The impact of geographic and socioeconomic variation on the incidence of hip fracture, and upon death and recovery after hip fracture.

This request is necessary to enable a study which will determine how much social deprivation affects outcomes after hip fracture in terms of death, recovery, institutionalisation, and readmission. The study will identify areas in the UK where hip fracture patients receive inequitable health care which is below the expected standard. The findings are designed to drive equal access to high quality services for all hip fracture patients across the country by influencing policy and the commissioning of services.

This 3 year program aims to establish:

1. Variation in the incidence of hip fractures across the different regional healthcare economies in England and Wales and how deprivation relates to incident hip fractures within these regions.

2. After sustaining a hip fracture, the effect of individual social deprivation on; (i) Day 7, Day 14, Day 21, Day 30, Day 60, Day 90, Day 120, Day 182, Day 274, Day 365

mortality, (ii) length of hospital stay, (iii) walking ability (iv) return home (vs. need for institutionalised care), (v) 30-day readmissions and (vi) days spent in hospital over the next 12 months.

3. Whether the effect of social deprivation on the outcomes in Aim 2 varies across different regional healthcare economies in England and Wales; identifying healthcare providers/CCGs with suboptimal outcomes necessitating revision to commissioned services.

4. The financial cost to the NHS, by healthcare provider/CCG and deprivation, of readmissions (all and fracture-related) over the 12 months after hip fracture, or until death; generating valuable intelligence for NHS commissioners, supported by a systematic review of readmission avoidance post hip fracture.

Reducing health inequalities is a fundamental health care goal. This proposal is important as it will address the lack of information on the extent of regional variation on hip fracture incidence, or the impact of social deprivation across the different regional healthcare economies on fundamental health outcomes after hip fracture such as a death, mobility, institutionalisation, and re admissions which carry such a high financial burden. Results are intended to influence national commissioning of hip fracture services and thus reduce health inequalities.

Only substantive employees of Bristol University will access the disseminated data and only for the purposes described in this document .

Under this agreement, a pseudonymised extract of linked NHFD and HES/Civil Registration data will supplied by NHS Digital to University of Bristol. The data will be exclusively stored on University of Bristol’s servers and will not be accessible to any third parties.

Data flow:

1. The cohort will be provided for linkage from Crown Informatics (who are the DP for the NHFD but play no other role in this application and receive no linked data) who will supply NHS number, DOB and postcode.

2. NHS Digital will link HES and Civil Registration data to the cohort and patients with related ICD/diagnosis codes.

3. NHS Digital will supply the linked pseudonymised data to Bristol (replacing date of death with death status at various stages in one year).

Over the course of a 3-year programme, the data will be analysed to produce research outputs in relation to the four aims listed above. The processing activities for each aim will take place in sequential order but there will be overlaps between the processing activities for different aims. The analyses and statistical programmes written will differ for each aim and different variables will be used.

For the 4 study aims, the respective processing activities are as follows:

1. Three years of data will be analysed to calculate rates of different types of hip fracture for different age groups amongst men and women across 11 geographical regions in England and Wales. Then the study will look at how these rates vary according to levels of social deprivation. Social deprivation will be measured using the Index of Multiple Deprivation (IMD).

2. The study will determine how levels of social deprivation relate to a range of outcomes after hip fracture, including:

a. A patient’s ability to walk indoors and outdoors 30 days after sustaining a hip fracture

b. Rates of death 2 days, 14 days, 21 days, 30 days, 60 days, 90 days, 120 days, 182 days, 274 days and 365 days after sustaining a hip fracture

c. How long patients stay in hospital, and afterwards in rehabilitation hospitals, after sustaining a hip fracture

d. How often patients are able to return to their own home, or whether they need to move to live in a care home, after a hip fracture. How often patients need to be readmitted to hospital having been discharged after an admission with hip fracture; calculating the total number of days spent in hospital in the year following a hip fracture.

3. The study will investigate how the relationships established in Aim 2, between social deprivation and hip fracture outcomes, vary across 11 different geographical regions (and smaller subgroups within these regions) in England and Wales. It will be determined whether these relationships vary according to whether patients live in rural or urban environments, or whether they are treated in larger teaching hospitals or smaller district general hospitals). The study will determine to what extent hospital characteristics explain difference in patient outcomes after hip fracture, such as delays in operating, access to medical assessment, specialist geriatricians, a full multidisciplinary team, fracture liaison services

4. The study will calculate the total costs associated with hospital readmissions following a hip fracture for each region and clinical commissioning group. The study will also perform a detailed review of the scientific literature to assess measures to avoid hospital readmission after hip fracture so that both the financial impact and the current evidence based can be presented to commissioners and policy makers.

There will be not data linkage undertaken with NHS Digital data provided under this agreement that is not already noted in the agreement.

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data).

The intention is for each of the 4 aims to produce at least one peer-reviewed published paper (target journals include: The BMJ, Osteoporosis International, Journal of Bone and Mineral Research) and at least one conference abstract for national/international presentation (target conferences: The National Osteoporosis Society conference, the European Fragility Fracture Network conference, The Bone Research Society, the American Society of Bone and Mineral Research). These will be delivered sequentially over the course of the 3-year programme with the first publication targeted for submission by the end of 2016.

The types of journals to be targeted will depend on the nature of the findings. All outputs will contain only aggregated data, with small number suppressed in line with the HES analysis guide.

As part of this programme, a systematic review assessing the effects of deprivation on hip fracture incidence will also be completed and published.

In preparing this proposal advice was obtained from a Commissioner at NHS England, advisor to the National Osteoporosis Society (NOS) and RCP Fracture Liaison Service Database committee representative. The Commissioner is well positioned, and with a vested interest, to help to disseminate our research findings in the interests of improving models of hip fracture care. The Commissioner has a voice amongst other NHS commissioners which will permit this research a direct path so that the findings directly influence national commissioning and hence lead to improved patient care. The rates at which patients need to move to care homes and the costs incurred through hospital re admissions are of crucial importance to commissioners.

This research is funded by the NOS and hence we will work with the NOS’ publicity office to disseminate our research findings.

The data produced by this study will inform Public Health England (PHE), for whom elimination of health inequalities is a priority target: PHE direct local organisations towards appropriately commissioned services.

Given current political priorities, it is also planned that findings will be disseminated directly to Westminster MPs. Furthermore, the Welsh Assembly clearly prioritized the tackling of health inequalities in its publication ‘Fairer Health Outcomes for All: Reducing Health Inequalities in Health Strategic Action Plan’; stating that currently there is little evidence of differential impacts on different socio-economic groups. One of the leaders of the study is well placed as National Hip Fracture Database (NHFD) clinical lead to feedback the findings to key stakeholders, such as the Royal College of Physicians. .

Findings will further be disseminated by the NHFD Publications and Scientific Committee which the applicant takes over as chair of this committee in May 2017.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide

Reducing health inequalities is a fundamental health care goal. This proposal is important as currently the extent of regional variation on hip fracture incidence is not known, nor the impact of social deprivation across the different regional healthcare economies on fundamental health outcomes after hip fracture such as a death, mobility, institutionalization, and readmissions which carry such a high financial burden.

Benefits to patients and the health system:

Around 60,000 older adults fracture a hip each year in England. As our population ages, fracture numbers are predicted to rise. Fractures represent a major trauma for individuals and a significant societal burden, both through direct medical costs (UK predicted £2.2 billion by 2025), and important social sequelae. Details regarding 95% of hip fractures are now routinely recorded through the National Hip Fracture Database (NHFD); after adjusting for case-mix, by 30-days between 3 and 17% of patients will have died and 5 to 75% will have returned home; percentages vary across the 186 NHS hospitals. Mean acute hospital length of stay varies from 9 to 32 days. Health and healthcare inequalities still persist.

Previous research has established lower socioeconomic status is a predictor of poorer health outcomes, associated with increased rates of incident hip fracture in Nottingham, whilst regional variation across the country is unknown. Previous research also shows that nationally there are identified geographic and socioeconomic variation in the provision of elective hip replacement , found that socioeconomic deprivation predicts poorer post-operative outcomes, and showed socioeconomic deprivation reduces the chance of returning to one’s own home following a hospital admission with a fall. Recent results suggest patients from deprived areas in southwest England, despite being younger, are more likely to be transferred to community rehabilitation hospitals following hip fracture, than be discharged directly home, with consequently longer lengths of stay in the NHS.

A third of hospital expenditure is spent on those in the last year of life, with 58% of UK citizens dying in hospital. Hip fracture is the commonest cause of injury related death. One-year mortality following hip fracture is approximately 30%. Lower socioeconomic status predicts higher inpatient mortality after hip fracture in England; however, the relationship with 30-day and one year mortality has not been defined nationally.

This research will investigate and quantify the true impact of deprivation on hip fracture outcomes and to identify deprived healthcare regions, with potentially the poorest outcomes, where peri-operative inpatient care may not be optimal.

Emergency 30-day readmissions following hip fracture have risen progressively over 10 years in England from 8.3% to 12.0%. The extent to which survival, co-morbidity, geographic and socioeconomic factors influence this trend has not been assessed. Given the high financial burden of readmissions, such data will have high utility to policy makers (e.g. Public Health England) and those commissioning local hip fracture services (e.g. Clinical Commissioning Groups (CCGs) in England).

Understanding the effects of deprivation on the incidence of hip fracture, the outcomes after hip fracture and the cost implications, and how this all varies across different parts of the country, will identify those health systems with greatest need, in greatest need of reform, and potentially those to be high-lighted as ‘gold-standards’. This research will ensure these patterns can be understood in order to design and implement change, to drive down the current health inequalities, improve patient health outcomes and reduce the economic burden on the health system.

Published Papers:

• Bhimjiyani A (2019) Social and Regional Inequalities in the Incidence of and Outcomes after Hip Fracture in England. PhD Thesis. Dept Translational Health Sciences University of Bristol, Bristol Medical School Thesis Repository

• Bhimjiyani A, Neuburger J, Jones T, Ben-Shlomo Y, Gregson CL (2018) Inequalities in hip fracture incidence are greatest in the North of England: regional analysis of the effects of social deprivation on hip fracture incidence across England. Public Health 162:25-31. doi:10.1016/j.puhe.2018.05.002

• Bhimjiyani A, Neuburger J, Jones T, Ben-Shlomo Y, Gregson CL (2018) The effect of social deprivation on hip fracture incidence in England has not changed over 14 years: an analysis of the English Hospital Episodes Statistics (2001-2015). Osteoporosis Int 29 (1):115-124. doi:10.1007/s00198-017-4238-2

• Glynn J, Hollingworth W, Bhimjiyani A, Ben-Shlomo Y, Gregson C (2020) How does deprivation influence secondary care costs after hip fracture? Osteoporosis International 31 (8):1573-1585

• Valentin G, Pedersen SE, Christensen R, Friis K, Nielsen CP, Bhimjiyani A, Gregson CL, Langdahl BL (2020) Socio-economic inequalities in fragility fracture outcomes: a systematic review and meta-analysis of prognostic observational studies. Osteoporosis International 31 (1):31-42. doi:10.1007/s00198-019-05143-y

• Patel R, Bhimjiyani A, Ben-Shlomo Y, Gregson C Social deprivation predicts adverse health outcomes after hospital admission with hip fracture in England Osteoporosis International 2020 (accepted subject to amendments)

Conference presentations:

• (2018) Bone research society, annual meeting 2017 proceedings. J Musculoskeletal Neuronal Interact 18 (1):108-151

• (2018) Osteoporosis Conference 2018 Birmingham, UK 2–4 December. Osteoporosis International 29 (2):S601-S649

These outputs underpinned a successful application to Versus Arthritis for further funding for the REDUCE study; REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (https://www.bristol.ac.uk/translational-health-sciences/research/musculoskeletal/rheumatology/research/hip-fractures/). This study has Royal Osteoporosis Society (ROS) (formerly the National Osteoporosis Society) lead for commissioning, as further evidence is required to influence clinical commissioning; and Public Health England is also part of this application. The chief investigator has reported results to the Royal College of Physicians Falls and Fragility Fracture Audit Programme, National Hip Fracture Database and to the ROS (including twice being featured in the ROS patient facing osteoporosis newsletter).