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Inequalities in use of total hip arthroplasty for hip fracture: population based study
Daniel C Perry1, David Metcalfe2, Xavier L Griffin3
1Institute of Translational Medicine, University of Liverpool, Liverpool, L12 2AP, UK danperry@liverpool.ac.uk.
Insights
Total hip arthroplasty (THA) use in hip fracture patients shows significant disparities, with poor adherence to National Institute for Health and Care Excellence (NICE) guidelines. Socioeconomic factors and weekend surgery impact THA provision, indicating inconsistent care.
Area of Science:
- Orthopedic Surgery
- Health Services Research
- Geriatric Medicine
Background:
- Displaced intracapsular femoral neck fractures commonly affect older adults.
- Total hip arthroplasty (THA) is a treatment option, with guidelines from the National Institute for Health and Care Excellence (NICE) to ensure appropriate use.
- Previous research suggests potential variations in THA provision for hip fractures.
Purpose of the Study:
- To evaluate whether total hip arthroplasty (THA) use in displaced intracapsular femoral neck fractures aligns with national NICE guidelines.
- To identify potential systematic inequalities in THA provision for these patients.
- To explore factors influencing THA decision-making beyond established criteria.
Main Methods:
- An observational cohort study utilized data from the National Hip Fracture Database (NHFD) in England, Wales, and Northern Ireland.
- Included were patients aged 60 and older with non-pathological displaced intracapsular hip fractures undergoing operative treatment between July 2011 and April 2015.
- The primary outcome measure was the provision of THA to patients meeting NICE eligibility criteria.
Main Results:
- Out of 114,119 hip fracture patients, 10.2% (11,683) received THA.
- Only 32% of patients meeting NICE criteria received THA, while 42% of those receiving THA did not meet the criteria.
- Factors like age (≤76), ambulation status, cognitive function, ASA score, socioeconomic deprivation, and day of surgery (weekday vs. weekend) significantly influenced THA use, often diverging from NICE recommendations.
Conclusions:
- There are significant disparities in THA use for hip fractures, with poor compliance with NICE guidelines.
- Patients with greater socioeconomic deprivation and those operated on during weekends were less likely to receive THA.
- Inconsistent adherence to NICE guidelines results in variable treatment for older adults, dependent on hospital presentation timing and location.
Objectives:
To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there are systematic inequalities.
Design:
Observational cohort study using the National Hip Fracture Database (NHFD).
Setting:
All hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland.
Participants:
Patients within the national database (all aged ≥60) who received operative treatment for a non-pathological displaced intracapsular hip fracture from 1 July 2011 to 31 April 2015.
Main Outcome Measures:
Provision of THA to patients considered eligible under criteria published by the National Institute for Health and Care Excellence (NICE).
Results:
114 119 patients with hip fracture were included, 11 683 (10.2%) of whom underwent THA. Of those who satisfied the NICE criteria, 32% (6780) : received a THA. Of patients who underwent THA, 42% (4903) did not satisfy the NICE criteria. A recursive partitioning algorithm found that the NICE eligibility criteria did not optimally explain which patients underwent THA. A model with superior explanatory power drew distinctions that are not supported by NICE, which were an age cut off at 76 and a different ambulation cut off. Among patients who satisfied the NICE eligibility, the use of THA was less likely with higher age (odds ratio 0.88, 95% confidence interval 0.87 to 0.88), worsening abbreviated mental test scores (0.49 (0.41 to 0.58) for normal cognition v borderline cognitive impairment)), worsening American Society of Anesthesiologists score (0.74, 0.66 to 0.84), male sex (0.85, 0.77 to 0.93), worsening ambulatory status (0.32, 0.28 to 0.35 for walking with a stick v independent ambulation), and fifths of worsening socioeconomic area deprivation (0.76 (0.66 to 0.88) for least v most deprived fifth). Patients receiving treatment during the working week were more likely to receive THA than at the weekend (0.90, 0.83 to 0.98).
Conclusions:
There are wide disparities in the use of THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those who require surgery at the weekend were less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimal treatment for older adults with hip fractures can depend on where and when they present to hospital.
