REFReSH: Models of care for the delivery of secondary fracture prevention after hip fracture
University Research Lecturer/Senior Researcher
+44 (0)1865 289263
|January 2013 - January 2017
|NIHR HS&DR – 11/1023/01
|Oxford NIHR Musculoskeletal Biomedical Research Unit, NDORMS, University of Oxford; MRC Lifecourse Epidemiology UnitUniversity of Southampton
REFReSH is a Natural Experimental Study to evaluate unplanned variation in secondary fracture prevention after hip fracture across hospitals in the South Central region and analyse their impact on costs and health outcomes and determine the cost-effectiveness of the different models of care. About 80,000 hip fractures occur annually in the UK and mostly from low impact falls in individuals with bone fragility due to osteoporosis. There are two main models of care that can be seen as complimentary to each other:
- Orthogeriatric services focusing on achieving optimal recovery after hip fracture.
- Optimising surgical procedure, early mobilisation and multidisciplinary management from admission to discharge.
- Nurse-led fracture liaison services (FLS) focusing on secondary fracture prevention.
- Case finding, osteoporosis assessment, treatment initiation and treatment adherence and monitoring.
However, there is considerable variation in models of care provided and in the way these are structured and organised between NHS hospitals. The research questions of the REFReSH study are:
1) Characterise the way hospitals in the South Central region have provided secondary fracture prevention services for hip fracture patients over the past decade
2) Identify the reasons why hospitals chose their specific model of service delivery and assess barriers to change
3) Establish the cost-effectiveness of different hospital models for delivery of secondary fracture prevention and provide a set of life-time health cost-profiles for patients with hip fractures
4) Evaluate the impact changes to the delivery of secondary fracture prevention have had on health outcomes by altering trends in hip re-fracture rates, NHS costs and life expectancy
To address these research questions, we combined large datasets with service and qualitative evaluations and used a mixed-methods approach to identify the optimal models of care. In terms of data, we obtained English national Hospital Episode Statistics (HES) data linked to national mortality data from 1999 to 2011 for the South Central region. A cohort of hip fracture patients (4260 patients per year in South Central) was identified through ICD diagnostic codes. The hospital provider code allowed the identification of the 11 hospitals in the region. Furthermore, a cohort of hip fracture patients from the UK General Practice Research Database (GPRD) from 1999 to 2011 was identified using READ/OXMIS codes.