The burden of care to manage hip fracture patients is growing with the number set to double by 2050 and a gap in fracture prevention strategies in countries around the globe.
Hip fracture is an acknowledged major public health problem worldwide, with a high burden of morbidity and mortality. A recent international study examined the incidence of hip fractures, postfracture treatment, and all-cause mortality following hip fractures, based on demographics, geography, and year, from 2005 to 2018.
Among the most remarkable results of this study, are the following:
Another significant result of the study was that hip fracture incidence rates have declined in recent years in most countries and regions. However, as the global population ages, the burden of hip fractures will increase, with the number of hip fractures projected to double by 2050. This, in combination with the gap in post-hip fracture prevention, means that we need to intensify the effort to optimise globally the multidisciplinary management of the patient with a fragility fracture, including secondary prevention, which is the cornerstone of FFN’s mission.
You can read the full study here!
Screening in primary care aims to decrease the risk of future fragility fractures among those without a prior fracture, and to reduce fracture-related morbidity, mortality, and costs. Potential harms have been also reported though, including overdiagnosis, adverse events of screening or treatment, and increased health care resource use.
The Canadian Task Force on Preventive Health Care has released guidelines that provide evidence-based recommendations on screening for primary prevention of fragility fractures. The target population is community-dwelling adults 40+ who are not on preventative pharmacotherapy for fragility fractures. The recommendations were based on an analysis of systematic reviews addressing benefits and harms of screening, predictive accuracy of risk assessment tools, patient acceptability and benefits of treatment.
In this guideline the “risk assessment-first” screening approach to prevent fragility fractures is recommended, which involves using a fracture risk estimation tool (e.g., FRAX without BMD), followed by shared decision making with the patient and BMD if the patient is interested in preventive treatment to lower their risk. If BMD measurement is requested, risk is then re-estimated by adding the BMD T-score to the calculation.
Shared decision-making was recommended in this framework, using an interactive decision aid which was developed to help patients consider the potential benefits and harms of preventive pharmacotherapy within their individual risk context.
Additionally, there is a strong recommendation against screening for females aged 40–64 years and males aged ≥ 40 years, as the risk of overdiagnosis and adverse events from potential medication outweighs the benefit of screening in these groups.
You can read the full paper here!
An Orthogeriatric approach to care has been presented in this article that considers current definitions and concepts based on publications and classifications of care models, and which reflects experience of model implementation in the field. The approach to care that has been developed shows that the growth of orthogeriatrics includes 4 stages: Core/initial services, Interdisciplinary, Quality, and finally Management.
The first stage of “Core” is fundamental from a functional point of view as the evidence indicates that a strong orthopedic-geriatric program reduces the reliance on a consultation-based system. Building on this new approach also allows the other professionals to ensure they are an integral part of the care team that provides quality care as the model develops.
Measurement of the implementation of an orthogeriatric program is critical to ensure it is meeting its mandate. There are numerous indicators that can be used as the model is developed, many of which are co-dependent.
Orthogeriatrics models are management models that emerged in the 1960s for hip fracture patients with the aim of improving their outcomes. The types of orthogeriatric programs around the world are diverse since they are created to address varied local circumstances however they have been found to have enormous clinical, social, organizational, epidemiological, and economic impact.
Since their inception, the models have expanded from acute care to prevention, rehabilitation, and follow-up (the Orthogeriatric cycle), and include involvement from clinical, academic, administrative, and political
sectors. The Orthogeriatric cycle can be used also as a tool, allowing a panoramic insight of the development of Orthogeriatrics in a given moment and site, and facilitating comparison between different models.
Dr. Dinamarca-Montecinos, the geriatrician from Chile who authored this paper, notes that “Understanding the foundations of the orthogeriatric programs facilitates decision-making on the best model to implement, as it allows for discussion on what is to be achieved as well as comparison between models. This will help to ensure that the model meets the local needs, builds on the local available resources, and can be compared with successful models from other places”.
Read the full paper here!
A study published in 2019 in Bone and Joint Journal finds that the implementation of pay for performance Best Practice Tariff (BPT) in England, United Kingdom (UK) in 2010 resulted in 7600 fewer deaths between 2010 and 2016. Additional results included significant reductions which were observed in the time to operation and length of stay (LOS) and a pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention.
The BPT was implemented following a national clinical audit being established in England and Wales in 2007 with the aim of improving hip fracture outcomes. This programme included a National Hip Fracture Database (NHFD) and support for local clinical teams to improve the quality of care provided to elderly patients with a hip fracture. The BPT scheme was introduced a number of years later and paid hospitals a supplement for each patient whose care satisfied six of the reported clinical standards, such as surgery within 36 hours. The improvements in LOS and re-admission suggest substantial resource savings attributable to the BPT in addition to reduced mortality. The BPT itself did not require a substantial investment.
The study notes that there were a number of other changes that could account for improved outcomes over time across the UK, including publication of clinical guidelines, increasing recognition of the need for early surgery and postoperative rehabilitation, and the emergence of orthogeriatrics as a medical subspecialty dedicated to caring for elderly patients with a fracture.
Matt Costa, Professor of Orthopaedic Trauma and one of the researchers involved with the study, noted that: “The success of the BPT was part of a comprehensive initiative that began with setting up clinical guidelines and using the national clinical audit to identify issues and design quality improvement processes. Data was easily accessible, being provided through online visual dashboards and in publicly accessible reports.” He further stated that “Once the structure was in place to improve performance, BPTs provided additional impetus that helped clinicians and hospital leaders to create business cases that justified local investment in hip fracture services.”
Implementation of the BPT was associated with a marked and sustained improvement in outcomes, however needs to be built on clinical standards and a reporting system that allows hospitals to identify and address their weaknesses.
Read more here!
The implementation of Best Practice Tariffs (BPT) has resulted in significant improvements in the outcomes of individuals who had sustained a hip fracture in the UK. This approach may help the USA in their work to improve the health care system to meet the needs of older adult health.
The way that hospitals and physicians are paid defines how care is provided around the world. In the USA the Affordable Care Act has resulted in Medicare introducing an expanded set of alternative-payment models in an effort to improve the care and resultant outcomes of older adults. A study was undertaken analyzing the use of the Best Practice Tariffs (BPT) which is the payment method used in the UK to support evidence-based management of hip fracture patients, to assess the implications to using this type of payment model in the USA.
The study published in the Annals of Surgery in 2022 analysed data from 2000 to 2016 Medicare (US) and death certificate-linked claims for people over 65 years in England. Analysis looked at US hip fracture trends as well as changes in English hip fracture trends before-and-after BPT implementation. It then compared changes in US-versus- English mortality and estimate total theoretical lives saved.
From the data, a total of 806,036 English and 3,221,109 US hospitalizations were included. In the UK, after BPT implementation, England’s 30-day mortality decreased by 2.6 percentage-points from a baseline of 9.9%. 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000 to 2016, USA outcomes were stagnant. As such it was determined that implementing the UK payment model could result in an inversion of the countries’ mortality with >38,000 potential lives saved each year.
Matt Costa, orthopaedic surgeon from the UK, and lead author stated: “The best practice tariffs are a payment mechanism that can drive improvement when they are used to support quality standards. To be successful, a mechanism to measure and report these standards is a critical first step.”
Read more here!
In Thailand, healthcare professionals do not initiate osteoporosis treatment for half the people who have experienced a hip fracture with the main factors being male, having a high comorbidity level, and having an education level at the secondary school level or below
Anti-osteoporosis medications are important to prevent fragility fractures, especially for those patients who previously had one. Surprisingly, the anti-osteoporosis treatment rate is low, globally. Understanding why patients do not receive medication is crucial to improving the overall rate of osteoporosis treatment. Multiple factors are affecting these rates and might be different per institution and country.
A study by Maihasavariya et al. (published Feb 2023) explored the osteoporosis treatment gaps in Siriraj Hospital, Mahidol University, a tertiary university medical center in Thailand. Using Siriraj’s FLS registry data from 2016 to 2019, they found out that the chief predictors for not receiving medication are 1) being male 2) high comorbidity level 3) education level (secondary school or below). Of all the patients eligible for this study, almost half did not receive anti-osteoporosis medication 1 year after hip fracture treatment because healthcare providers neither discussed nor initiated pharmacological treatment for osteoporosis. Financial constraints, patient perception against anti-osteoporosis medication, concerns about adverse medication effects, and inappropriate medical conditions, make up half of the reasons why they did not receive medication after 1 year. It was also found in the study that when medication was prescribed, non-persistence primarily stemmed from transportation difficulties that resulted in patients missing follow-ups.
The authors said in the paper, "this finding underscores attitudes toward anti-osteoporosis medications might improve the rate of treatment” and that, “developing a follow-up team and facilitating access to medications (e.g., courier delivery to patients) would help to decrease the number of patients who discontinue anti-osteoporosis treatment.” Preventing a second fracture is a critical strategy to improve the lives of people in Thailand.
Read more here!
In April 2022, a new reimbursement scheme for the Japanese Fracture Liaison Service was implemented in Japan for patients who have sustained a fragility hip fracture. The reimbursement scheme has been designed to improve post-fracture patient care and increase access to the prevention of secondary fractures.
The new scheme covers the evaluation for secondary fracture prevention throughout care. This approach will ensure that patients who have suffered a hip fracture will be automatically assessed for osteoporosis and given the necessary treatment which aligns with international guidelines and FLS clinical standards.
Since last April, extensive work has been undertaken by FFN Japan to register hospitals on the Japan Hip Fracture Registry so that there is a system to track hospital performance. There has also been the development of educational tools.
There are an estimated 13 million people living with osteoporosis in Japan and 240,000 patients annually who experience a hip fracture due to osteoporosis. Many patients don’t get the treatment they need at the time of the fracture. This further deteriorates as they return home with only about 20% still being on medication one year later. Osteoporosis is a bone disorder that results in painful and disabling fragility fractures, often leading to long-term loss of mobility and independence in older adults.
Professor Takeshi Sawaguchi, the president of Fragility Fracture Network Japan (FFN-J) stated: "Japan has one of the longest life expectancies which over the next few years will create a burden on the health care system. We know that one hip fracture is a risk factor for a second fracture, so prevention is essential. A Japanese study showed that compared to the general population, women aged 65 years of age and over who sustain an initial hip fracture are four times as likely to sustain an additional hip fracture."
The gap in the management of fragility fracture treatment is a problem around the globe. FFN understands that implementing best practices requires changes at both a clinical and a policy level. Japan, through the leadership of FFN Japan, has shown what can be achieved by working together.
At FFN, we will learn from the successes of the project and share relevant information with colleagues around the world so that we can improve the care of patients with fragility fractures.
The management of patients with hip fracture includes evidence-based care throughout the patients journey from the emergency department to discharge. A position paper that addresses the challenges and outlines the evidence-based post hip fracture orthogeriatric care has been released in Canada.
The paper is embedded in the three clinical pillars of FFN that address the needs of patients using a multidisciplinary orthogeriatric approach to care through acute care, rehabilitation and secondary prevention. The paper was developed using a comprehensive narrative review to identify and synthesize key articles on post hip fracture care for each of the sections and recommendations were developed.
The paper provides evidence recommendations on:
Throughout the paper, recommendations consider secondary fracture prevention including the management of osteoporosis. Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. All patients who have had a hip fracture are high risk for osteoporosis and should be assessed and treated as appropriate to prevent a further fracture. However less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying condition.
One of the authors, Dr. Jenny Thain, a geriatrician in London, Ontario says “This position paper was written to align with health care systems across Canada. Implementing the recommendations would help reduce recurrent fractures, improve the functional and mobility outcomes post hip fracture and reduce healthcare costs”.
Read the full text here!
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