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Orthogeriatric collaboration and hip fracture audit

Orthogeriatric collaboration and hip fracture audit. David Marsh Emeritus Professor of Orthopaedics, University College London President, Fragility Fracture Network of the Bone and Joint Decade Chairman, UK Arthritis and Musculoskeletal Alliance. An epidemiological emergency.

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Orthogeriatric collaboration and hip fracture audit

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  1. Orthogeriatric collaboration and hip fracture audit David Marsh Emeritus Professor of Orthopaedics, University College London President, Fragility Fracture Network of the Bone and Joint Decade Chairman, UK Arthritis and Musculoskeletal Alliance

  2. An epidemiological emergency • The ageing population will lead to massive increase in hip fractures over next 25 yearsIn Europe and USA: • 2X the number of cases • 3X the cost • In Asia and South America – 6X increase • Unless we do something about it

  3. What has the UK contributed? • Orthogeriatric co-management of patients in the acute phase after fragility fracture • The ability of continuous national audit to drive up standards • The Fragility Fracture Network of the Bone and Joint Decade

  4. Key features of UK progress • Alliance between orthopaedics and geriatrics • Clinical and political • National Hip Fracture Database • Best Practice Tariff

  5. The fragility fracture ‘career’- a chronic disease Morbidity Dependence No fractures – increasing morbidity due to ageing alone Age 50 60 70 80 90 Age Adapted from Kanis JA, Johnell O; 1999

  6. The fragility fracture ‘career’- a chronic disease Morbidity Dependence Hip fracture Added morbidity from fractures Vertebral fracture Colles' fracture No fractures – increasing morbidity due to ageing alone Age 50 60 70 80 90 Age Adapted from Kanis JA, Johnell O; 1999

  7. Why Hip Fractures are the key Hip fractures – 87% of total cost of all fragility fractures (£2.0 billion in UK) 1.2 million bed days per year in UK Often considerably increased dependency

  8. Comparison with other priorities Issues: Strokes Heart Fragility & TIAs attacks fractures ----------------------------------------------------------------------------------------- Incidence/year 110,000 275,000 310,000 Current trend Falling Falling Rising NHS bed days* 1.85m 1.15m 1.2m (hips) Annual costs £2.8bn £1.7bn £2bn UK figures from the Department of Health

  9. Mortality after hip fracture Royal Victoria Hospital, Belfast 1999-2003 1003 deaths by one year in 5553 patients

  10. Complexity of elderly patients • Mean age hip fracture = 83 yrs • Comorbidities (median ASA 3) • Cardiac murmurs • Renal - Dialysis • COPD - home O2 • Diabetes • Delirium / dementia • Pseudo-obstruction • Alcohol abuse • Impaired metabolic response to injury • Hyponatraemia • Management problems • Consent • Theatre scheduling • Discharge planning • Polypharmacy • Warfarin • Plavix • Neurotropics

  11. Acute medical management • Elderly hip fracture patients are among the most medically complicated patients in the hospital • Difficult judgement – balance between medical optimisation and prompt surgery • Inexperienced surgical trainees not the best people to look after such people and prepare them for surgery • Ideal solution is close supervision by senior physicians having expertise with elderly patients • pre- and peri-operatively, not just for rehabilitation

  12. Senior medical backup • Can come from different specialists, depending on health care system • Anaesthesia • Internal medicine • Geriatrics • Orthogeriatricsa key role in UKand several other countries

  13. Compared four types of model • Integrated care on an orthopaedic ward gave the best • Mortality rate • Length of stay • Time to surgery

  14. J Am Geriatric Soc 2008 • Geriatric Fracture Center in Rochester, USA • Comparison with other fracture services in locality • In-hospital mortality 1.5% vs 3.2% • Readmission 9.7% vs 19.4% • Length of stay 4.6 vs 5.2 days

  15. Orthogeriatric co-management of the acute episode • Gives the patient a better quality of care with better outcomes • Saves money by enabling • more efficient use of resources • fewer readmissions Treating fragility fractures well is cheaper than treating them badly

  16. Four big messages Multidisciplinary approach to the management of fragility fracture patients Reliable secondary prevention osteoporosis falls Chronic disease model Quality assurance the NHFD

  17. BOA-BGS Blue Booksix standards for hip fracture care • All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation • All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, during normal working hours • All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer • All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from the time of admission • All patients presenting with fragility fracture should be assessed to determine their need for bone-protective therapy to prevent future osteoporotic fractures • All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls

  18. UK National Hip Fracture Database- jointly led by BOA and BGS • Measures compliance with Blue Book standards • A web-based national database, modelled on MINAP, now including every fracture unit in England, Wales and N. Ireland • Feed back to units their performance compared to national and regional peers • A professional steering group to manage analysis of, and access to the data • Extensile for research • Adopted by government as a national clinical audit

  19. Smart commissioning • Alliance between multidisciplinary providers and healthcare commissioners can tackle fragility fractures and drive change • Prioritisation • Incentivisation

  20. UK DoH package for older people Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards Hip fracture patients Top priority Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Non-hip fragility fracture patients Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Individuals at high risk of 1st fragility fracture or other injurious falls Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards Older people

  21. Best Practice Tariff (BPT)From April 2010 • Reimbursement to Hospitals for each case of hip fracture varies according to the quality of care • Two criteria used: • Time to theatre less than 36 hours • Involvement of orthogeriatrics in the acute phase • Including secondary prevention • Compliance for each case determined from the record in the National Hip Fracture Database

  22. National average cost Now the hospital CEO gives a damn PAYMENT PER CASE ~£500 BPT supplement before April 2010

  23. BPT attainment 2010 - 2012

  24. BPT attainment 2010 - 2012

  25. BPT attainment 2010 - 2012

  26. Moving average of patient mortality at 30 days from admission 2008/09 − 2010/11 Binomial test p−value < 0.001 99% confidence interval for change: [−2.5, −0.4] Change in percentage: −1.4

  27. Change in Length of Stay2010 - 2011

  28. National average cost Now - carrot plus stick ~£1300 BPT supplement

  29. Next steps • Explore the variation • We need to prevent hip fractures as well as treat them well if they happen • By responding to earlier fractures we could reduce the future incidence by ~25% • This requires a Fracture Liaison Service model • Can a FLS-database drive change similarly?

  30. Earlier fractures signal the hip fracture Morbidity Dependence Hip fracture Added morbidity from fractures Vertebral fracture Colles' fracture No fractures – increasing morbidity due to ageing alone Age 50 60 70 80 90 Age Adapted from Kanis JA, Johnell O; 1999

  31. Secondary prevention • Secondary prevention is more cost-effective than primary prevention

  32. Prevalence of prior fractures among patients presenting with hip fracture n=2124 n=632 n=701 Lyles KW et al. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. ASBMR 2006 Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research, 461, 226-230 McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland.

  33. 16% of women over 50 have had at least one low trauma fracture 50% of hip fractures from 16% of the population 50% of hip fractures from 84% of the population UK figures

  34. Target 100% 100% 100% ~70% Interventions after low trauma fracture National Clinical Audit of Falls and Bone Health (2007) Clinical Effectiveness and Evaluation Unit, RCP, London

  35. Secondary prevention • Secondary prevention is more effective than primary prevention • A systems approach is needed, where capture of patients is automatic

  36. Capturing patients reliably • Employment of a dedicated coordinator in the fracture service is the most effective system

  37. NEW FRACTURE INPATIENT ORTHO/TRAUMA WARD OUTPATIENT FRACTURE CLINIC FALLS RISK ASSESSMENT EXERCISE CLASSES Rx FOR FRACTURE 2Y PREVENTION EDUCATION PROGRAMME PRESCRIPTION ISSUED BY GP McLellan et al OI 2003, 14:1028-1034.

  38. Secondary prevention • Secondary prevention is more effective than primary prevention • A systems approach is needed, where capture of patients is automatic • When it is done vigorously, it is cost-saving

  39. Cost-saving • Per 1000 fragility fracture patients, 18 fractures (11 hip) prevented – net saving £21,000

  40. Secondary prevention • Anti-osteoporosis treatment reduces the incidence of further fractures by ~50% • If universally applied, coordinator-based systems in fracture units could • Prevent ~25% of the burden of disease from hip fractures • Save money

  41. Risk of fragility fracture Bone Density Postural Instability Bone Turnover Slow Responses Falls Risk Bone Strength Bone Architecture Frailty Skeletal Geometry Environment Mineralisation Lack of Padding

  42. SARCOPENIA FRAILTY

  43. SARCOPENIA FRAGILITY OSTEOPOROSIS

  44. Sarcopenia, frailty, rehabilitation • Falls really are as important as osteoporosis • Rehabilitation after fracture is inadequate • Drug companies are more excited about anti-sarcopenic drugs than anti-osteoporotic • Except bone anabolics

  45. But fractures will still occur • So efficient, high quality care of the acute episode remains crucial • FFN is the only international organisation that gives equal importance to prevention and treatment • Although the FFN is multidisciplinary, the strongest professional group in it is orthopaedics – also unique

  46. 3250 668 400 600 629 1990 1990 1990 1990 2050 2050 2050 2050 100 Projected Hip Fractures Worldwide 742 Total number ofhip fractures:1990 = 1.66 million2050 = 6.26 million 378 Adapted from Cooper C et al, Osteoporosis Int, 1992; 2:285-9

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