Landmark international study highlights need to reduce time that hip fracture patients spend in hospital in England

An innovative international study has used electronic medical records to compare the cost and quality of care between health care systems in 11 OECD countries, including the NHS in England. 

The International Collaborative on Costs, Outcomes and Needs in Care (ICCONIC) study has been led by researchers at Harvard University and LSE, and co-funded by the Commonwealth Fund and the Health Foundation. The data for England – compiled and analysed by the Health Foundation – has focused on two groups of high-need older patients which represent priority areas for the NHS and other health systems – those hospitalised with a hip fracture and those hospitalised with heart failure who also have diabetes.  

Looking at pre-pandemic data from 2014/15 to 2017/18, the study found that, for both groups of patients, England had the highest mortality rates of any country, despite performing relatively well on several other measures of quality of hospital care. One year after hip fracture surgery, almost a third (31%) of patients in England had died of any cause compared with less than a quarter of patients in in Canada (23%), Australia (22%) and France (20%).  

Another key area where England stands out from other countries included in the analysis is the length of time that hip fracture patients spend in hospital. Patients in England spent an average of 21.7 days in hospital after their surgery – the highest of all 11 countries evaluated.  

The findings add weight to national audits that have identified several areas for improvement in the care of hip fracture patients. More generally, the study provides further evidence that, while the NHS remains a relatively low-cost health care system that performs well in some areas, mortality rates for some patients are higher than in comparable countries – including in key areas such as cancer and cardiovascular disease.

The Health Foundation says the findings warrant further investigation – it notes that it is notoriously difficult to draw comparisons between health care systems that serve different populations and collect information about patients in different ways, and that doing so often raises more questions than it answers. The independent charity says that the results ultimately highlight major gaps in the available data in England and the need for investment to better understand what is happening to patient care across acute hospitals, rehabilitation services, support in the community and social care. 

However, by using patient-level data (which was not shared between countries) and enabling comparisons across primary, secondary and post-acute care, the ICCONIC study provides health care policymakers with vital information on how current care strategies are influencing the quality of care in the NHS in England, while also highlighting opportunities to significantly improve productivity. The Health Foundation says that such improvements in productivity are much needed as the NHS grapples with a growing elective care backlog that has accumulated during the pandemic and widespread workforce shortages. 

A key area highlighted by the study is the potential to free up additional capacity by reducing the time that patients remain in hospital after hip fracture surgery – the most common reason for emergency surgery. The Health Foundation says that there is broad agreement that hospital is not the best place for a frail older patient to stay following surgery as it is not conducive to rehabilitation. By investing in post-hospital care, there may be scope to reduce the length of hospital stays for hip fracture patients and free up additional capacity to deal with the backlog of care. 

In contrast to England, countries such as the Netherlands, Sweden and Canada have been able to provide accessible post-hospital care for hip fracture rehabilitation in either community-based or short-term residential care settings, resulting in much shorter hospital stays than patients in England. 

High mortality among hip fracture patients is occurring despite England performing well on other care quality measures – for example, over 82% of hip fracture patients in England received hip surgery within 48 hours of admission, second only to 85% of patients in Sweden. This is recommended as a key component of high-quality care. However, one year after their initial admission, 31% of English patients had died, compared with only 25% of Swedish patients.