Periprosthetic femoral fractures: data, management and outcomes

Research question What variations exist around periprosthetic femoral fracture (PPFF) treatment and outcomes, why do those variations exist, and what should be done to improve the situation? Background Hip and knee joint replacements are common operations and, due to an ageing and increasingly frail population, are forecast to grow greatly in the coming years. With this will come a rise in PPFFs, a known complication, when the bone around the prosthesis breaks. Costs are high, and outcomes can be poor. There is a lack of reliable data on the extent of variations in management and outcomes and the reasons for them. Other than our team’s initial work, existing data have been little analysed. There is also uncertainty over which service model(s) is considered best by staff and patients. We aim to fill these key gaps through a mixed-methods study of three work packages (WPs). Aims and objectives 1. Assess the variation between hospitals in England in how these patients are managed and their outcomes 2. Obtain healthcare professionals’ views on how patients should be managed, collecting new qualitative data from case study hospitals 3. Obtain patients’, family members’ and carers’ views on what they want from care during and after the fracture has been treated, including, for instance, on whether they would be willing to travel to a specialised centre 4. Define measures of quality of care to assess future improvement efforts, also exploring the best way to collect any necessary additional data Methods WP1 (Objective 1) will use Hospital Episodes Statistics (HES), the National Hip Fracture Database (NHFD), Trauma Audit and Research Network (TARN) and the National Joint Registry (NJR), each telling us part of the picture. Predictors of outcomes and variations in processes and outcomes between hospitals and service models will be estimated through multilevel models and funnel plots. Models will include a volume-outcome analysis. WP2 (Objectives 2 and 3): 4-6 case study sites, identified from HES data in WP1 and purposively sampled for ‘maximum variation’ of geographical and demographic variations, access to specialised services, and service models (referral centre, referring centre and self-sufficient centre). Case studies will follow an instrumental approach, involving in-person visits, interviews with staff, patients and carers, and review of protocols, guidelines and policies. WP3 (Objective 4): Delphi study to agree on quality-of-care measures, risk-adjustment and the process for collecting new data. This will use a three-step process, with the initial measure set drawn from WP1 findings, the literature and team expertise. We will also co-produce resources for patients and families on what to expect from PPFF treatment and recovery. Timelines M1-6: set-up, ethics and data applications, early HES analysis to identify case study sites M7-24: WP1 analysis for HES, NHFD and TARN and write-up; WP2 data collection and analysis M25-30: WP1 analysis for NJR; WP2 write-up; WP3 M31-36: remaining WP1 analysis and write-up; report to funder Anticipated impact and dissemination Our findings will inform clinical guidelines and service redesign decisions. We will disseminate through our networks, professional bodies, NHS England, NICE, charities, and through blogs and academic routes. Hospital-level feedback and reporting of performance measured through our indicators will be possible in the future via the NJR’s and NHFD’s existing web portals.