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Quality indicators in the treatment of geriatric hip fractures: literature review and expert consensus

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A Correction to this article was published on 22 April 2022

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Abstract

Purpose

Even though hip fracture care pathways have evolved, mortality rates have not improved during the last 20 years. This finding together with the increased frailty of hip fracture patients turned hip fractures into a major public health concern. The corresponding development of an indicator labyrinth for hip fractures and the ongoing practice variance in Europe call for a list of benchmarking indicators that allow for quality improvement initiatives for the rapid recovery of fragile hip fractures (RR-FHF). The purpose of this study was to identify quality indicators that assess the quality of in-hospital care for rapid recovery of fragile hip fracture (RR-FHF).

Methods

A literature search and guideline selection was conducted to identify recommendations for RR-FHF. Recommendations were categorized as potential structure, process, and outcome QIs and subdivided in-hospital care treatment topics. A list of structure and process recommendations that belongs to care treatment topics relevant for RR-FHF was used to facilitate extraction of recommendations during a 2-day consensus meeting with experts (n = 15) in hip fracture care across Europe. Participants were instructed to select 5 key recommendations relevant for RR-FHF for each part of the in-hospital care pathway: pre-, intra-, and postoperative care.

Results

In total, 37 potential QIs for RR-FHF were selected based on a methodology using the combination of high levels of evidence and expert opinion. The set consists of 14 process, 13 structure, and 10 outcome indicators that cover the whole perioperative process of fragile hip fracture care.

Conclusion

We suggest the QIs for RR-FHF to be practice tested and adapted to allow for intra-hospital longitudinal follow-up of the quality of care and for inter-hospital and cross-country benchmarking and quality improvement initiatives.

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Fig. 1

Adapted from Kotter et al. 2012: step 1 to 4 of the stepwise approach for a guideline-based development of QI

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Availability of data and material

The shortlist of 306 process recommendations is available upon request.

Code availability

Not applicable.

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References

  1. Williamson S, Landeiro F, McConnell T, Fulford-Smith L, Javaid MK, Judge A, Leal J (2017) Costs of fragility hip fractures globally: a systematic review and meta-regression analysis. Osteoporos Int 28(10):2791–2800. https://doi.org/10.1007/s00198-017-4153-6

    Article  CAS  PubMed  Google Scholar 

  2. Rapp K, Büchele G, Dreinhöfer K, Bücking B, Becker C, Benzinger P (2019) Epidemiology of hip fractures. Z Gerontol Geriatr 52(1):10–16. https://doi.org/10.1007/s00391-018-1382-z

    Article  PubMed  Google Scholar 

  3. Brown CA, Starr AZ, Nunley JA (2012) Analysis of past secular trends of hip fractures and predicted number in the future 2010–2050. J Orthop Trauma 26(2):117–122. https://doi.org/10.1097/BOT.0b013e318219c61a

    Article  PubMed  Google Scholar 

  4. Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR (2009) Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 301(5):513–521. https://doi.org/10.1001/jama.2009.50

    Article  CAS  PubMed  Google Scholar 

  5. Guzon-Illescas O, Perez Fernandez E, Crespí Villarias N, Quirós Donate FJ, Peña M, Alonso-Blas C, García-Vadillo A, Mazzucchelli R (2019) Mortality after osteoporotic hip fracture: incidence, trends, and associated factors. J Orthop Surg Res 14(1):203. https://doi.org/10.1186/s13018-019-1226-6

    Article  PubMed  PubMed Central  Google Scholar 

  6. Al-Ani AN, Samuelsson B, Tidermark J, Norling A, Ekström W, Cederholm T, Hedström M (2008) Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Jt Surg Am 90(7):1436–1442. https://doi.org/10.2106/jbjs.G.00890

    Article  Google Scholar 

  7. Gupta A, Havelock W (2014) A new future for hip fracture care—orthogeriatrician lead in an ‘Acute’ Hip Unit. Clin Med 14(6):591–596. https://doi.org/10.7861/clinmedicine.14-6-591

    Article  Google Scholar 

  8. Bracey DN, Kiymaz TC, Holst DC, Hamid KS, Plate JF, Summers EC, Emory CL, Jinnah RH (2016) An orthopedic-hospitalist comanaged hip fracture service reduces inpatient length of stay. Geriatric orthopaedic surgery & rehabilitation 7(4):171–177. https://doi.org/10.1177/2151458516661383

    Article  Google Scholar 

  9. Panella M, Seys D, Sermeus W, Bruyneel L, Lodewijckx C, Deneckere S, Sermon A, Nijs S, Boto P, Vanhaecht K (2018) Minimal impact of a care pathway for geriatric hip fracture patients. Injury 49(8):1581–1586. https://doi.org/10.1016/j.injury.2018.06.005

    Article  PubMed  Google Scholar 

  10. Lamb LC, Montgomery SC, Wong Won B, Harder S, Meter J, Feeney JM (2017) A multidisciplinary approach to improve the quality of care for patients with fragility fractures. J Orthop 14(2):247–251. https://doi.org/10.1016/j.jor.2017.03.004

    Article  PubMed  PubMed Central  Google Scholar 

  11. Moyet J, Deschasse G, Marquant B, Mertl P, Bloch F (2019) Which is the optimal orthogeriatric care model to prevent mortality of elderly subjects post hip fractures? A systematic review and meta-analysis based on current clinical practice. Int Orthop 43(6):1449–1454. https://doi.org/10.1007/s00264-018-3928-5

    Article  CAS  PubMed  Google Scholar 

  12. Talevski J, Sanders KM, Duque G, Connaughton C, Beauchamp A, Green D, Millar L, Brennan-Olsen SL (2019) Effect of clinical care pathways on quality of life and physical function after fragility fracture: a meta-analysis. J Am Med Dir Assoc 20 (7):926 e921–926 e911. doi:https://doi.org/10.1016/j.jamda.2019.02.022

  13. Flikweert ER, Diercks RL, Izaks GJ, Wendt KW, Stevens M, Reininga IHF (2019) Strict adherence to evidence-based protocol in choice of implants and surgical technique leads to fewer hip fracture reoperations. PLoS ONE 14(1):e0210239. https://doi.org/10.1371/journal.pone.0210239

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. van Zelm R, Coeckelberghs E, Sermeus W, Wolthuis A, Bruyneel L, Panella M, Vanhaecht K (2020) Effects of implementing a care pathway for colorectal cancer surgery in ten European hospitals: an international multicenter pre–post-test study. Updates Surg 72(1):61–71. https://doi.org/10.1007/s13304-020-00706-9

  15. Middleton M (2018) Orthogeriatrics and hip fracture care in the UK: factors driving change to more integrated models of care. Geriatrics 3(3):55

    Article  PubMed Central  Google Scholar 

  16. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA (2003) The quality of health care delivered to adults in the United States. N Engl J Med 348(26):2635–2645. https://doi.org/10.1056/NEJMsa022615

    Article  PubMed  Google Scholar 

  17. Voeten SC, Arends AJ, Wouters M, Blom BJ, Heetveld MJ, Slee-Valentijn MS, Krijnen P, Schipper IB, Hegeman JHH, Dutch Hip Fracture Audit G (2019) The Dutch hip fracture audit: evaluation of the quality of multidisciplinary hip fracture care in the Netherlands. Arch Osteoporos 14(1):28. https://doi.org/10.1007/s11657-019-0576-3

    Article  PubMed  PubMed Central  Google Scholar 

  18. Farrow L, Hall A, Wood AD, Smith R, James K, Holt G, Hutchison J, Myint PK (2018) Quality of care in hip fracture patients: the relationship between adherence to national standards and improved outcomes. J Bone Jt Surg Am 100(9):751–757. https://doi.org/10.2106/JBJS.17.00884

    Article  Google Scholar 

  19. Mears SC, Kates SL (2015) A guide to improving the care of patients with fragility fractures, Edition 2. Geriatr Orthop Surg Rehabil 6(2):58–120. https://doi.org/10.1177/2151458515572697

    Article  PubMed  PubMed Central  Google Scholar 

  20. Seys D, Sermon A, Sermeus W, Panella M, Bruyneel L, Boto P, Vanhaecht K (2018) Recommended care received by geriatric hip fracture patients: where are we now and where are we heading? Arch Orthop Trauma Surg 138(8):1077–1087. https://doi.org/10.1007/s00402-018-2939-4

  21. Kammerlander C, Roth T, Friedman SM, Suhm N, Luger TJ, Kammerlander-Knauer U, Krappinger D, Blauth M (2010) Ortho-geriatric service–a literature review comparing different models. Osteoporos Int 21(Suppl 4):S637-646. https://doi.org/10.1007/s00198-010-1396-x

    Article  CAS  PubMed  Google Scholar 

  22. Lloyd R (2019) Quality health care: a guide to developing and using indicators, 2nd edn. Jones & Bartlett Learning, Burlington, MA

    Google Scholar 

  23. Expert Panel on Effective Ways of Investing in Health (EXPH) (2019) Opinion on Defining value in “value-based healthcare.” In European Commission. https://doi.org/10.2875/35471

  24. WHO, OECD, TWB (2018) Delivering quality health services. http://apps.who.int/bookorders

  25. OECD (2014) Geographic Variations in Health Care. https://doi.org/10.1787/9789264216594-en

  26. Campbell SM, Braspenning J, Hutchinson A, Marshall MN (2003) Research methods used in developing and applying quality indicators in primary care. BMJ 326(7393):816–819. https://doi.org/10.1136/bmj.326.7393.816

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Dimick JB (2010) What makes a “Good” quality indicator?: Comment on “Quality Indicators for Evaluating Trauma Care.” Arch Surg 145(3):295–295. https://doi.org/10.1001/archsurg.2009.291

    Article  PubMed  Google Scholar 

  28. Mainz J (2003) Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 15(6):523–530. https://doi.org/10.1093/intqhc/mzg081

    Article  PubMed  Google Scholar 

  29. Kötter T, Blozik E, Scherer M (2012) Methods for the guideline-based development of quality indicators–a systematic review. Implement Sci 7(1):21. https://doi.org/10.1186/1748-5908-7-21

    Article  PubMed  PubMed Central  Google Scholar 

  30. Donabedian A (1988) The quality of care. How can it be assessed? Jama 260(12):1743–1748. https://doi.org/10.1001/jama.260.12.1743

    Article  CAS  PubMed  Google Scholar 

  31. Campbell SM, Braspenning J, Hutchinson A, Marshall M (2002) Research methods used in developing and applying quality indicators in primary care. Qual Saf Health Care 11(4):358–364. https://doi.org/10.1136/qhc.11.4.358

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Martin-Khan M, Burkett E, Schnitker L, Jones RN, Gray LC (2013) Methodology for developing quality indicators for the care of older people in the Emergency Department. BMC Emerg Med 13(1):23. https://doi.org/10.1186/1471-227X-13-23

    Article  PubMed  PubMed Central  Google Scholar 

  33. Voeten SC, Krijnen P, Voeten DM, Hegeman JH, Wouters M, Schipper IB (2018) Quality indicators for hip fracture care, a systematic review. Osteoporosis Int 29(9):1963–1985. https://doi.org/10.1007/s00198-018-4558-x

    Article  CAS  Google Scholar 

  34. National Institute for Health and Care Excellence (NICE) (2011) The management of hip fracture in adults (clinical guide- line CG124).(N. I. for H. and C. Excellence, Ed.)

  35. Scottish Intercollegiate Guidelines Network (SIGN) (2009) Management of hip fracture in older people. SIGN Guideline No. 111. http://www.sign.ac.uk/guidelines/fulltext/111/

  36. Australian and New Zealand Hip Fracture Registry (ANZHFR) (2014) Australian and New Zealand guideline for hip fracture care: improving outcomes in hip fracture management.

  37. American Academy of Orthopaedic Surgeons (AAOS) (2014) Management of hip fractures in the elderly. Evidence Based Clinical Practice Guideline

  38. Pitzul KB, Munce SE, Perrier L, Beaupre L, Morin SN, McGlasson R, Jaglal SB (2017) Scoping review of potential quality indicators for hip fracture patient care. BMJ Open 7(3):e014769. https://doi.org/10.1136/bmjopen-2016-014769

    Article  PubMed  PubMed Central  Google Scholar 

  39. Nijs S (2018) Rapid Recovery Fragility Fracture: HIP. Evidence-based recommendations summary update

  40. Dong Y, Xu J (2016) Introduction. In: Dong Y, Xu J (eds) Consensus building in group decision making: searching the consensus path with minimum adjustments. Springer, Singapore, pp 1–15. https://doi.org/10.1007/978-981-287-892-2_1

  41. Zhu S, Qian W, Jiang C, Ye C, Chen X (2017) Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis. Postgrad Med J 93(1106):736–742. https://doi.org/10.1136/postgradmedj-2017-134991

    Article  PubMed  Google Scholar 

  42. Liu VX, Rosas E, Hwang J, Cain E, Foss-Durant A, Clopp M, Huang M, Lee DC, Mustille A, Kipnis P, Parodi S (2017) Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system. JAMA Surg 152(7):e171032. https://doi.org/10.1001/jamasurg.2017.1032

    Article  PubMed  PubMed Central  Google Scholar 

  43. Paduraru M, Ponchietti L, Casas IM, Svenningsen P, Zago M (2017) Enhanced recovery after emergency surgery: a systematic review. Bull Emerg Trauma 5(2):70–78

    PubMed  PubMed Central  Google Scholar 

  44. Kehlet H (2008) Fast-track colorectal surgery. Lancet 371(9615):791–793. https://doi.org/10.1016/S0140-6736(08)60357-8

    Article  PubMed  Google Scholar 

  45. Zanker J, Duque G (2017) Rapid geriatric assessment of hip fracture. Clin Geriatr Med 33(3):369–382. https://doi.org/10.1016/j.cger.2017.03.003

    Article  PubMed  Google Scholar 

  46. Klestil T, Roder C, Stotter C, Winkler B, Nehrer S, Lutz M, Klerings I, Wagner G, Gartlehner G, Nussbaumer-Streit B (2018) Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Sci Rep 8(1):13933. https://doi.org/10.1038/s41598-018-32098-7

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Baer M, Neuhaus V, Pape HC, Ciritsis B (2019) Influence of mobilization and weight bearing on in-hospital outcome in geriatric patients with hip fractures. SICOT J 5:4. https://doi.org/10.1051/sicotj/2019005

    Article  PubMed  PubMed Central  Google Scholar 

  48. Warren J, Sundaram K, Anis H, McLaughlin J, Patterson B, Higuera CA, Piuzzi NS (2019) The association between weight-bearing status and early complications in hip fractures. Eur J Orthop Surg Traumatol 29(7):1419–1427. https://doi.org/10.1007/s00590-019-02453-z

    Article  PubMed  Google Scholar 

  49. Kristensen MT, Kehlet H (2018) The basic mobility status upon acute hospital discharge is an independent risk factor for mortality up to 5 years after hip fracture surgery. Acta Orthop 89(1):47–52. https://doi.org/10.1080/17453674.2017.1382038

    Article  PubMed  Google Scholar 

  50. Seys D, Bruyneel L, Decramer M, Lodewijckx C, Panella M, Sermeus W, Boto P, Vanhaecht K (2017) An international study of adherence to guidelines for patients hospitalised with a COPD exacerbation. Copd 14(2):156–163. https://doi.org/10.1080/15412555.2016.1257599

  51. Aeyels D, Sinnaeve PR, Claeys MJ, Gevaert S, Schoors D, Sermeus W, Panella M, Coeckelberghs E, Bruyneel L, Vanhaecht K (2017) Key interventions and quality indicators for quality improvement of STEMI care: a RAND Delphi survey. Acta Cardiol. https://doi.org/10.1080/00015385.2017.1411664

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Acknowledgements

We wish to thank Nikj Mancini (San Raffaele Hospital), Monica Celi (Policlinico Tor Vergata), Julie Parkinson (Leeds Teaching Hospitals NHS Trust), Till Berk (University Hospital Zürich), Daniel Schmitt (University Hospital Zürich), and Maziar Mohaddes (Sahlgrenska University Hospital Mölndal) for their participation in the consensus meeting.

Funding

This study was supported by a grant of Zimmer Biomet.

Author information

Authors and Affiliations

  1. KU Leuven, Leuven, Belgium

    An Sermon, Cedric Slock & Stefaan Nijs

  2. Traumatology Department at University Hospitals Leuven, Leuven, Belgium

    An Sermon

  3. Leuven Institute for Healthcare Policy, Leuven, KU, Belgium

    Ellen Coeckelberghs, Deborah Seys, Luk Bruyneel & Kris Vanhaecht

  4. European Pathway Association, Leuven, Belgium

    Ellen Coeckelberghs, Massimiliano Panella & Kris Vanhaecht

  5. Università Degli Studi del Piemonte Orientale “Amedeo Avogadro”, Novara, Italy

    Massimiliano Panella

  6. Hôpital Riviera Chablais, Rennaz, Switzerland

    Alain Akiki

  7. Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España

    Pablo Castillon

  8. Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, España

    Pablo Castillon

  9. Consultant Trauma and Orthopaedic Surgeon, East Kent Hospitals NHS Trust, Kent, UK

    Alex Chipperfield

  10. Klinik für Orthopädie und Unfallchirurgie, Sporttraumatologie, Landeskrankenhaus Feldkirch, Feldkirch, Austria

    René El Attal

  11. Departments of Anaesthesia and Intensive Care, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Nicolai Bang Foss

  12. Orthopaedic Department, Østfold Hospital Trust, Grålum, Norway

    Frede Frihagen

  13. Associate Professor, Institute of Clinical Medicine, University of Oslo, Oslo, Norway

    Frede Frihagen

  14. Head of Orthopaedic Trauma, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg

    Torsten G Gerich

  15. Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany

    Denis Gümbel

  16. Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany

    Denis Gümbel

  17. Leeds Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

    Nikolaos Kanakaris

  18. Departments of Physiotherapy and Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark

    Morten Tange Kristensen

  19. Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Morten Tange Kristensen

  20. Sahlgrenska University Hospital, Gothenburg, Sweden

    Inger Malchau

  21. Head of Department, Department of Orthopedics, Copenhagen University Hospital Bispebjerg, Bispebjerg, Denmark

    Henrik Palm

  22. Department of Trauma, University of Zurich, Universitäts Spital Zurich, Zurich, Switzerland

    Hans-Christoph Pape

  23. Department of Quality, University Hospitals Leuven, Leuven, Belgium

    Kris Vanhaecht

Authors
  1. An Sermon
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  2. Cedric Slock
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Contributions

AS, CS, EC, and DS wrote the article. KV, AS, SN, LB, and MP contributed to the design and implementation of the research, to the analysis of the results, and to the review process of the manuscript. All authors reviewed the article.

Corresponding author

Correspondence to Kris Vanhaecht.

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Conflicts of interest

AS is an associate professor at KU Leuven and trauma surgeon at the University Hospitals Leuven and has no conflicts to disclose. CS is a research assistant at the Leuven Institute for Healthcare Policy and has no conflicts to disclose. SN is a full professor at the KU Leuven and head of traumatology department at the University Hospitals Leuven and has no conflicts to disclose. EC is a postdoctoral researcher at the Leuven Institute for Healthcare Policy, office manager of the European Pathway Association, and has no conflicts to disclose. DS is a postdoctoral researcher at the Leuven Institute for Healthcare Policy and has no conflicts to disclose. LB is a postdoctoral researcher at the Leuven Institute for Healthcare Policy and has no conflicts to disclose. MP is full professor at Università degli Studi del Piemonte Orientale “Amedeo Avogadro” and president of the European Pathway Association. KV is associate professor at the Leuven Institute for Healthcare Policy, Policy Advisor of the Department of Quality, University Hospitals Leuven, Belgium and Secretary General of the European Pathway Association and has received a research grant from Zimmer Biomet to conduct this study.

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Sermon, A., Slock, C., Coeckelberghs, E. et al. Quality indicators in the treatment of geriatric hip fractures: literature review and expert consensus. Arch Osteoporos 16, 152 (2021). https://doi.org/10.1007/s11657-021-00995-6

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