REDUCE Study

REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales; the REDUCE study 

Breaking a hip is a devastating injury to sustain. 80,000 older adults break (or fracture) a hip each year in the UK. Despite national guidelines, how health services organise hip fracture care varies greatly across UK hospitals. Finding out which parts of the hip fracture care pathway explain variation in patient outcomes will tell us what service changes are needed and help us to develop a new step-by-step guide to ensure consistent, high quality care is equally available to all.

Using large anonymised clinical datasets which have been collected systematically across England and Wales, we will be able to assess hip fracture services, including how care is delivered in emergency departments, on wards, in operating theatres, and during rehabilitation. Statistical analyses will identify which organisational factors explain variation in patient outcomes after hip fractures (e.g. death, length of hospital stay, hospital readmissions, osteoporosis treatment) and identify hospital care pathways that are associated with high-quality consistent patient outcomes. Cost analyses will calculate the costs from hip fractures which are attributable to different organisational factors. Interviews with staff from hospitals providing different levels of fracture care will identify barriers and facilitators to optimal care delivery. With our system-wide understanding of hip fracture care we will develop an Implementation Toolkit in partnership with key national stakeholders, particularly the Royal Osteoporosis Society, to overcome organisational barriers when implementing sustainable high-quality fracture services for patients. We will make this Toolkit freely available to hospital managers, clinical leads and those who organise healthcare services.

Researchers: Dr Celia Gregson, Prof Andrew Judge, Prof Yoav Ben-Shlomo, Dr Elsa Marques, Professor Rachael Gooberman-Hill, Dr Sarah Drew, Dr Rita Patel, Dr Katie Whale

External Collaborators: Mr Tim Chesser, Mr Xavier Griffin, Dr M. Kassim Javaid, Mr Tim Jones, Ms Francesca Thompson, Ms Jill Griffin, Dr Antony Johansen

Funder: Versus Arthritis (£396,264)

Project timeline: 2019-2023

Publications to date: None currently

Project Data:

To answer our research questions we are analysing a large national dataset from the Royal College of Physician’s Falls and Fragility Fracture Audit programme (RCP FFFAP), specifically the National Hip Fracture Database (NHFD) alongside data from NHS Digital. NHS Digital links the data from NHFD to information it collects and extracts details of all hospital admissions (Hospital Episodes Statistics; HES) and data from the Office of National Statistics (ONS) for the study.

NHS Digital securely transfers the linked data to the University of Bristol as pseudonymised data (i.e. all patient identifiers are removed and replaced with a unique patient ID), so patients cannot be identified. The data are then held securely at the University of Bristol (the Data Controller).  The ONS data provides us with information as to whether people have died at specific time points throughout the year following hip fracture.

NHS Research Ethics Committee approval: Pending

NHS Digital Data Sharing Agreement: Pending

FFFAP approval: December 2019

Further details regarding the NHFD data are available here, including the process to follow if you do not want your data to be included in this clinical audit and associated research activity.   

A related study is to be found below:

The impact of geographic and socioeconomic variation on the incidence of hip fracture, and upon death and recovery after hip fracture

Researchers: Dr Arti Bhimjiyani, Prof Yoav Ben-Shlomo, Dr Celia L Gregson

External Collaborators: Dr Jenny Neuberger, Dr Antony Johansen

Funder: The National Osteoporosis Society  (£79,457)

Outline: Each year 60,000 older adults break their hip in England and Wales; this will increase with our ageing population. A month after hip fracture between 3 and 17% have died and 25-95% have still not returned home. The number of hip fractures and their outcomes are variable across different parts of the country. We plan to determine how commonly hip fractures occur in different parts of the country. Unfortunately socially deprived individuals may be more likely to break a hip and less likely to recover from it. We will examine how varying levels of deprivation across our country influences how people recover from hip fractures; for example, how frequently they die, how long they stay in hospital, how likely they are to walk and return to their own home (versus move to a care home), and how frequently they have to go back into hospital.  We will determine whether these inequalities are caused by differences in health before the fracture, or by housing circumstances, standards of hospital care or differences in recovery.  This will help with the design of policies to reduce inequalities. Our findings are designed to drive equal access to high quality services for all hip fracture patients.

Project timeline: 2015-2019

Publications to date:

The effect of social deprivation on hip fracture incidence in England has not changed over 14 years: an analysis of the English Hospital Episodes Statistics (2001-2015). Osteoporosis Int. 2018 Jan;29(1):115-124. Bhimjiyani A, Neuburger J, Jones T, Ben-Shlomo Y, Gregson CL.

Inequalities in hip fracture incidence are greatest in the North of England: regional analysis of the effects of social deprivation on hip fracture incidence across England  Science Direct. 2018 Sep; Vol 162: 25-31. Bhimjiyani A, Neuburger J, Jones T, Ben-Shlomo Y, Gregson CL.

How does deprivation influence secondary care costs after hip fracture? Osteoporisis Int. 2020 Apr. Glynn J, Hollingworth W, Bhimjiyani A, Ben-Shlomo Y, Gregson CL. Press release here.

Project Data:

To answer our research questions we are analysing a large national dataset from the Royal College of Physician’s Falls and Fragility Fracture Audit programme (RCP FFFAP) , specifically the National Hip Fracture Database (NHFD) alongside data from NHS Digital. NHS Digital links the data from NHFD to information it collects and extracts details of all hospital admissions (Hospital Episodes Statistics; HES) and data from the Office of National Statistics (ONS) for the study.

NHS Digital securely transfers the linked data to the University of Bristol as pseudonymised data (i.e. all patient identifiers are removed and replaced with a unique patient ID), so patients cannot be identified. The data are then held securely at the University of Bristol (the Data Controller).  The ONS data provides us with information as to whether people have died at specific time points throughout the year following hip fracture.

NHS Research Ethics Committee approval: 15/LO/1056

NHS Digital Data Sharing Agreement: DARS-NIC-30645-Z2Z2K-v1.2

RCP FFFAP approval:  FFFAP/2015/001

Further details regarding the NHFD data are available here, including the process to follow if you do not want your data to be included in this clinical audit and associated research activity. 

Image of a hip fracture - source National Hip Fracture Database
Image credit: National Hip Fracture Database
Some of the REDUCE team at Jan 2020 Core Investigator Meeting
Edit this page