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Systematic Review

Which performance indicators are used globally for evaluating healthcare in patients with a hip fracture?

a mixed methods systematic review

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Abstract

Aims

Performance indicators are increasingly used to evaluate the quality of healthcare provided to patients with a hip fracture. The aim of this review was to map the variety of performance indicators used around the world and how they are defined.

Methods

We present a mixed methods systematic review of literature on the use of performance indicators in hip fracture care. Evidence was searched through 12 electronic databases and other sources. A Mixed Methods Appraisal Tool was used to assess methodological quality of studies meeting the inclusion criteria. A protocol for a suite of related systematic reviews was registered at PROSPERO (CRD42023417515).

Results

A total 24,634 articles were reviewed, of which 171 met the criteria of the review. Included studies were heterogenous in design and came from varied healthcare systems in 34 different countries. Most studies were conducted in high-income countries in Europe (n = 118), followed by North America (n = 33), Asia (n = 21), Australia (n = 10), and South America (n = 2). The highest number of studies in one country came from the UK (n = 45). Only seven of the 171 studies (< 2,000 participants) were conducted across ten low- and middle-income countries (LMICs). There was variation in the performance indicators reported from different healthcare systems, and indicators were often undefined or ambiguously defined. For example, there were multiple definitions of 'early' in terms of surgery, different or missing definitions of ‘mobilization’, and variety in what was included in an ‘orthogeriatric assessment’ in hip fracture care. However, several performance indicators appeared commonly, including time to surgery (n = 142/171; 83%), orthogeriatric review (n = 30; 17%), early mobilization after surgery (n = 58; 34%), and bone health assessment (n = 41; 24%). Qualitative studies (n = 18), mainly from high-income countries and India, provided evidence on the experiences of 192 patients and 138 healthcare professionals with regard to the use of performance indicators in clinical care and rehabilitation pathways. Themes included the importance of education and training in parallel with the introduction of performance indicators, clarity of roles with the clinical team, and the need for restructuring or integration of care pathways.

Conclusion

This review identified a large number of performance indicators related to the delivery of healthcare for patients with a hip fracture. However, their definitions and thresholds varied across studies and countries. Evidence from LMICs is sparse. Both qualitative and quantitative evidence indicates that there remains a pressing need for further research into the use and standardization of performance indicators in hip fracture care and their influence on patient outcomes and economic costs.

Cite this article: Bone Jt Open 2025;6(3):275–290.

Take home message

Hip fracture care is marked by significant variability in the performance indicators used and how they are defined which makes meaningful comparisons across healthcare systems challenging.

Although healthcare professionals acknowledge the importance of data collection, there is limited evidence on the actual impact of these indicators on patient outcomes and healthcare costs, with even less known about the experiences of those involved in managing them.

Standardization of terminology and definitions is essential to enable evidence synthesis, alongside further research into their use, particularly in low- and middle-income settings.

Introduction

Hip fracture is a common, serious, and costly public health issue.1 The incidence rates are currently highest in North America and Europe, but the global incidence is expected to double over the next 20 to 30 years due to the growing proportion of older people in many regions of the world.2 Hip fractures have serious consequences for patients. Of hip fracture patients in the UK, 25% die within a year and survivors have a reduction in their health-related quality of life, similar to having a stroke.3 The outlook is likely to be even worse for people in low- and middle-income countries (LMICs) with fewer resources to support recovery and long-term care.4 The annual costs of care for patients with hip fracture in the USA, the UK, and nine Asian countries are estimated at USA$12 trillion,5 USA$3 trillion, and USA$15 billion, respectively.6

Hip fracture care typically requires input from multiple specialties at different points of the patient ‘journey’. To inform this process, several countries have developed clinical practice guidelines and regional or national audits to optimize the delivery of appropriate hip fracture care. These guidelines and audit datasets often include performance indicators, sometimes referred to as ‘best practice quality standards’. Performance indicators were introduced to improve patient health outcomes by quantifying aspects of care delivery that are associated with improved recovery after a hip fracture.7 However, the use of performance indicators, and the different types of performance indicator used in different healthcare settings, is not clearly described in the literature.

The aim of this review was to identify performance indicators used in the care of patients with hip fracture in different healthcare systems around the world. We also explored how performance indicators are defined in clinical practice and how they are used by healthcare professionals and policy makers.

Methods

We performed a mixed-methods systematic review of evidence on performance indicators used globally for evaluating healthcare in patients with hip fractures. This review is part of a suite of systematic reviews evaluating healthcare of patients with fractures (registered at the International Prospective Register for Systematic Reviews (PROSPERO).8 The review is reported according to the PRISMA statement,9 and the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement.10

Search strategy

A comprehensive search strategy without age, period, or language restrictions was iteratively derived with input from information specialist and hip fracture experts (Supplementary Table i). Overall, 12 bibliographic databases were searched for studies published from database inception to 25 April 2023: MEDLINE; Embase; EMCARE; Ovid Global Health; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); the Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; Scopus; Web of Science; World Health Organization (WHO) Global Index Medicus; Centre for Reviews and Dissemination (CRD) NHS Economic Evaluations Database (to 31 March 2015); and the International Network of Agencies for Health Technology Assessment (INAHTA) Health Technology Database.

The search involved using relevant index terms and free-text terms, synonyms, and phrases in the title and abstract fields for relevant papers on performance indicators, quality indicators, health care/quality improvement AND fractures, trauma, injuries or injury, in order to meet the aims of the protocol.

All references were exported into EndNote v. 20 reference manager (Clarivate, USA), and duplicates were removed using the Bramer method.11 Snowballing, websites, personal databases, and citations were searched for additional records.

Study selection

To ensure high level of agreement between reviewers and to minimize any reviewer-related biases, a subset of articles was piloted for independent double review among all authors (AT, JM, MC, MP, SG, VMP) at each stage of the review process (i.e. title and abstract screening, data extraction, and quality assessment) and results were compared. Titles and abstracts were then independently screened by AT, MP, and VMP using EndNote v. 20 (Clarivate). Articles appearing to meet this review’s inclusion criteria (Supplementary Table ii) were retrieved for full text review and details of these studies were recorded in pre-piloted spreadsheets with reasons for excluding studies. Foreign language papers were translated using Microsoft (USA)/Google translator (Google, USA) and native speakers were contacted if anything was unclear. Uncertainty about inclusion criteria and disagreements were resolved by discussion among all authors.

Quality assessment

The Mixed Methods Appraisal Tool (MMAT) v. 201812 was used to assess the methodological quality of included studies. All authors were trained to use the tool and a sample of studies were piloted for quality assessment. Two reviewers (AT, VMP) independently assessed the quality of all included studies. Any disagreement between the reviewers over the risk of bias of an included study, was resolved by discussion at team meetings. The quality assessment stage underpinned the context of the synthesized findings and was not used to exclude studies.

Data extraction and analyses

Two reviewers (AT, VMP) independently extracted data of relevant studies into a pre-piloted study design specific spreadsheet. For quality assurance, all studies meeting the inclusion criteria were double reviewed by a second reviewer to ensure agreement and consistency in data extraction and reporting. Additionally, to minimize reviewer related bias, the evidence tables of included studies were further double reviewed and analyzed by AT, MC, and VMP.

Data synthesis

The heterogeneity between quantitative studies, in terms of study designs and study periods, precluded meta-analysis. A narrative synthesis of quantitative and qualitative data was therefore undertaken.

Extracted qualitative and quantitative data were analyzed and synthesized by one reviewer (VMP) and mapped by country of study, study period, and study design. Evidence was synthesized on the variety of performance indicators used around the world and how they are defined. Additionally, qualitative evidence from patients and healthcare professionals was summarized by ET, JM, MC, and VMP. Finally, summaries of the qualitative and quantitative data were integrated by ET, MC, and VMP using 'the parallel results convergent design synthesis'.13

Results

A total of 24,448 articles were identified from searching 12 electronic databases in April 2023. These were screened, and 221 full text articles were reviewed (including 12 other language papers). Full texts of 175 additional studies were identified from reference lists and other sources and were also reviewed. A total of 171 studies met the inclusion criteria. A PRISMA flow diagram summarizes the literature search strategy in Figure 1.

Fig. 1 PRISMA flow diagram of the systematic search for evidence on performance indicators used globally for evaluating hip fracture care. CINAHL, the Cumulative Index to Nursing and Allied Health Literature; HTA, Health Technology Assessment; NHSEED, NHS Economic Evaluations Database.

Fig. 1

PRISMA flow diagram of the systematic search for evidence on performance indicators used globally for evaluating hip fracture care. CINAHL, the Cumulative Index to Nursing and Allied Health Literature; HTA, Health Technology Assessment; NHSEED, NHS Economic Evaluations Database.

The articles were heterogenous in terms of health systems, study designs, study periods, performance indicators, and performance indicator definitions (Supplementary Tables iii to ix for summary of extracted data and quality assessment). There were two multinational cross sectional surveys,14,15 two randomized controlled trials,16,17 two control pre- and post-intervention studies,18,19 two quasi-experimental,20,21 four mixed methods,22-25 14 qualitative studies,26-39 27 prospective cohort studies,40-66 42 mixed prospective and retrospective pre/post intervention studies,67-108 and 76 retrospective cohort studies,109-185 which provided evidence on the performance indicators of hip fracture care in 34 countries. The retrospective study design and other limitations had an impact on the methodological quality of included studies with 23% studies being of high quality, while 63% and 14% studies were of intermediate and low quality, respectively.

The study period was not reported in 13 included studies. However, it appears that all included studies were conducted between years 1981 and 2021 and subsequently published between years 1986 and 2023. Of these 171 studies, 63% were published in recent years between years 2015 and 2023. Only 32% studies were published between 2001 and 2014 and around 5% studies were published between 1986 and 2000.

Evidence collected was mainly from high-income countries in North America (n = 33), Europe (n = 118 with 45 studies from the UK), Australia (n = 10), South America (n = 2), and Asia (n = 21) (Figure 2). Evidence from LMICs was limited with only seven out of 171 studies reporting evidence from ten LMICs (Mexico, India, China, Serbia, Pakistan, Nepal, Sri Lanka, Malaysia, Thailand, and Philippines).14,20,22,51,53,76,164

Fig. 2 Mapping evidence by countries in which the studies were originally conducted.

Fig. 2

Mapping evidence by countries in which the studies were originally conducted.

Two studies did not report the total number of participants from each of the three (Belgium, Italy, and Portugal),16 and seven (Canada, USA, Australia, New Zealand, Denmark, Sweden, and Ireland)15 countries represented.

Overall, in Asia, studies were conducted in 13 countries with a total of 75,659 participants. Studies from Australia and New Zealand had > 2,195 participants, while studies in Europe were conducted in 15 countries and had > 3,456,765 participants, although most of the participants (2,525,926) were from the UK. Finally, North America (Canada and USA) had > 446,412 participants, and two countries from South America – Chile and Mexico – had 647 and 83 participants, respectively.

Performance indicators used globally in hip fracture care and how they are defined

Across the 171 articles, 241 performance indicators were described. Supplementary Table x lists performance indicators/proxy performance indicators. However, the performance indicators were often undefined or variably defined in the different articles. The 12 most commonly reported performance indicators are shown in Table I. Time to hospital admission (42 articles (24.6%)) is variably defined as time from fall/injury to arrival in the emergency department (ED)/diagnosis/admission to the hospital. Review by a physician specializing in care of older patients was reported by 30 studies (17.5%). However, the target time for the review was often unreported and, where reported, ranged from ≤ 48 to ≤ 72 hours. The clinician performing the review was also described inconsistently, ranging from geriatrician, orthogeriatric to orthopaedic surgeon. Time to surgical intervention was reported in 142/171 (83%) articles but there was variation in the target time (< 12 hours to > ten days) and start point for the timing, ranging from arrival in the ED through decision to admit, to admission to the hospital ward. Time to mobilization after surgery was reported as a performance indicator in 58 (34%) articles; however, there was substantial variation in how, when, and by whom mobilization was initiated postoperatively. Other commonly reported performance indicators were: bone health assessment was reported in 41 studies (24%), pain assessment in 31 (18%), anaesthesia risk assessment in 16 (9.4%), antibiotic prophylaxis assessment in 11 (6.4%), thrombolytic prophylaxis assessment in 15 (8.77%), medication prescription assessment in 20 (11.7%), cognitive impairment assessment was reported by 29 (17%) studies, and a return to home risk assessment in 69/171 (40.3%).

Table I.

Summary of quantitative studies investigating performance indicators in hip fracture care of older patients.

Performance indicator Studies exploring each indicator* Performance indicators mostly undefined or with multiple definitions
Prompt admission to a surgical ward from the emergency department 4,8,9†,25,29,36,38,40,41,42,46,

49,52,57,59,60,63,75,76,84,95,98,

101,102,104,106,110,115,118,120,

127,128,130,132,140,141,143,150,

151,156,169,170‡

  • Time to transfer or present patient to ED (from fall) or admit to acute ortho care

  • Time in ED/emergency triage priority (< 2 to 4 hrs)

  • Time from hospital admission to medical clearance

  • New or transferred patient admission (door to hospital/ward/ortho/ geriatric/medicine/ED/trauma/theatre/other department)

  • Day/date/time to ortho/trauma/ward admission

  • Admission to hospital (within 24 hrs of fracture/arrival)

  • Admission within four hrs of first presentation or directly to theatre from ED within four hrs

  • Admission delays due to diagnostic interval

  • Admission due to fractures in hospital vs home
Prompt review by a physician specializing in care of older patients 2,5§,30,37,40,45,46,47,49,52,

53,54,58,66,72,75,77,95,102,104,

112,113,115,126,128,140,145,147,149,156

  • 'Comprehensive' geriatric/geriatrician review/'Critical care review'/Cumulative illness rating scale-geriatric

  • Joint geriatric/orthopaedic care/geriatrician directed MDT rehab

  • Orthogeriatric assessment in patients > 75 yrs within 48 to 72 hrs of admission.

  • MDT co-managed/Use of agreed MDT protocol

  • Care review done by other healthcare professionals

  • Access to acute orthogeriatric care/geriatric depression score

*Additionally, several studies also reported assessments on

  1. Medical/medication history/diagnostics

  2. Frailty index/physical/functional status (Parker mobility score, ADL, ASA, KATZ6, Barthel index, etc.)

  3. Quality of life (GOS-E, EQ-5D, EQ-VAS, SF-12/36, etc.)

  4. Nutritional risk

  5. Falls risk assessment/falls prevention

  6. Pressure ulcer care/risk assessment
Bone health assessment 2,5§,6,30,34,37,40,46,50,52,54,

58,61,69,70,72,75,79,97,103,104,109,

113,116,117,118,124,125,126,131,

133,134,139,140, 142,145,151,

154,155,170‡,171

  • Bone health/refracture risk/osteoporosis assessment
Early surgical intervention 2,3,4,5§,6,7,8,9†,10,25,26,27,29,30,31,

32,33,34,36,37,38,39,40,41,42,43,44,

45,46,47,49,50,51,52,53,54,55,56,57,58,59,

60,61, 62,63,64,65,66,67,68,69,70,71,72,73,

75,76,77,79,80,81,82,83,84,85,86,87,88,89,90,

91,92,93,94,95,96,97,98,99,100,101,102,

103,104,105,107**,109,110,111,112,113,114,115,

116,117,118, 119,120,121,123,124,126,127,128,

129,130,131,132,134,135,136,137,138,139,

140,141,143,144,145,146,147,148,149,151,

152,153,155,156,157,158,160,161,162,163,

164,165,166,167,168,169,170‡,171

  • Time from medical clearance to surgery

  • Time to surgery/theatre/start of anaesthesia/within normal working hours/pre-holiday surgery

  • Surgery within 12/ ≤ 24/24 to 48/36/48/ > 48/ ≤ 72/ > 72/96/ > 96 hrs, next/2 calendar day/3 to 5 days/6 to 10 days/> 10 days (from decision to admit/presentation/hospital registration/arrival to ED/admission (to hospital/ward/from diagnosis if inpatient)/early/delayed/late (from time of admission)

  • Emergency/elective surgery

  • Time from door to theatre ( ≤ 24 hrs and > 48 hrs)

* Additionally, some studies also assessed:

  1. Reasons for delay in surgery, year/period of surgery

  2. Duration/length of surgery, operating time and day, surgery type

  3. Time between surgery and completing surgery record
Early mobilization after surgery 1,2,5§,6,7,28,30,34,35,48,50,54,58,59,

61,66,68,70,73,74,77, 78††,79,80,81,

82,83,88,90,97,99,100,103,106,107,108,

109,111,113,115,116,117,118,121,122,124,

125,128,131,133,134,142,148,152,155,156,

165,171

  • Mobility/ambulatory/weightbearing status i.e. ability to walk/independent mobility (postoperative/at or after discharge)

  • Ambulation/mobilization (on postop day 1, 2, 3, 4, 5), mobility related activities (sedentary, sitting, upright standing, upright stepping, walking)

  • Time to mobilization/rehab/to sit in bed, to or beyond chair, walk 3 m/weightbearing activities/first getting up/exercises (within 24 to 48 hrs postoperatively, in patients who can walk before fracture)/delay between surgery and first getting up)/within 48 hrs of admission

  • Time between admission and request of a place in a rehabilitation facility

  • Physiotherapy (< 24 hrs/day after postop), occupational therapy (< 36 hrs postop), rehab programme (in hospital or at discharge)
Pain assessment 1,2,6,34,35,61,65,66,68,70,75,

82,83,84,87,109,115,117,125,128,

131,133,134,142,147,150,152,154,

156,170‡,171

  • Pain assessment/analgesia management/nerve block prescription
Anaesthesia risk assessment 1,6,9†,71,78††,82,84,90,95,100,

102,104,107**,108,113,152

  • Anaesthesia type (general, regional, spinal), time of administration, who prescribed anaesthesia
Antibiotic prophylaxis assessment 2,6,29,59,66,70,83,84,90,155,169

  • Timing of antibiotic prescriptions
Thrombolytic prophylaxis assessment 6,34,59,66,69,70,83,90,98,118,

151,155,156,169,171

  • Thrombolytic/coagulopathy prophylaxis
Medication prescription assessment 2,5§,6,27,37,69,70,75,97,109,117,118,

124,125,131,133,134,139,142,156

  • Polypharmacy/medication (including anti porosis) prescription
Cognitive impairment assessment 1,2,7,26,30,35,42,45,46,67,68,72,77,

78††,79,80,89,92,93,115,116,126,128,

140,148,149,156,161,170‡

  • Cognitive status assessments (via AMTS/Glasgow coma/MMSE/SPMSQ score)
2,6,7,47,50,69,73,76,82,83,84,88,104,106,108,

111,112,150,158, 159,169

  • Dementia assessment
5§,6,7,29,30,34,51,68,69,71,72,73,79,87,92,

108,111,116,118, 127,152,159,170‡,171

  • Delirium assessment

* Additionally, several studies also assessed

  1. Other comorbidities (via Charlson/RAND comorbidity/chronic health evaluation score etc)

  2. Hospital (various wards) duration
Return to home risk assessments 1,2,3,4,6,7,27,29,32,34,35,36,

38,40,42,43,46,47,48,49,50,51,

61,62,66,67,68,71,72,73,76,79,

80,83,84,86,87,88,94,97,98,99,

103,104,105,109,112,113,116,117,

118,122,125,126,128,131,132,134,

135,144,148,149,151,152,154,156,

157,165,171

  • Pre/post fracture living, cohabitation, residential status, discharge destination

  • Care transition/prepare for home/discharge planning/protocol (commenced within 48 hours of admission)/facilitate smooth discharge to destination

  • Social worker visit (during hospitalization)

  • Provision of adequate explanation/information about home medication prescription

  • Arrangement of extra support to patients who need when going home

  • Functional independence (FIM score), rehabilitation arrangements
  1. *

    Study number as per Supplementary Tables iii to ix.

  1. †

    India.

  1. ‡

    Nepal, Sri Lanka, Malaysia, Thailand, and Philippines.

  1. §

    Mexico.

  1. China.

  1. **

    Pakistan.

  1. ††

    Serbia

  1. ADLs, activities of daily living; AMTS, Abbreviated Mental Test Score; ASA, American Society of Anesthesiologists; ED, emergency department; EQ-VAS, EuroQol-visual analogue scale; FIM, Functional Independence Measure; GOS-E, Glasgow Outcome Scale - Extended; MDT, multidisciplinary team; MMSE, Mini-Mental State Examination; SF-12, 12-Item Short Form Health Survey; SF-36, 36-Item Short Form Health Survey; SPMSQ, Short Portable Mental Status Questionnaire.

Synthesis of qualitative evidence

There were 18 studies mainly from developed countries and India that reported qualitative data from approximately 330 participants (range 5 to 31) (192 patients and 138 healthcare professionals regarding their experiences on performance indicator use in hip fracture clinical care and rehabilitation pathways; Table II). Four mixed methods studies provided evidence from healthcare professionals in Australia,23 Canada,24 India,22 and Sweden25 (Supplementary Table iv). Two of the studies did not specify the number of healthcare professional participants.22,23 Additionally, 14 qualitative studies conducted between 2001 to 2021 mainly from Europe – Sweden (n = 5), Denmark (n = 2), Norway (n = 1), and the UK (n = 5) – and Israel (n = 1), provided healthcare professional or patient perceptions on aspects of clinical care and rehabilitation pathways related to acute care performance indicators (Supplementary Table v). Six of these studies had only healthcare professional participants,22,23,25,29,30,36 two had both patients and healthcare professional participants,24,35 and ten studies had only patient participants. Only four studies indicated the participation of carers/relatives/family members, but their details or experiences were not clearly described. The qualitative studies generally did not define specific performance indicators but asked more general questions about patient and staff experience of aspects of care related to performance indicators.

Table II.

Summary of qualitative studies investigating performance indicators in hip fracture care of older patients.

Study ID, country,

Study period		 Study aim Population Study design Analyses method (theory/framework/model used) Themes/subthemes Categories/subcategories
Haslam-Larmer et al

(Canada)

Study period: 201924		 To identify factors influencing participation in early mobility activities after hip fracture surgery Hip fracture Patients: 19

Family members: NR

Healthcare professionals: 10

(Physiotherapists, occupational

therapists, therapy assistants, and registered nurses)		 Part of mixed method study.

Qualitative method: Face to face semi structured interviews

The Healthcare professionals interview questions based on Theoretical Domains Framework

The patient & family member questions were grounded in the COM behaviour change model		 Theoretical Domains Framework

Capability, Opportunity, Motivation, Behaviour (COM-B) change model		 Patients

  • Patient’s pre-fracture functional status

  • Patients’ cognitive status

  • Medical unpredictability



Healthcare professionals

  • Healthcare provider perceptions

  • Healthcare providers attitudes and behaviours

  • Preconceived notions held by healthcare providers and patients



Patients and Healthcare professionals

  • Environment factors

  • Psychological and physiological factors

  • Mismatch of expectations

 Patients and Healthcare professionals

Factors affecting early mobility:

  • external to patient

  • unique to person
Jensen et al

(Denmark)

Study period: 201530		 To describe experiences of the hip fracture pathway. Hip fracture Patients:10

Relatives: 4

(daughter, husband, wife)

Health professionals*:15

(*physiotherapists, nurses, geriatrician, physicians, healthcare workers and PhD student)		 Qualitative – semi structured interviews and field observations to gain a broader and richer description and to clarify if the patients feel empowered and able to perform selfcare after short time stay in hospital. Phenomenological and Reflective Lifeworld Research approach

Phenomenon: 'hip fracture pathway with short time stay in hospital (STSH)'		 NR Patient

  • Pre-conceived notions

  • Importance of autonomy

  • 'Master in my own house'

  • Will and zest for life



Health professional

  • Self-care and empowerment

  • Cross sectional collaboration

  • Preparing for discharge
Mow et al

(Australia)

Study period: unclear, sometime between 2013 to 201523		 To identify processes that could be clarified and streamlined, with the agreement of relevant stakeholders, in the creation of a new hip fracture pathway Clinical staff: NR

(Anaesthetists, radiographer, ortho surgeon, ortho registrar, medical registrar, physician, allied HP, theatre nurse)		 Part of mixed method study.

Qualitative method: Unclear		 Smart simplicity model

(to drive progress toward the common goal by cooperative process

restructuring, allowing staff involved in the processes to explore jointly the approaches that were best supported by evidence)		 Clinical staff

  • Cultural issues causing delay to hip fracture patient progress through the pathway

 NR
Rath et al

(India)

Study period: 2014 to 201522		 To document current practices, barriers and facilitators to adopting best practice guidelines and consequently make recommendations for improving the management of older adults with hip fracture Healthcare professionals*: NR

(*Involved in pre to postop hip fracture care and included clinical leads, residents, and nurses from orthopaedics, anaesthesia, geriatrics, medicine, and physiotherapy depts)		 Part of mixed method study.

Qualitative method: open ended question interviews and focus group discussions to obtain information on existing care pathways within their hospital setting and potential barriers and facilitators to adopting best practices		 Behaviour change wheel framework

COM model		 Healthcare professionals

  • Persuasion in hip fracture patients’ care pathways

  • Modelling

  • Enablement

  • Education & training

  • Environmental restructuring

 Healthcare professionals

  • COM behaviour change

  • Communication/marketing

  • Guidelines

  • Service provision

  • Environmental/social planning

  • Regulation
Gunningberg et al

(Sweden)

Study period: 200025		 To investigate possible changes in nursing and treatment routines in pressure ulcer risk Multiprofessional group*: 6

(*Ortho surgeon, nurses & technicians from ED, operation theatre, and ortho ward)		 Part of mixed method study.

Qualitative method: focus group interviews to investigate possible changes in nursing and treatment routines		 Framework of the Plan-Do-Study-Act model & VIPS model based on four key concepts (wellbeing, respect for integrity, prevention, and safety) Multiprofessional staff

  • Intervention functions

  • Service provision

  • Enablement

  • Modelling

  • Environmental restructuring

  • Education and training

 Multiprofessional staff

  • Audit nursing and treatment routines

  • Fast track care of hip fracture patients

  • Identify risk factors

  • Develop pressure prevention programme in orthopaedic wards
Volkmer et al (UK)

Study period: NR29		 To explore physiotherapists’ perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit. Physiotherapists: 21 Qualitative – one-to-one and semi-structured telephone interview.

Open-ended questions about their experiences working with hip fracture patients; their views on potential reasons for reported variation in physiotherapy after hip fracture; the types of patients they treat, the structure of their service, the role of other healthcare professionals, patients and informal/formal carers in early recovery after hip fracture		 Normalization Process Theory Physiotherapists

  • Achieving protocolised and personalized care

  • Patient and carer engagement

  • Multidisciplinary team engagement across the care continuum

  • Strategies for service improvement

 NR
Jensen et al

(Denmark)

Study period: 201630		 To use a Habermasian lens to illuminate health professionals' perspective of the gap between what the system provides, and patients’ needs and wishes, with a view to supporting patient empowerment. Mixed group of health professionals*: 16

(*doctor in chief, leading orthopaedic doctor, nurses, endocrinologist, geriatricians, researchers, external observers, social and healthcare assistants, physiotherapists)		 Qualitative – three focus groups

Open-ended questions which allowed participants to freely discuss their thoughts, perceptions and ideas on hip fracture care and generated follow-up questions		 Habermas' theoretical framework Health professionals

  • Systematized pathways and clinical guidelines are inevitable

  • How to counteract patients' lack of information

 Health professionals

  • Objective world (e.g. knowledge)

  • Social world (rules/norms of social interactions, patient expectations, health related decisions)

  • Subjective world (intentions, thoughts, emotions and wishes)
Christie et al (UK)

Study period: NR36		 To explore a multidisciplinary collaborative approach to implementing evidence-based, person-centred hip fracture care. Clinical leaders*: 16

(*From different disciplines and were knowledgeable in the field of hip fracture care and were in a position to influence others)		 Qualitative – data collected during eight two-hour action meetings Collaborative inquiry approach

(underpinned by the combination of critical theory and Habermas’ concept of lifeworld, Mezirow’ action orientated approach to learning from experience and Rogers’ humanistic psychology of person-centred practice)		 Clinical leaders

  • What it was like

  • Overcoming the risks together

  • Thinking differently

  • Enhanced experience

 NR
Schroeder et al (Israel)

Study period: 202126		 To understand the perspective of the patient’s experience of rehabilitation following hip fracture Hip fracture Patients: 15 Qualitative method: Open-ended questions semi-structured interviews and focus groups via video conference and telephone

Questions were about the physical, emotional, personal goals of rehabilitation as well as the participant’s view of optimal timing for administration of the SF36 questionnaire.		 SF-36 model

(used SF-36 questionnaire for patient reported outcome measurements)

The Lincoln and Guba Framework		 Patients

  • Uniqueness

  • Physical needs

  • Roles (physical, social, emotional)

 Patients

  • Identify needs post hip fracture

  • Ageism, old age, falls & fractures

  • Physical functioning

  • Independence

  • Therapy

  • Rehabilitation/training

  • Physical role

  • Bodily pain

  • Vitality

  • Social role

  • Emotional role (fear of falls, uncertain future, moods, guilt and sadness)
Southwell et al (UK)

UK

Study period: NR27		 To explore older adult’s perceptions of early rehabilitation and recovery after hip fracture, as a

complement to the UK standards for acute physiotherapy after hip fracture.		 Hip fracture patients: 15 Qualitative – In-depth semi-structured interviews with three open-ended questions on starting rehabilitation, rehabilitation activities and benefits, and challenges of rehabilitation for recovery). Bury’s biographical disruption theoretical framework. Patients

  • Importance of self-determination

  • Reliance on professional support

  • Importance of meaningful feedback

  • Anxiety about the future

  • Reliance on social capital

 NR
Asplin et al (Sweden)

Study period: 201628		 To explore patients’ experiences during inpatient rehabilitation after hip fracture surgery and the use of Traffic Light System -Basic ADL in their rehabilitation process Hip fracture patients:19 Qualitative – semi-structured interviews with questions on experiences of recovery and participation in their rehabilitation process including the use of TLS-BasicADL Content analysis using

Graneheim and Lundman method		 Patients

  • Being seen as a person

  • Striving for Independence

 Patients

  • Interaction gives trust and security

  • Information is key to understanding

  • Encouragement is essential to promote activity

  • Accepting the situation while trying to remain positive

  • The greener the better, but it’s up to me

  • Ask me, I have goals

  • Uncertainties concerning future
Segevall et al (Sweden)

Study period: 2016 to 201731		 To describe rural older people’s experiences of recovering after hip fracture surgery Hip fracture patients: 13 Qualitative –individual semi-structured interviews, according to

Kvale and Brinkman method.

Participants were asked to talk about the fall, how they perceived their hospital stay, and how their life now compares with how it was prior to the fall.		 Phenomenological content analysis using Catanzaro procedure. Patients

  • An unexpected life-altering event

  • Preparing to return home

  • Needing adjustment and support at home

  • Struggling to manage at home.

 NR
Bruun-Olsen et al (Norway)

Study period: NR32		 To explore how elderly patients with hip fracture enrolled in an ongoing RCT have experienced their recovery process Hip fracture patients: 8 Qualitative – semi-structured interviews with open-ended questions on the issues related to their experiences of barriers and facilitators of the different stages in the recovery process Phenomenological approach Patients

  • Feeling vulnerable

  • A span between self-reliance and dependency

  • Disruption from normal life

 Patients

  • Feeling of subservience

  • Feeling of gloominess and hopelessness

  • The gap between expectations and reality

  • Recovery as self-reliance

  • Recovery as dependent on actions from others

  • Less independence and mobility

  • The impact of age
Ivarsson et al (Sweden)

Study period: NR33		 To elucidate perceived situations of significance experienced by patients with hip fracture during the prehospital- and in-hospital care. Hip fracture patients: 8 Qualitative – semi- structured interviews with open-ended questions on their experiences as hip fracture patients Critical incident technique approach Patients

  • Oscillating between being satisfied and enduring a new demanding situation

 Patients

  • Pain and pain management

  • Feeling fear and satisfaction in perioperative care

  • Experiencing continuity in care

  • Considering information

  • Feeling encouragement and assistance
Gesar et al (Sweden)

Study period: 201334		 To explore healthy older patients’ perception of their own capacity to regain pre-fracture function in the acute phase (the first two to five days) after hip fracture surgery Hip fracture patients: 30 Qualitative - Semi-structured interviews with open-ended questions to describe their hip fracture experiences and the possibilities of regaining functions and recovery after hip surgery. Explorative inductive qualitative design.

Data analyzed using manifest inductive content analysis		 Patients

  • To end up in a new situation with or without control

 Patients

  • Belief in recovery, nothing will be altered

    • No problem, I will manage this

    • unexpected event, determination will be needed

  • Adapting to a new situation in hospital

    • Need for appraisal

    • Context as a negative influence

  • An unpredictable future

    • When and how to recover

    • Uncertainty
Griffiths et al (UK)

Study period: 201237		 To explore what patients consider important when evaluating their recovery from hip fracture and to consider how these priorities could be used in the evaluation of the quality of hip fracture services. Hip fracture Patients: 31 Qualitative – semi- structured interviews to explore with patients and, where appropriate, their carers, what they consider to be important outcomes and to explore variation across this patient group. NR Patients

  • Mobility (within 24 hrs post surgery)

  • Valued day-to-day activities

  • Self-care

  • Pain

  • Mental wellbeing

  • Fear of falling

  • Leg shortening.

 NR
Olsson et al (Sweden)

Study period: NR38		 The aim of this study was to describe the hip fracture patients’ own perceptions of their situation and views of their responsibility in the rehabilitation process. Hip fracture Patients: 13 Qualitative – semi-structured interview questions, related to the informants’ perception of the transitional properties, Phenomenographic analysis Patients

  • Common patient traits

  • Variations in need for information

 Patients

  • Lacked awareness

  • Were shocked by the hip fracture accident/event

  • Had a strong desire to recuperate

  • The Autonomous (who knew what they wanted after discharge)

  • The Modest (who gave the impression of being vulnerable and dependent on others and they expressed themselves cautiously)

  • The Heedless (who appeared to view their situation with some detachment, almost as if it did not really concern them)
Archibald et al (UK)

Study period: 200139		 This study was conducted to explore the experiences of individuals who had suffered a hip fracture to inform nursing practice. Hip fracture Patients: 5 In-depth, open-ended, unstructured interviews Phenomenological methodology, grounded theory approach Patients

  • The injury experience,

  • The pain experience,

  • The recovery experience

  • The disability experience

 Patients

  • Storytelling, recalling the experience of the injury itself

  • Coping with the pain

  • Involved the operation, beginning the struggle of recovery, and regaining independence.

  • The disability itself, depending on others, and being housebound
  1. *

    Study number as per Supplementary Tables iv and v.

  1. ADLs, activities of daily living; COM, capability, opportunity, and motivation; HP, healthcare professional; N/R, not reported; RCT, randomized controlled trial; TLS, traffic light system.

The qualitative studies were of poor (61%) or intermediate (39%) methodological quality. They were heterogenous in terms of study aims, types of healthcare professionals interviewed, timing of data collection from patients in relation to the hip fracture which could introduce recall bias, theoretical models/frameworks and content analyses. Furthermore, the nomenclature used in different studies made integration challenging, with different researchers using terms such as ‘themes’, ‘sub themes’, ‘categories’, and ‘sub-categories’ interchangeably across papers. This heterogeneity makes synthesis of the qualitative data challenging.

Nevertheless, we grouped 'themes' under headings: personal factors, injury related factors, care pathway factors, and areas indicting the need for new or different performance indicators (Supplementary Table xi). Several studies identified the need for education/training/guidance to raise awareness of the importance of performance indicators in hip fractures care. Other cross-cutting themes included the need for clarity of roles within the clinical team, the need for restructuring or integration of care pathways linked to performance indicators and the requirement for regulation of data and processes.

Although lived experience of hip fracture was the focus for many of the qualitative studies involving patients, the participants identified several themes relevant to the use of performance indicators. These studies report that the interpretation of healthcare performance was influenced by personal/social attitudes, including beliefs, perceptions, and fears. With regard to medical/hospital care, themes including the need for teamwork/multidisciplinary care, a supportive environment and information about patient progress in their recovery, with particular regard to information about rehabilitation. The patients expressed a desire to be kept informed about progression on the care pathway, as it related to their care in particular. These themes suggest the potential need for more patient-centred performance indicators, to address the complexity of patient needs and contextual elements such as trust, humanistic approach, multi morbidity, frailty, and psychosocial care, within care pathways. For example, regarding their expectations of meeting performance indicator targets, one patient quoted, “It is very important to ask patients what they want from the treatment, what the patient’s expectations are from the treatment, even though we are older women”.26 With regards to early mobilization one patient stated, “I thought I probably could have done more, but I didn’t know how much I should do, I left it to them”.24

Analyses of the qualitative data from eight studies involving healthcare professionals revealed several themes which could be subdivided at individual/personal, patient, and hospital/environmental levels. The healthcare professionals sought and found empowerment through the use of, and reporting of, performance indicators in hip fracture care. They felt able to use performance indicators to drive organizational restructuring and optimize multi-disciplinary team roles, as well as improving individual patient care. They also identified the need for training to change behaviour and achieve specific performance indicator targets. Healthcare professionals also expressed some concerns regarding the use of performance indicators in hip fracture care. These included suboptimal engagement of stakeholders, particularly patients and healthcare professionals, in the choice of performance indicators and the design of the clinical pathway. Leading to, for example, a lack of obvious links between performance indicators and patient-centred outcomes such as quality of care.

A common theme in both patient and healthcare professional interviews was the mismatch of expectations between patients and their carers and the clinical staff looking after them. This could lead to very different interpretations of data pertaining to performance indicators in the context of hip fracture. This mismatch was influenced by cultural attitudes to hip fracture and personal beliefs, for example the belief that older patients with hip fracture were less important than other trauma patients and therefore of a lower priority for urgent care. Other common themes included: the importance of psychological factors and motivation, assessments of general health risk, falls risk, discharge planning, and the provision of information to patients (Supplementary Table xi).

Discussion

This mixed methods review summarizes the peer reviewed literature and provides a holistic overview on the use of performance indicators in hip fracture care. A total of 171 studies were conducted between the years 1981 and 2021 across 34 countries. Of these studies, 63% were published within the last eight years or so (between 2015 and 2023). Studies were heterogenous in design, health systems studied, and study periods.

There was considerable variation in the performance indicators used for hip fracture care and, where performance indicators were defined, considerable variation in the definitions used. This variation makes it difficult to compare and contrast the performance of healthcare centres and systems, both within a single country and between countries. Of the 241 performance indicators described, ‘time to surgery’ was mostly commonly used (83% of included studies). Other commonly used indicators were ‘time to mobilization post-surgery’, ‘orthogeriatric assessment’, and ‘bone health assessment’. Performance indicators related to acute care predominated, with very little attention given to post-acute care and rehabilitation.

The experiences of patients and healthcare professionals with regards to the use of performance indicators was generally poorly documented. However, common themes emerging from qualitative studies included the need for education/training/guidance on the use of performance indicators to facilitate positive behavioural and organizational change, and the need to link performance indicators to demonstrable improvements in patient-centred outcomes.

Performance indicators are increasingly collected as part of national hip fracture registries/audits. Some healthcare systems have gone further, linking healthcare funding to performance indicators such as ‘best practice tariffs’ or ‘pay for performance’ initiatives but data on the benefits of such schemes, in terms of patient outcomes and healthcare costs, are limited.7,186

This review is not without limitations. The variable terminology used in describing performance indicators – quality standards, quality indicators, performance indicators, performance metrics, etc – made it difficult to develop a comprehensive search strategy. We attempted to mitigate this using ‘snowballing’ methods, which included conducting an extensive review of reference lists from retrieved studies and by searching the associated grey literature. However, it is still possible that our search strategy missed relevant studies. The heterogeneity in the use of and definition of performance indicators for hip fracture care, precluded numerical synthesis of data from different studies, and hence the review is limited to a narrative summary.

In conclusion, the use of performance indictors to manage hip fracture care is increasing in healthcare systems around the world. Healthcare professionals clearly see value in collecting these data. However, there is great variation in the performance indicators used, and how these performance indicators are defined. While it is important that performance indicators are relevant to the healthcare system in which they are used, standardization of the terminology and definitions of the commonly used performance indicators in hip fracture care would facilitate evidence synthesis and comparisons both within and between healthcare systems. Evidence with regard to stakeholder experiences in the collection and management of performance indicators is lacking.

There remains a pressing need for further research into the use and standardization of performance indicators in hip fracture care and their influence on patient outcomes and economic costs. More robust studies are also required into the barriers and facilitators for the use of performance indicators, in different healthcare systems and in different countries. The use of performance indicators for hip fracture care in low- and middle-income settings is currently poorly documented.

Correspondence should be sent to Dr Veena Mazarello Paes. E-mail:

V. Mazarello Paes et al, on behalf of the HIPCARE investigators*

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Author contributions

V. Mazarello Paes: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

A. Ting: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – review & editing

J. Masters: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – review & editing

M. V. I. Paes: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – review & editing

E. Tutton: Data curation, Formal analysis, Methodology, Validation, Writing – review & editing

S. M. Graham: Conceptualization, Data curation, Investigation, Methodology, Validation, Writing – review & editing

M. L. Costa: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing

Funding statement

The author(s) disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: National Institute for Health and Care Research and Oxford Biomedical Research Centre.

ICMJE COI statement

M. L. Costa reports that his employer, the University of Oxford, receives research grant funding from the National Institute for Health and Care Research (NIHR) and Wellcome for research into musculoskeletal trauma, which is unrelated to this work. J. Masters declares that the research was carried out at the NIHR and the Oxford Biomedical Research Centre, which is related, and grant funding from the Academy of Medical Sciences, The Royal College of Surgeons of England, and AO UK, which is unrelated. V. Mazarello Paes discloses a grant from the NIHR (no. 203194), which is related to this study.

Data sharing

All data generated or analyzed during this study are included in the published article and/or in the supplementary material.

Acknowledgements

This study has been delivered through the National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre (BRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. We also acknowledge Ms Elinor Harriss’ help with the electronic database search strategy.

Open access funding

The open access fee was funded via the National Institute for Health and Care Research (NIHR) RIGHT HIPCARE grant no. 203194

Supplementary material

Tables showing: a) the search strategy; b) inclusion and exclusion criteria; c) summary of extracted data and quality assessment of various study designs (experimental, mixed methods, qualitative, before/after intervention, prospective/retrospective cohort studies and cross-sectional surveys); d) performance indicators/proxy performance indicators investigated via prospective cohort studies; and e) summary of themes from qualitative evidence from patients and healthcare professionals.

*HIPCARE collaboration investigators

Professor Matt Costa

Professor Irewin Tabu

Dr Dipendra Pandey

Professor Sunil Kumar Joshi

Professor Vijay Sharma

Dr Jagnoor Jagnoor

Dr Paphon Sa-ngasoongsong

Professor Quang La

Professor Nguyen Duc Chinh

Professor Cuong Pham V

Dr Juul Achten

Dr Duncan Appelbe

Mr Richard Grant

Dr Sofia Massa

Dr Corneliu Bolbocean

Professor Stavros Petrou

Professor David Keene

Dr Anna Palagyi

Dr Elizabeth Armstrong

Professor Rebecca Ivers

© 2025 Mazarello Paes et al, on behalf of the HIPCARE investigators* This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

Information

Journal

Bone & Joint Open

Volume

6 No.3 | Pages 275 - 290

Section

Systematic Review

Published

06 March 2025

DOI

PubMed

40043739

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Research Fellow in Global Health

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK

veena.mazarellopaes@ndorms.ox.ac.uk

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Honorary researcher, Trauma & Orthopaedic Surgery Core Surgical Trainee (London Deanery)

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK

Epsom and St Helier University Hospitals NHS Trust, London, UK

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Associate Professor of Orthopaedic Trauma

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK

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Biomedical Sciences

Queen Mary University of London, London, UK

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Senior Research Fellow in Patient Experience and Qualitative Methods

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK

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Associate Professor of Orthopaedic Trauma

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK

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Professor of Orthopaedic Trauma Surgery

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK

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Figures

Fig. 1 PRISMA flow diagram of the systematic search for evidence on performance indicators used globally for evaluating hip fracture care. CINAHL, the Cumulative Index to Nursing and Allied Health Literature; HTA, Health Technology Assessment; NHSEED, NHS Economic Evaluations Database.

Fig. 1

PRISMA flow diagram of the systematic search for evidence on performance indicators used globally for evaluating hip fracture care. CINAHL, the Cumulative Index to Nursing and Allied Health Literature; HTA, Health Technology Assessment; NHSEED, NHS Economic Evaluations Database.
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Fig. 2 Mapping evidence by countries in which the studies were originally conducted.

Fig. 2

Mapping evidence by countries in which the studies were originally conducted.
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