbers suppressed in line with HES analysis guide.

In the UK KCL will work with the Chartered Society of Physiotherapy to disseminate findings to the national community of physiotherapists through their website and publication Frontline. To date, the first published manuscript has been disseminated to physiotherapy members of the Chartered Society of Physiotherapy Hip Fracture special interest group.

KCL will communicate findings nationally through the FFFAP, the British Orthopaedic Society, the British Geriatrics Society, and the Royal College of Occupational Therapists to substantiate their position on access to therapy. KCL will present findings locally (London, Bristol, Bath, Cardiff, Oxford, Norwich hospitals), nationally (Physiotherapy UK, British Geriatrics Society and British Orthopaedic Society conferences), and internationally (Fragility Fracture Network conference). To date, findings have been presented at local hospitals, as well as at the Scottish Hip Fracture Audit physiotherapy special interest group.

KCL will continue to partner with the Royal Osteoporosis Society to disseminate findings to the public via their various media streams: updates/articles in their quarterly membership magazine Osteoporosis News (23,000 readership); their Bone Matters e-newsletter (21,000 readership); and on the research section of the website (www.nos.org.uk/research). A lay version of the findings of each paper will be disseminated to patients and the public interested in research on hip fractures through the Royal Osteoporosis Society (lay abstract for paper 1 submitted for review).

KCL will provide briefing papers and PowerPoint slide decks to policymakers who influence hip fracture quality care indicators for Best Practice Tariffs such as Public Health England, FFFAP, and NHS Improvement. KCL will also present briefing papers and slide decks to NICE in preparation for future updates to the NICE Hip Fracture guideline (CG 124).

Internationally, KCL will work with the Fragility Fracture Network physiotherapy and rehabilitation special interest groups. KCL will disseminate findings to the International Coordinating Council for the Bone and Joint Decade, the International Osteoporosis Foundation, and the European Geriatric Medicine Society.

All publications and conference presentations will be promoted on twitter via the Kings School of Population Health and Environmental Sciences account (>1000 followers), the Falls & Fragility Fracture Audit Programme account (>1500 followers) and study personnel (>2000 followers). The first paper received considerable attention and was in the 96th percentile (ranked 12,846th) of the 389,013 tracked articles of a similar age in all journals and the 99th percentile (ranked 1st) of the 45 tracked articles of a similar age in the journal Osteoporosis International.

The dissemination of research outputs outlined above includes communication activities to target all stakeholders including patients and the public, clinicians, researchers, and policymakers. KCL will also work with the School of Population Health and Environmental Sciences communication team to develop press releases for media engagement.

This project will help to inform a reduction in unwarranted variation in current rehabilitative care to ensure high standards of quality and safety of rehabilitative health care and in turn promote patient health. This will be achieved by addressing the aims outlined above which will identify and report health inequities in access and delivery of rehabilitation after hip fracture and the impact of those inequities on outcomes, and dissemination of the findings to stakeholders involved in the receipt, delivery, and organisation of rehabilitation after hip fracture, as outlined in the outputs section.

75,000 people incur hip fracture each year. On average, these patients spend 15.5 days in hospital at £400 per day. If a reduction in unwarranted variation in rehabilitation duration, frequency, or type led to one less day in hospital for half of all admissions this would reflect a cost saving of £15,000,000 each year.

It is therefore in the public interest to ensure high standards of quality and safety of rehabilitative health care for these people. It is appropriate for the proposed analysis to be completed and results disseminated as they will inform quality improvement initiatives to reduce unwarranted variation and improve the standards of quality and safety of rehabilitative health care.

In 2017, the National Hip Fracture Database audit demonstrated marked national variation in the duration, frequency, and type of acute rehabilitation delivered by physiotherapists. The audit was not resourced to evaluate the association between duration, frequency, and type of rehabilitation with outcomes. The outputs will address all aims outlined above and therefore determine the association between duration, frequency, and type of rehabilitation and outcomes. Moreover, the outputs will be disseminated to all stakeholders to facilitate implementation of quality improvement initiatives to reduce unwarranted variation.

The requested HES data contributes a significant impact to the aims outlined above. First, it will enable KCL to determine the association between rehabilitation duration, frequency and type and readmission and survival at 30-days. These outcomes are key to informing future quality improvement initiatives. Second, without these data, the analyses will fail to control for potential confounders for the putative association between rehabilitation duration, frequency, and type on outcomes. Third, without these data, KCL will not be able to determine whether different subgroups of patients respond differently to rehabilitation duration, frequency, and type.

These analyses are likely to inform a reduction in unwarranted variation in access and delivery of rehabilitation to improve outcomes by identifying and reporting health inequities (as they relate to outcomes).

Patients and the NHS will achieve the benefit through improvements in standards of quality and safety of rehabilitative health care.

The benefit will be measured through successful completion of the dissemination strategy outlined in ‘Specific outputs expected, including target date’.

The analysis are anticipated to be completed and disseminated 36 months after release of data.

King's College London (KCL)'s first publication indicated an association between the frequency and duration of physiotherapy and time to discharge after hip fracture. The association for frequency was observed irrespective of surgical timing, whilst the association for duration was only observed for those who underwent surgery within 36 hours of hospital presentation. KCL found no association between the type of physiotherapy delivered and discharge. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6-7 days in the first postoperative week. Moreover, more frequent physiotherapy could mitigate the impact of surgical delays on time spent in hospital. Therefore, KCL propose a seven-day physiotherapy service totaling at least two hours in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture. To date, these results have been circulated to physiotherapists working with patients after hip fracture directly via the Chartered Society of Physiotherapists, to the Royal College of Physicians to inform key performance indicators for hip fracture care, and to the Royal Osteoporosis Society for dissemination to members of the public.