>> Hello, I'm Jacqui Close.
I'm an orthogeriatrician in Sydney.
I'm a co-chair
of the Australian New Zealand Hip Fracture Registry.
I'm going to be talking to you today
about clinical variation and hip fracture care
and how the hip fracture registry has been a vehicle
both to identifying variation
in practice and importantly driving change.
So the first step is really to select a priority area.
So why select hip fracture
for assessing and reporting variation?
Well, hip fracture is high volume.
There are over 20,000 hip fractures in Australia every year.
It's high cost, it's high cost to the health system,
and perhaps more importantly, high cost to the individual
in terms of loss of function and loss of independence.
We have evidence-based guidelines that actually direct care.
And we also know
that if we follow evidence-based guidelines
we deliver better outcomes for older people.
And what's more, we also know when we deliver better care
that it actually costs less.
In terms of building our case for change,
this was a paper we published in 2014
and it specifically is looking at variation this time
in adjusted 30-day mortality, it's New South Wales data
and it highlights variation in 30-day mortality
across the different hospitals
delivering hip fracture care.
So the yellow diamonds are hospitals that have
an orthogeriatric service,
the black diamonds are hospitals
that don't have an orthogeriatric service
and the orange circles are our major trauma centres.
And what this slide shows is
that you are significantly less likely to be dead at 30 days
if you're cared for
in a hospital that has an orthogeriatric service.
We also know from the UK, who are ahead of us in terms
of registry data, they were looking at ...
This is an external evaluation of the registry,
and even before the introduction of the registry.
So this is again 30 day adjusted, 30-day mortality.
We can see that hip fracture 30-day mortality was already
coming down before the introduction of the hip
fracture registry in the UK.
But what you do see after the introduction is a more
precipitous reduction in 30-day mortality
and the BMJ produced a paper suggesting
that the introduction of the registry in the UK has probably
saved as many as a thousand lives.
So step two - How we identify clinical variation?
How we will assess it?
So for the hip fracture registry, it has been our triad
of NHMRC endorsed guidelines which tell us what
the evidence says in terms of how we should be
delivering care.
Our 2016 clinical care standard produced by the Commission,
which provides us with seven clinical standards
with clinical indicators,
which are then reported in the hip fracture registry.
So to show you how it all comes together,
we have the guideline which tells us, as one example,
perform surgery on the day of
or day after presentation to hospital with a hip fracture.
The clinical care standard tells us to operate on people
within 48 hours, unless there's a contra-indication.
The indicator that is partnered
with the standard is the proportion
of patients receiving surgery within 48 hours,
and that data is collected and reported in the registry.
So you can see how it's all brought together.
So I'm going to give you some examples
of how we share that data across Australia.
Here's Time to Surgery.
We have the hospitals listed down here,
you won't be able to see the names
but the names are actually reported.
But I'm showing you here significant variation
across the hospitals in Australia
in terms of Time to Surgery.
So we have the top performing hospitals up here,
we've got Royal North Shore, Charles Gardner,
Rockhampton, Fiona Stanley, St Vincent's in Darlinghurst.
They're all managing to get people
to surgery within 24 hours.
Meanwhile, we have a number
of hospitals down here who are struggling to
get people to hospital within 48 hours.
It's also important to start looking
as to why those delays are happening.
And in the 2020 report, we can see
that the most commonly reported cause
for delay is actually access to theatres.
We've still got issues with clearing people medically
and anticoagulation, but there's an indicator here
that tells us we need to be doing more around access
to theatres for this population.
We can track change at a number of different levels.
So this is Australia-wide data,
I'm showing you nerve blocks before surgery,
so a form of pain relief, and in 2015
we'll see that people got nerve blocks
in the emergency department and the operating theatre,
or just the emergency department, just over 30%.
That percentage has increased quite dramatically.
And the last report, 77% of patients coming
through our emergency departments with a hip fracture
are getting a nerve block prior to surgery.
So that's a significant improvement in performance,
thanks a lot to work
through the emergency department and anaesthetics.
We can also track change at a hospital level.
I can only show you Prince of Wales data
because that's where I work.
We've been entering data
from the very beginning of the registry,
and at the very beginning of the journey for us
our average time to surgery was about 44 hours.
You can see here, over time our performance has improved
and we're now sitting around 24 hours.
And that's a concerted, focused effort predominantly
through theatres and orthopaedics, securing access
to theatres for our patients.
We're also able with this report to compare our performance
with Australia, which is the continuous blue line,
and New South Wales with the dotted line.
Of course, the report when we publish it
is actually out of date.
And what the exciting part of the registry now is
is the ability to look at your data live.
So I'm doing this presentation on the 9th of December,
you can see that the entry
for Prince of Wales was on the 8th of December,
so this is up-to-date data.
We've had 158 records in 2020,
and this right hand panel here tells us how
we are performing in terms
of our times in the emergency department,
they're not good enough. Here's our median time to surgery
as of yesterday, our acute and our total length of stay.
And importantly for accreditation
against the national standards,
the live dashboard actually provides you
with up-to-date data
on how we are performing against the quality standards.
So here, for Prince of Wales
94% of our patients this year are having surgery
within 48 hours.
And we know that's an improvement
from our performance last year.
So step four - So it's okay
identifying clinical variation,
but you'd need to do something with that information.
So for the hip fracture registry
we use that data really to start conversations.
And we've had a series
of hip festivals across all states in 2019,
COVID-19 put pay to the hip festivals for 2020
but we hope to resume them again in 2021.
And really these are people coming together to
share their learnings, their successes, and their failures.
And it is important to learn from the high performers.
So this is a picture of the team at Fiona Stanley hospital,
so one of the top performers in terms of time to surgery.
This is their 7:30 trauma meeting
that they have every weekday morning where the anaesthetists,
the surgeons and the geriatricians sit down together
and plan the day, Who's going first?
Who still needs to be reviewed?.
And they run like a well-oiled machine.
So lots for all of us to learn
from those top performing hospitals.
The reality is a lot
of clinicians are inherently competitive,
so we are in a bit of a competition
through the Leading Better Value Care work
in New South Wales. The Prince of Wales,
Liverpool, St.George and Sutherland are competing
to improve their time to surgery.
But the overall goal of this particular project is
that by the end of 2020, all four hospitals combined,
over 85% of patients will receive surgery within 48 hours,
and we are on track to achieve that.
And in terms of rewarding practice at the end
of each quarter, the top performing hospital
is given a $500 voucher to spend on whatever they want.
It's a small amount of money
but it's recognising good practice.
So the sorts of things that have been purchased -
this is a pocket talker, which helps communicating
with people who are very hard of hearing.
This is a speaker that one of the hospitals wanted
to be able to play music in the hip fracture theatre
It's also, of course, important to be aware of the onus
and the work that it takes to collect this data.
So it is important to try
and maximise how we use data through data linkage.
So this year is the first time we've reported
adjusted 30-day mortality.
And we do that by linking to the national death index.
And what you can see here
with this caterpillar plot, again is substantial variation
in 30-day mortality across the hospitals.
Now we haven't named hospitals this year,
hospitals will get the option of
whether they want to be named in next year's report.
But overall
our 30-day mortality is 7.1%, that compares very favourably
with the equivalent work from the UK.
But there is very definitely a difference in mortality,
even when you adjust for baseline differences.
Also important to use the data to drive change.
And here's an example of how that's been done.
This is James Brinton,
he was a senior nurse down
in Illawarra Shoalhaven.
He was responsible for some of the work
at the Wollongong hospital, and the Wollongong hospital was
unfortunate enough to find itself at the bottom of the table
in terms of time to surgery for hip fracture.
And this is for the 2017 report,
and they were struggling even to get 50% of patients
to hospital within 48 hours.
They did a concerted piece of work
through the emergency department, surgery, theatres
et cetera,
and this is where Wollongong hospital sits
in the 2020 report.
So evidence that they've owned the data,
done something with it,
and as a result we see improvements in practice.
In terms of reporting and recording activities,
we continue to report on an annual basis
for the hip fracture registry.
But as I said, the live dashboards
are becoming increasingly important when
you're using data to drive a quality improvement agenda,
and certainly that live dashboard sits very nicely
with being able to report for the Commission's
standards for hospitals.
So what next for the registry?
Well, we're still fairly acute focused.
What we really want to know is
whether our systems and processes of care are actually
delivering better outcomes that are meaningful for patients,
so we are collecting data at 120 days
including quality of life data.
We're giving serious consideration
to having a public facing dashboard that tells us how,
or tells the public how we are performing as a country
and as individual hospitals
against the clinical care standards.
We're looking at developing apps
which make it much easier to look at performance over time.
When you're sitting down
with a manager to have a conversation, being able to bring
up that live dashboard at the push of a button.
We are certainly going to be using data linkage to try
and collect more information,
so links to the Pharmaceutical Benefits Scheme,
to the aged care data,
to see what's happening to people further down the track
and whether we're managing to get people
on treatment for osteoporosis as an example.
We're aware of the encumbrance of data collection
and we want to avoid duplication of data collection,
so how we embed the components
of the registry into the electronic medical record
that's a conversation that is ongoing.
We've had previous conversations about putting a price
on quality and instead of penalising poor practice
how do we change the conversation
to actually rewarding high quality care?
And I guess ultimately the annual report will become a thing
of the past as we move to reporting real time data.
So I hope that gives you a snapshot
as to how the registry is identifying variation,
and equally important how it is using that data
to start conversations
to drive a quality improvement agenda.
So I look forward to participating in the discussion.
Thank you.