REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study (Work package 1)

The research group based at the University of Bristol requires HES and mortality data linked to National Hip Fracture Database (NHFD) data, for the purpose of investigating sources of variation in the delivery of hip fracture care and its effects on patient outcomes for the REDUCE study. This study is being undertaken at the Musculoskeletal Research Unit (MRU) within the University of Bristol.

Each year in the UK approximately 80,000 older adults fracture a hip, incurring £1.2 billion in direct medical costs alone and conveying a 30% 1-year mortality and a 22% reduction in quality-of-life. Fracture services are provided through complex multidisciplinary organisational structures. Despite UK standards and guidelines, the research group and others have shown substantial variation in hospital delivery of hip fracture care, potentially reflecting local organisational legacies and lack of commissioning expertise. Nationally, there is wide variation in hip fracture outcomes between hospitals (e.g. mortality, functional recovery, requirement for institutionalised care); whilst in part explained by patient-level risk factors, it is hypothesized that organisational factors are responsible for unwarranted variation in fracture care pathways and hence patient outcomes. Understanding sources of variation in care delivery (i.e. healthcare access), its effects on patient outcomes (i.e. inequity), permits service-level interventions to reduce unwarranted variation, maximise health equity and ultimately improve patient experience.

Researchers will analyse NHFD-HES-mortality data which covers hospitals in England, together with multiple publicly available organisational-level audits and data sources which characterise each service providing care to patients with hip fractures. The research group will quantify organisational capacity to manage fragility fractures, including delivery of emergency, orthopaedic, orthogeriatric, anaesthetic, nursing, and rehabilitation services. Statistical analyses using multi-level models, will identify the organisational factors that are responsible for the greatest variation in patient outcomes (e.g. death, length of hospital stay, osteoporosis treatment, hospital readmission's) and which typify care pathways with high-quality, consistent outcomes. Health Cost analyses will calculate NHS resource, in the year following hip fracture, attributable to organisational factors.

The research group at the MRU recently performed and published two analyses of HES data, examining inequalities in hip fracture incidence in England over the previous 14 years, and by geographic region (see https://www.ncbi.nlm.nih.gov/pubmed/28965213 and https://www.ncbi.nlm.nih.gov/pubmed/29945041). These papers examine patient-level factors. The REDUCE study follows on from this work and aims to examine how organisational-level factors explain avoidable variation in hip fracture care.

The researchers require data for processing under General Data Protection Regulation Article 6(1) (e) and Article 9(2) (j). The researchers believe that this research is in the public interest as findings will inform future commissioning/ service planning priorities for hip fracture care; provide hospital summary reports outlining their strengths and vulnerabilities; inform national review processes for hip fracture services; and together with a new Toolkit, this programme will minimize avoidable variation in fracture care and improve the quality of care for patients across the UK. The REDUCE study is a 3.5-year funded programme of work which commenced the 1st Oct 2019. It consists of three work packages. This application is for disseminated data for Work package 1:

Work package 1 (WP1)

Data are requested from the NHFD (which records all hip fractures in the NHS in England and Wales), linked to national Hospital Episodes Statistics (HES) providing clinical, surgical, anaesthetic and hospital admissions data, linked to data from the Civil Registration which records deaths, requested from NHS Digital. (For hospitals in Wales the research group have a similar dataset from the NHS Wales Informatics Service, Patient Episode Database for Wales.) To these datasets the research group will link audit and publicly available data sources, detailing how fracture services are delivered at each hospital. This will include for example, how busy the hospital’s emergency department is each year and how often patients are delayed before being found a bed, how many orthopaedic surgeons, orthogeriatricians and specialist fracture nurses each hospital employs, whether weekend orthogeriatrician cover is routine, how frequently anaesthetics for hip fracture are given by senior anaesthetists, how much post-operative physiotherapy is usually delivered, what access to rehabilitation beds is available, whether services have routine multi-disciplinary clinical governance meetings, whether bone density scanning equipment is available on site, and much more. The research group will determine which components of these hospital services account for poor patient outcomes, and which services successfully lead to good patient outcomes (both will need specific evaluation in work package 2 and will inform work package 3). There are dependencies between WP1 and WP 2 and 3.

Outputs from WP1 will:

(1) determine which four hospitals will be visited for the semi-structured interviews in WP2.

(2) identify the key organisational components impacting patient outcomes. These will be included in the WP2 semi-structured interview topic guide, to identify the best delivery models for these components of care, and barriers and facilitators to implementation.

(3) identify which organisational components of the hip fracture care pathway to focus on for the WP3 Implementation Toolkit.

(4) inform the Toolkit cost-benefit calculator for WP3 through cost analysis.

These analyses will allow The research group to distinguish between how much of these patient outcomes are explained by the health of the patient themselves and how much by the hospital services which they encounter. The research group will consider ‘competing outcomes’, e.g. a service may appear to have a short length of hospital stay, but this is explained by a high rate of early death; The research group will take such factors into account in the analyses.

The research group will provide reports for each hospital treating hip fracture in England summarising their performance using aggregated data. The research group will calculate how much is spent financially on patients in the year after hip fracture, and specifically how much is attributable to the different services hip fracture patients receive (HES Admitted Patient Care, Outpatients and Accident and Emergency). Summaries of these financial calculations will inform development of work package 3.

Work package 2 (WP2)

First, The research group will visit two hospitals with high and two hospitals with low variation in performance and conduct detailed interviews with all principal members of their hip fracture teams to understand the barriers faced by hospital services when trying to provide consistent high-quality fracture care, and the solutions that some hospitals have found which enable them to perform to a higher standard. Second, the research group will analyse 20 detailed reports which have been produced by the British Orthopaedic Association (BOA) over the last 6 years. These reports have been produced when underperforming UK hospitals have requested a ‘peer-review’, so that they can improve their hip fracture service. These reports also include a series of recommendations made by the multi-disciplinary assessment team; however, they have never been collectively analysed. There will be common themes and solutions (“lessons learnt”) in these reports which the research group believe will be of benefit to other hospitals, and which they plan to identify to inform of the outputs.

Work package 3 (WP3)

The research group will work with the Royal Osteoporosis Society (ROS) who have established experience developing Toolkits for use by hospital managers, clinical leads, and service commissioners; they have many years of experience in driving quality improvement initiatives within the osteoporosis field. Together the research group will develop an ‘Implementation Toolkit’ which will be freely available online and provide a series of instructions and guides (i.e. ‘tools’) for managers, clinical leads and commissioners to use to improve their hospital hip fracture services, encompassing service redesign/restructuring, organisational culture, and approaches to improve efficient use of limited healthcare resources. Tools will include a service improvement guide, a resource to help write a business case, a cost calculator to help budget savings versus expenditure, and a project plan. The research group will launch this Toolkit with the ROS, the British Orthopaedic Association (BOA) and the Royal College of Physicians (RCP). The ROS will provide ongoing free online access and maintenance of this Toolkit beyond the duration of this study through its website.

This application is for Work package 1 with these specific aims:

1. To determine which organisational-level factors account for patient-level outcomes (e.g. mortality, osteoporosis treatment, functional recovery, institutionalisation, re admissions and length of stay) after hip fractures across England. Mortality following a hip fracture will include deaths inside and outside hospital, based on Civil registration mortality data.

2. To calculate health costs attributable to hip fracture, incurred in the year following hip fracture, e.g. due to readmission's, long ‘super-spell’ length of stay.

The University of Bristol request linked patient-level data without personal information to enable the above analyses.

Data subjects include all men and women aged 60+ years who sustain a hip fracture, admitted to an English hospital from 1st April 2016 to 31st March 2019. However, additional HES APC data from the 1st April 2013 - 31st March 2020 are required because HES APC data for 3 years prior to the hip fracture episode and 1 year post hip fracture episode are necessary to calculate comorbidities and to derive outcomes.

The University of Bristol has considered data minimization and has taken steps to ensure the data requested are justified and limited to patients in England diagnosed in 2016-19 with hip fracture or matching the NHFD. The study team will provide a list of diagnosis ICD codes which relate to fracture of the hip (femur) and restrict the request to only those patients with these specific fractures.

In order to capture all episodes of hip fracture the researchers will use the list of diagnosis ICD codes which relate to fracture of the hip. ICD10 codes are being requested on top of the audit cohort because it will help to pick up anyone who was not captured in the audit data but had presented with the same clinical need. This HES/CRD dataset will be linked to NHFD data. It is expected that the HES/CRD extract will contain episodes not matched to NHFD data, because some hospitals may not have fail-safe systems established to capture every single hip fracture that occurs (e.g. may miss one admitted on a Sunday). It is essential to have hip fractures determined by ICD codes to allow verification of the proportion of hip fractures captured by the NHFD, and to determine how the hip fracture care pathways and outcomes compare for the group of individuals not included in the NHFD data (as those not included may be looked after by systems that are not so efficient in their care). Hip fracture is very painful and usually results in hip fracture surgery during the same episode of care, it is recommended that surgery take place within 36 hours of admission. Of note only a small proportion (<5% have a hip replacement, most are fixed using other types of operative fixation).

The University of Bristol requires details of all of the data subjects' episodes of inpatient care 3 years prior to the hip fracture episode, to understand their past medical history to see if the individuals have comorbidities. It is not feasible to limit the types of previous hospital episodes to specific ICD codes as this would bias the findings of the study.

The University of Bristol is requesting all inpatient hospital episodes and linked mortality data after the individual’s hip fracture and mortality data up to 2020, to calculate mortality, readmission (e.g.re-fracture/re operation, follow-up care), length of total hospital stay, and for calculation of health service costs post hip fracture. The date of death will enable researchers to accurately censor the patients within the survival and health costs analysis e.g. when investigating the true rate of readmission's (i.e. someone who has died cannot be readmitted).

HES APC, Outpatients, and Accident & Emergency data from 2016 - 2020 are required to derive costs to the NHS for hip fracture care in admitted patient and outpatient care and unplanned admission rates in the year following hip fracture. The research team will cost NHS resources used in the year post hip fracture, using ICD10 and OPSC4 (Intervention & Procedure) codes and spell durations, to derive Healthcare Resource Group (HRG) codes for inpatient stays and readmissions. Clinic codes will identify further outpatient and Emergency Department visits. The research team will value resources using Department of Health reference costs [References: Leal J, Gray AM, Prieto-Alhambra D, et al. Impact of hip fracture on hospital care costs: a population-based study. Osteoporosis International 2016; 27(2): 549-58 and Department of Health. NHS reference costs, 2016] and follow the statistical multiple imputation model to impute missing cost data.

Linked NHFD data are required for more detailed information regarding the hospital stay and discharge destination after hip fracture.

National data are required in order for the results to be generalizable, for all hip fractures and treating hospitals to be included and avoid selection bias. The number of years requested is necessary to account for trends in outcomes and changes in services and is limited to a specific time period. There is no alternative, less intrusive ways of achieving the study purpose.

The sole Data Controller is the University of Bristol. The Data Processor is the University of Bristol. Of the REDUCE quantitative study team, only substantive employees of the University of Bristol will access the disseminated data and only for the purposes described in this document.

The role of non-University of Bristol personnel or organisations involved in the wider REDUCE study, as described in the study protocol, have solely advisory responsibilities, contributing to the interpretation and implementation of aggregated findings, no data access/processing would be undertaken by them and all decisions about data analysis would remain with the University.

This research is funded by the research charity Versus Arthritis (VA). The funder has no role in the study design, data collection and analysis, and decision to publish, or preparation of any manuscripts.

Throughout all stages of this programme, the research team will engage with key stakeholders including NHS managers, healthcare professionals, patients and the public for interpretation, dissemination, and direct communication of the main findings. This will be facilitated through collaborations including those with the Royal Osteoporosis Society and Patient and Public Involvement (PPI) representation.

The following list shows the outputs that will be disseminated using the data received from NHS Digital specific to work package 1.

1) REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study. (Journal article and conference presentations)

2) Health costs associated with REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study. (Journal article and conference presentations)

3) Toolkit development for REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study. (Journal article and conference presentation)

4) Provision of hospital trust summary reports (n=173), with bench-marking against national standards to hospital managers. Online publication of these reports 12 months later.

However, as mentioned there are dependencies between WP1, WP 2 and 3, which include: WP1 will inform the Implementation Toolkit development, and qualitative work package.

New freely available Implementation Toolkit for service leads to inform improved hip fracture care (developed with and maintained online by the Royal Osteoporosis Society).

Revised evidence-base to support the current British Orthopaedic Association hospital peer-review process.

These will be delivered sequentially over the course of the 3.5-year programme with the first publication targeted for submission by the end of 2020. The types of journals to be targeted will depend on the nature of the findings.

The intention is for aims 1) and 2) 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 Royal Osteoporosis Society conference, the European Fragility Fracture Network conference, The Bone Research Society, the American Society of Bone and Mineral Research).

All outputs will adhere to the HES analysis guide so that data are only shown in aggregate form with small numbers suppressed.

The research team will work alongside charities and learned societies to disseminate the findings of this study using established platforms that include social media such as Twitter and a study website, as more patients are now turning to these resources for information about hip fracture care. The research team will develop Plain English summaries of findings for communication to patients and members of the public.

This research is funded by the research charity Versus Arthritis (VA) and hence the research group will work with the VA publicity office to disseminate the research findings.

The data produced by this study will inform Public Health England (PHE), for whom elimination of health inequalities is a priority target. 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, of which the applicant is chair.

Disseminating outputs to commissioners, operational managers and change agents

The commissioning landscape is changing with CCGs working together in communities that express their aims and priorities through plans for integrated care, including the integration of falls and fracture services, such as the Fracture Liaison Service (FLS). It is the research groups assessment that the precise arrangements for commissioning, including job roles, organisational structure, funding flows and so on will change during the course of this research. The research group will adopt a flexible approach to dissemination, led by the Royal Osteoporosis Society (ROS) which has skill and capacity in this area.

Disseminating outputs to health care professionals

There is a well-developed and well-motivated cohort of clinicians working in the fields of osteoporosis and fracture care. The ROS has a team of professionals and a set of networks and activities already in place that engages with this community.

Disseminating outputs for patients and the public

The outputs of this research will be hugely valuable in creating messages and information products directed at very large groups including patients with diagnosed disease; people at higher risk of fragility fracture; and the wider public. Accurate and compelling information on standards of hip fracture care help to create a favourable climate for change through mechanisms such as membership of health and well-being boards; membership of foundation trusts; messages about what patients should expect from their hip fracture teams in terms of standards of care (to compliment current NHFD patient standards); and messages about the potential for improving fractures services through a proven and cost-effective service model.

Disseminating outputs to collaborators and stakeholders

Close work with collaborators and stakeholders will enable wide dissemination of findings and the Toolkit to ‘coalface service users.

The interim expected time frame for completion of the data processing, production and dissemination of the outputs would be 24 months, with a further 18 months retention of data after this to respond to changes based on peer-review comments from journals and from funding bodies.

The research group based at the University of Bristol requires HES and mortality data linked to National Hip Fracture Database (NHFD) data, for the purpose of investigating sources of variation in the delivery of hip fracture care and its effects on patient outcomes for the REDUCE study. This study is being undertaken at the Musculoskeletal Research Unit (MRU) within the University of Bristol.

Each year in the UK approximately 80,000 older adults fracture a hip, incurring £1.2 billion in direct medical costs alone and conveying a 30% 1-year mortality and a 22% reduction in quality-of-life. Fracture services are provided through complex multidisciplinary organisational structures. Despite UK standards and guidelines, the research group and others have shown substantial variation in hospital delivery of hip fracture care, potentially reflecting local organisational legacies and lack of commissioning expertise. Nationally, there is wide variation in hip fracture outcomes between hospitals (e.g. mortality, functional recovery, requirement for institutionalised care); whilst in part explained by patient-level risk factors, it is hypothesized that organisational factors are responsible for unwarranted variation in fracture care pathways and hence patient outcomes. Understanding sources of variation in care delivery (i.e. healthcare access), its effects on patient outcomes (i.e. inequity), permits service-level interventions to reduce unwarranted variation, maximise health equity and ultimately improve patient experience.

Researchers will analyse NHFD-HES-mortality data which covers hospitals in England, together with multiple publicly available organisational-level audits and data sources which characterise each service providing care to patients with hip fractures. The research group will quantify organisational capacity to manage fragility fractures, including delivery of emergency, orthopaedic, orthogeriatric, anaesthetic, nursing, and rehabilitation services. Statistical analyses using multi-level models, will identify the organisational factors that are responsible for the greatest variation in patient outcomes (e.g. death, length of hospital stay, osteoporosis treatment, hospital readmission's) and which typify care pathways with high-quality, consistent outcomes. Health Cost analyses will calculate NHS resource, in the year following hip fracture, attributable to organisational factors.

The research group at the MRU recently performed and published two analyses of HES data, examining inequalities in hip fracture incidence in England over the previous 14 years, and by geographic region (see https://www.ncbi.nlm.nih.gov/pubmed/28965213 and https://www.ncbi.nlm.nih.gov/pubmed/29945041). These papers examine patient-level factors. The REDUCE study follows on from this work and aims to examine how organisational-level factors explain avoidable variation in hip fracture care.

The researchers require data for processing under General Data Protection Regulation Article 6(1) (e) and Article 9(2) (j). The researchers believe that this research is in the public interest as findings will inform future commissioning/ service planning priorities for hip fracture care; provide hospital summary reports outlining their strengths and vulnerabilities; inform national review processes for hip fracture services; and together with a new Toolkit, this programme will minimize avoidable variation in fracture care and improve the quality of care for patients across the UK. The REDUCE study is a 3.5-year funded programme of work which commenced the 1st Oct 2019. It consists of three work packages. This application is for disseminated data for Work package 1:

Work package 1 (WP1)

Data are requested from the NHFD (which records all hip fractures in the NHS in England and Wales), linked to national Hospital Episodes Statistics (HES) providing clinical, surgical, anaesthetic and hospital admissions data, linked to data from the Civil Registration which records deaths, requested from NHS Digital. (For hospitals in Wales the research group have a similar dataset from the NHS Wales Informatics Service, Patient Episode Database for Wales.) To these datasets the research group will link audit and publicly available data sources, detailing how fracture services are delivered at each hospital. This will include for example, how busy the hospital’s emergency department is each year and how often patients are delayed before being found a bed, how many orthopaedic surgeons, orthogeriatricians and specialist fracture nurses each hospital employs, whether weekend orthogeriatrician cover is routine, how frequently anaesthetics for hip fracture are given by senior anaesthetists, how much post-operative physiotherapy is usually delivered, what access to rehabilitation beds is available, whether services have routine multi-disciplinary clinical governance meetings, whether bone density scanning equipment is available on site, and much more. The research group will determine which components of these hospital services account for poor patient outcomes, and which services successfully lead to good patient outcomes (both will need specific evaluation in work package 2 and will inform work package 3). There are dependencies between WP1 and WP 2 and 3.

Outputs from WP1 will:

(1) determine which four hospitals will be visited for the semi-structured interviews in WP2.

(2) identify the key organisational components impacting patient outcomes. These will be included in the WP2 semi-structured interview topic guide, to identify the best delivery models for these components of care, and barriers and facilitators to implementation.

(3) identify which organisational components of the hip fracture care pathway to focus on for the WP3 Implementation Toolkit.

(4) inform the Toolkit cost-benefit calculator for WP3 through cost analysis.

These analyses will allow The research group to distinguish between how much of these patient outcomes are explained by the health of the patient themselves and how much by the hospital services which they encounter. The research group will consider ‘competing outcomes’, e.g. a service may appear to have a short length of hospital stay, but this is explained by a high rate of early death; The research group will take such factors into account in the analyses.

The research group will provide reports for each hospital treating hip fracture in England summarising their performance using aggregated data. The research group will calculate how much is spent financially on patients in the year after hip fracture, and specifically how much is attributable to the different services hip fracture patients receive (HES Admitted Patient Care, Outpatients and Accident and Emergency). Summaries of these financial calculations will inform development of work package 3.

Work package 2 (WP2)

First, The research group will visit two hospitals with high and two hospitals with low variation in performance and conduct detailed interviews with all principal members of their hip fracture teams to understand the barriers faced by hospital services when trying to provide consistent high-quality fracture care, and the solutions that some hospitals have found which enable them to perform to a higher standard. Second, the research group will analyse 20 detailed reports which have been produced by the British Orthopaedic Association (BOA) over the last 6 years. These reports have been produced when underperforming UK hospitals have requested a ‘peer-review’, so that they can improve their hip fracture service. These reports also include a series of recommendations made by the multi-disciplinary assessment team; however, they have never been collectively analysed. There will be common themes and solutions (“lessons learnt”) in these reports which the research group believe will be of benefit to other hospitals, and which they plan to identify to inform of the outputs.

Work package 3 (WP3)

The research group will work with the Royal Osteoporosis Society (ROS) who have established experience developing Toolkits for use by hospital managers, clinical leads, and service commissioners; they have many years of experience in driving quality improvement initiatives within the osteoporosis field. Together the research group will develop an ‘Implementation Toolkit’ which will be freely available online and provide a series of instructions and guides (i.e. ‘tools’) for managers, clinical leads and commissioners to use to improve their hospital hip fracture services, encompassing service redesign/restructuring, organisational culture, and approaches to improve efficient use of limited healthcare resources. Tools will include a service improvement guide, a resource to help write a business case, a cost calculator to help budget savings versus expenditure, and a project plan. The research group will launch this Toolkit with the ROS, the British Orthopaedic Association (BOA) and the Royal College of Physicians (RCP). The ROS will provide ongoing free online access and maintenance of this Toolkit beyond the duration of this study through its website.

This application is for Work package 1 with these specific aims:

1. To determine which organisational-level factors account for patient-level outcomes (e.g. mortality, osteoporosis treatment, functional recovery, institutionalisation, re admissions and length of stay) after hip fractures across England. Mortality following a hip fracture will include deaths inside and outside hospital, based on Civil registration mortality data.

2. To calculate health costs attributable to hip fracture, incurred in the year following hip fracture, e.g. due to readmission's, long ‘super-spell’ length of stay.

The University of Bristol request linked patient-level data without personal information to enable the above analyses.

Data subjects include all men and women aged 60+ years who sustain a hip fracture, admitted to an English hospital from 1st April 2016 to 31st March 2019. However, additional HES APC data from the 1st April 2013 - 31st March 2020 are required because HES APC data for 3 years prior to the hip fracture episode and 1 year post hip fracture episode are necessary to calculate comorbidities and to derive outcomes.

The University of Bristol has considered data minimization and has taken steps to ensure the data requested are justified and limited to patients in England diagnosed in 2016-19 with hip fracture or matching the NHFD. The study team will provide a list of diagnosis ICD codes which relate to fracture of the hip (femur) and restrict the request to only those patients with these specific fractures.

In order to capture all episodes of hip fracture the researchers will use the list of diagnosis ICD codes which relate to fracture of the hip. ICD10 codes are being requested on top of the audit cohort because it will help to pick up anyone who was not captured in the audit data but had presented with the same clinical need. This HES/CRD dataset will be linked to NHFD data. It is expected that the HES/CRD extract will contain episodes not matched to NHFD data, because some hospitals may not have fail-safe systems established to capture every single hip fracture that occurs (e.g. may miss one admitted on a Sunday). It is essential to have hip fractures determined by ICD codes to allow verification of the proportion of hip fractures captured by the NHFD, and to determine how the hip fracture care pathways and outcomes compare for the group of individuals not included in the NHFD data (as those not included may be looked after by systems that are not so efficient in their care). Hip fracture is very painful and usually results in hip fracture surgery during the same episode of care, it is recommended that surgery take place within 36 hours of admission. Of note only a small proportion (<5% have a hip replacement, most are fixed using other types of operative fixation).

The University of Bristol requires details of all of the data subjects' episodes of inpatient care 3 years prior to the hip fracture episode, to understand their past medical history to see if the individuals have comorbidities. It is not feasible to limit the types of previous hospital episodes to specific ICD codes as this would bias the findings of the study.

The University of Bristol is requesting all inpatient hospital episodes and linked mortality data after the individual’s hip fracture and mortality data up to 2020, to calculate mortality, readmission (e.g.re-fracture/re operation, follow-up care), length of total hospital stay, and for calculation of health service costs post hip fracture. The date of death will enable researchers to accurately censor the patients within the survival and health costs analysis e.g. when investigating the true rate of readmission's (i.e. someone who has died cannot be readmitted).

HES APC, Outpatients, and Accident & Emergency data from 2016 - 2020 are required to derive costs to the NHS for hip fracture care in admitted patient and outpatient care and unplanned admission rates in the year following hip fracture. The research team will cost NHS resources used in the year post hip fracture, using ICD10 and OPSC4 (Intervention & Procedure) codes and spell durations, to derive Healthcare Resource Group (HRG) codes for inpatient stays and readmissions. Clinic codes will identify further outpatient and Emergency Department visits. The research team will value resources using Department of Health reference costs [References: Leal J, Gray AM, Prieto-Alhambra D, et al. Impact of hip fracture on hospital care costs: a population-based study. Osteoporosis International 2016; 27(2): 549-58 and Department of Health. NHS reference costs, 2016] and follow the statistical multiple imputation model to impute missing cost data.

Linked NHFD data are required for more detailed information regarding the hospital stay and discharge destination after hip fracture.

National data are required in order for the results to be generalizable, for all hip fractures and treating hospitals to be included and avoid selection bias. The number of years requested is necessary to account for trends in outcomes and changes in services and is limited to a specific time period. There is no alternative, less intrusive ways of achieving the study purpose.

The sole Data Controller is the University of Bristol. The Data Processor is the University of Bristol. Of the REDUCE quantitative study team, only substantive employees of the University of Bristol will access the disseminated data and only for the purposes described in this document.

The role of non-University of Bristol personnel or organisations involved in the wider REDUCE study, as described in the study protocol, have solely advisory responsibilities, contributing to the interpretation and implementation of aggregated findings, no data access/processing would be undertaken by them and all decisions about data analysis would remain with the University.

This research is funded by the research charity Versus Arthritis (VA). The funder has no role in the study design, data collection and analysis, and decision to publish, or preparation of any manuscripts.

Throughout all stages of this programme, the research team will engage with key stakeholders including NHS managers, healthcare professionals, patients and the public for interpretation, dissemination, and direct communication of the main findings. This will be facilitated through collaborations including those with the Royal Osteoporosis Society and Patient and Public Involvement (PPI) representation.

The following list shows the outputs that will be disseminated using the data received from NHS Digital specific to work package 1.

1) REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study. (Journal article and conference presentations)

2) Health costs associated with REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study. (Journal article and conference presentations)

3) Toolkit development for REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study. (Journal article and conference presentation)

4) Provision of hospital trust summary reports (n=173), with bench-marking against national standards to hospital managers. Online publication of these reports 12 months later.

However, as mentioned there are dependencies between WP1, WP 2 and 3, which include: WP1 will inform the Implementation Toolkit development, and qualitative work package.

New freely available Implementation Toolkit for service leads to inform improved hip fracture care (developed with and maintained online by the Royal Osteoporosis Society).

Revised evidence-base to support the current British Orthopaedic Association hospital peer-review process.

These will be delivered sequentially over the course of the 3.5-year programme with the first publication targeted for submission by the end of 2020. The types of journals to be targeted will depend on the nature of the findings.

The intention is for aims 1) and 2) 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 Royal Osteoporosis Society conference, the European Fragility Fracture Network conference, The Bone Research Society, the American Society of Bone and Mineral Research).

All outputs will adhere to the HES analysis guide so that data are only shown in aggregate form with small numbers suppressed.

The research team will work alongside charities and learned societies to disseminate the findings of this study using established platforms that include social media such as Twitter and a study website, as more patients are now turning to these resources for information about hip fracture care. The research team will develop Plain English summaries of findings for communication to patients and members of the public.

This research is funded by the research charity Versus Arthritis (VA) and hence the research group will work with the VA publicity office to disseminate the research findings.

The data produced by this study will inform Public Health England (PHE), for whom elimination of health inequalities is a priority target. 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, of which the applicant is chair.

Disseminating outputs to commissioners, operational managers and change agents

The commissioning landscape is changing with CCGs working together in communities that express their aims and priorities through plans for integrated care, including the integration of falls and fracture services, such as the Fracture Liaison Service (FLS). It is the research groups assessment that the precise arrangements for commissioning, including job roles, organisational structure, funding flows and so on will change during the course of this research. The research group will adopt a flexible approach to dissemination, led by the Royal Osteoporosis Society (ROS) which has skill and capacity in this area.

Disseminating outputs to health care professionals

There is a well-developed and well-motivated cohort of clinicians working in the fields of osteoporosis and fracture care. The ROS has a team of professionals and a set of networks and activities already in place that engages with this community.

Disseminating outputs for patients and the public

The outputs of this research will be hugely valuable in creating messages and information products directed at very large groups including patients with diagnosed disease; people at higher risk of fragility fracture; and the wider public. Accurate and compelling information on standards of hip fracture care help to create a favourable climate for change through mechanisms such as membership of health and well-being boards; membership of foundation trusts; messages about what patients should expect from their hip fracture teams in terms of standards of care (to compliment current NHFD patient standards); and messages about the potential for improving fractures services through a proven and cost-effective service model.

Disseminating outputs to collaborators and stakeholders

Close work with collaborators and stakeholders will enable wide dissemination of findings and the Toolkit to ‘coalface service users.

The interim expected time frame for completion of the data processing, production and dissemination of the outputs would be 24 months, with a further 18 months retention of data after this to respond to changes based on peer-review comments from journals and from funding bodies.

Yielded Benefits is not a requirement for new applications.