Protocol for a scoping review to explore governance for national hip fracture clinical audits

Introduction

Globally there are millions of fragility fractures each year due to osteoporosis and this is growing annually due to the increased ageing of populations around the world, resulting in ever growing costs and reduction in quality of life. These fractures are associated with significant disability and increased mortality¹. Hip fractures are considered one of the most devastating fragility fractures and therefore the development of hip fracture audits have been recognised as key drivers for improvement in patient care and outcomes². The first national clinical audit (NCA) for hip fracture was established in 1988 in Sweden, entitled Rikshöft³. It would take a further five years before the second national hip fracture audit was established in Scotland in 1993⁴. In 2024, there are a growing number of NCAs, mainly in Europe, with other large regional data collection with many participating hospitals. Additionally, there are several countries with emerging hip fracture audits. The Global Fragility Fracture Network (FFN), which is a global network of multidisciplinary activists committed to improving the prevention, care and recovery from fragility fractures, was established in 2011. To improve international comparability, the Global FFN advocates for a minimum common dataset across all existing and emerging hip fracture audits⁵, representing the simplest dataset that all national audits should aim to collect. Findings from this scoping review can be used to compliment the Hip Fracture Registry Toolbox: A collaboration between the Asia Pacific Hip Fracture Registry Toolbox (APFFA) Hip Fracture Registry Working Group and the FFN Hip Fracture Audit Special Interest Group published in 2020. This toolkit focuses mainly on the areas with emerging hip fracture audits and draws some learnings from a small number of the established audits⁶

Substantial research attention has been paid to incidence of hip fracture, hip fracture quality indicators⁷, differences in hip fracture care⁸ and outcomes^9,10. However, there are considerably less publications focusing on the governance of a national hip fracture clinical audit and no review of the core governance components required when establishing a NCA for hip fracture.

Clinical governance involves systems of accountability through which healthcare teams are measured for the quality, safety and experience of patients in the care they have delivered¹¹. Governance means that healthcare staff can specify the clinical standards for delivery and indicate the measurements made to demonstrate that what was set out to be done was done. Governance provides a critical framework for ensuring that clinical audits meet established standards including, clear accountability, continuous quality improvement, transparency, interdisciplinary working, leadership, supporting performance and ultimately contribute to quality improvement efforts¹². Evidence from established NCA’s have demonstrated reduction in mortality, costs and improvement in patient outcomes^2–4

As interest in hip fracture and fragility fracture care has grown through engagement with organisations like the Global FFN, hip fracture audits have been leveraged to drive these global campaigns to improve care quality. Due to the exponential growth in the number of emerging hip fracture NCAs, there is a need to describe the governance requirements for such audits to support the existing and offer guidance to future NCAs for hip fracture. To address the gap in knowledge, this scoping review is being conducted. Scoping reviews are a useful approach for describing a complex concept or subject and a way to summarise the findings¹³. The aim of this review is to identify governance components that are integral to establishing a NCA for hip fracture.

Methods

This scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for conducting scoping reviews^14,15 and subsequent JBI guidance for engagement with knowledge users¹⁶. This methodology was chosen due to its transparency, through publication of a pre-defined protocol and explicit data extraction and analysis, as well as its alignment with international reporting standards, such as the PRISMA-ScR. JBI methodology for scoping reviews includes the following stages:

1) Defining and aligning the objective(s) and question(s)

2) Developing and aligning the inclusion criteria with the objective(s) and question(s)

3) Describing the planned approach to evidence searching, selection, data extraction, and presentation of the evidence

4) Searching for the evidence

5) Selecting the evidence

6) Extracting the evidence

7) Analysis of the evidence

8) Presentation of the results

9) Summarising the evidence in relation to the purpose of the review, making conclusions, and noting any implications of the findings.

The findings of the scoping review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guidelines¹⁷.

Engagement

The reviewers in this study work either in the field of hip fracture care and audit and /or are experts in conducting scoping reviews. All reviewers are interested in improving the care and outcomes of hip fracture patients.

The lead author has worked in hip fracture care since 2001 and has 15 years of experience in hip fracture audit. Through the management of the Irish Hip Fracture Database (IHFD) under the operational governance of the National Office of Clinical Audit, the lead author has worked closely in its initiation, maturation and collaborates internationally with many of the established national hip fracture audits and has held central roles in the Global FFN as the former General Secretary (2019–2022) and is a member of the Global FFN Hip Fracture Audit Special Interest Group. This group comprises of nominated representatives from each of the established or emerging national hip fracture audits, international FFN representatives, and senior figures from the Global FFN administration¹⁸.

The IHFD, a clinically led web-based audit established in Ireland in 2012, has a multidisciplinary governance committee that oversees the audit, and includes public and patient representation and senior healthcare managers. The IHFD is clinically endorsed by the Irish Gerontological Society and Irish institute of Trauma and Orthopaedic Surgery¹⁹. Through this experience and connections with the Global FFN Hip Fracture Audit Special Interest Group and the IHFD, knowledge users will be engaged at specific stages to:

Review questions

The broad research question identified for this research is entitled ‘Understanding governance for national hip fracture clinical audit, a scoping review’. Specifically, the review questions are:

Inclusion criteria

The inclusion criteria will follow the PCC mnemonic (Population, Concept and Context) for scoping reviews¹⁵.

Relevant studies

A comprehensive search strategy will be designed in collaboration with an information specialist, incorporating MeSH terms relating to hip fracture and clinical audit (see Table 1). Additional relevant articles will be identified by examining the reference lists of included studies (backward citation searching) and by identifying studies that cite the included articles (forward citation searching). A search of the grey literature pertaining to NCA’s for hip fracture will also be included. The search strategy will use electronic databases including:

To ensure that sources are relevant, date restrictions will be applied from 1988 onwards as the first hip fracture NCA was established in Sweden. Language will be restricted to English only. Abstracts for conferences and editorials will be excluded. A comprehensive search strategy will be designed in collaboration with an information specialist. Table 1 provides a sample MEDLINE search string, which will be adapted for other databases. Citations from included articles will also be reviewed and considered for inclusion.

Study selection

Two reviewers will undertake an independent review of the titles and abstracts of all identified citations and any discrepancies will be resolved by a third reviewer who will help to reach a consensus. The full text review will be completed by two reviewers independently using the inclusion and exclusion criteria and a third reviewer will be consulted where disagreements occur. Citations excluded during the full-text review stage will be documented together with the reasons for their exclusion as part of the PRISMA flow diagram²⁰.

Data extraction

A standardised extraction form will be developed specifically for this review. Two reviewers will test and calibrate the extraction form on three papers and then two reviewers will independently extract data for the remaining full texts. Data extraction checked for accuracy and omissions by a third reviewer. Covidence a web based tool will be used to streamline the primary screening and data extraction processes.

Data synthesis and presentation

All identified NCAs for hip fracture will be described. A list of emerging hip fracture audits and large representative regional hip fracture audits will also be included to signpost potential future areas for study. Data will be presented in tables identifying the presence of core components for the governance of NCAs for hip fracture in each audit. Identified core governance components for hip fracture NCAs will undergo descriptive analysis and be reported as frequencies. Recommendations for key governance components based on the available data will be compiled by the reviewers.

Dissemination of findings

The findings will be presented at national hip fracture meetings, international fragility fracture or related conferences and through the FFN Hip Fracture Audit Special Interest Group.

Discussion

This study will build on a larger piece of work to describe the work of the IHFD since its inception in 2012. The scoping review findings will contribute to future studies aimed at describing the hip fracture NCA governance components from the Irish context. The findings from this scoping review will be of interest to the existing NCAs for hip fracture and will be very useful for emerging national hip fracture audits or countries that have yet to embark on establishing a NCA for hip fracture as it can act as a guide on how best to approach setting up a NCA. It will provide guidance to support their development and specify key features that are common in developed audits that are important.

Study status

Formal screening of search results against the eligibility criteria is ongoing.

Ethics

Ethical approval and written consent were not required for this study.