Bone health

Lessons from the Hip Fracture Registry: Professor Jacqui Close

Getting the strategy right at the start, sharing of data in an open transparent way, and being prepared for a marathon are all key factors to building a fracture registry that will ultimately have a positive impact on patient care, says Professor Jacqueline Close, geriatrician and co-chair of the Australian and New Zealand Hip Fracture Registry.

Sharing the experiences of the ANZHFR registry at the FLS Forum hosted by Amgen in Sydney, Professor Close told delegates that to put up a compelling argument for a registry there needed to be a certain number of components.

“There needs to be high volume, high cost, evidence that you can make a difference and a way to manage performance… hip fracture fits very nicely with all this because we have approximately 20,000 new hip fractures each year at an enormous cost to the economy of $1 billion, numbers are set to rise, and there is evidence to support the way we practice and it’s possible to measure,” she told the audience.

It was also important to identify unwarranted clinical variation in practice – variation that results in a negative impact to people – particularly when interacting with policy makers and politicians.

“Clinicians need to be the drivers but they cannot be the only people involved, you have to learn how to engage effectively with policy makers and politicians who also have an important role in this national agenda,” she added.

The Holy Trinity 

According to Prof. Close, the development of the Australian and New Zealand guidelines for hip fracture care were an important first step in the registry journey.

“We were told by the Australian Commission on Safety and Quality in Healthcare  that if we were ever to have clinical standard for hip fracture we must have an NHMRC endorsed guideline…. It was a requirement and a huge undertaking,” she said.

But this allowed the registry team to work with the Commission to move onto the next step of developing the hip fracture care clinical standard which is now endorsed by all jurisdictions.

“This is now embedded into the accreditation of hospitals so there are reasons for doing the standards through the Commision and not by ourselves…we call it the Holy Trinity, the guideline, the standard and the registry,” Prof. Close said.

Getting results

To date, the registry has released four reports, the latest one was published in September 2019 and involved 67 hospitals and 11,995 patients.

One example of progress identified in the report was the significant national improvement in hospital pain management for people being treated for a broken hip.

Overall, 87% of patients in Australia received a nerve block injection to help manage pain after a hip fracture, up from 59% when annual reporting began in 2015.

“From a patient perspective managing pain very definitely impacts their experience of their hip fracture journey… There is lots of evidence to support the use of nerve blocks and now more people are getting nerve blocks before and at the time of surgery in Australia and New Zealand… it’s an example of the fact that we’re seeing improvement over time which is fantastic, but there’s still a huge amount of variation across the country,” Prof. Close said.

According to Prof. Close the identification of individual hospitals in the report has been a strong driver of change as it has motivated local clinicians and managers to focus on opportunities for improvement.

“Naming hospitals has been a really important factor in terms of people taking it seriously, having your hospital there and being able to see where you sit is incredibly powerful… clinicians are inherently competitive and managers hate being seen as poor performers!”  she told the audience.

Last year also saw the roll out of ‘Hip Fests’ – one-day, state-based workshops bringing together people involved in hip fracture care to share experiences with the aim of improving local and regional systems.

“We’ve been to every state in the last year and the whole purpose of the hip fracture festivals is to share the learning and celebrate the successes, of which there are a number across the whole country, but also to engage where there are challenges,” Prof. Close noted.

Prepare for a marathon 

Prof. Close warned delegates that setting up a registry was less of a sprint and more of a marathon.

“Our journey started in 2011 when people really came together and agreed that hip fracture care was not optimal and we could do better, we should do better and there are other countries doing it better.”

“We got a steering group in 2012, we produced some guidelines in 2014, the first clinical standards and patient level report came out in 2016…so it’s definitely a journey”.

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