We know how to reduce mortality after hip fracture. But do we care enough to?
A hip fracture is a catastrophic injury. Among medical professionals, it is often considered a symptom of pre-existing and ongoing decline. A hip fracture is also a sentinel event—a harbinger of further losses in mobility and independence, of medical complications, and of death. In fact, nearly 10 percent of patients will die within 30 days of sustaining a hip fracture, and nearly one in three will have died within one year. What’s more troubling is that these outcomes have remained virtually unchanged for the past 30 years.
Why have advances in hip fracture care stagnated, whereas outcomes for other conditions, such as heart attacks and cancer, improved during the same time period? I would argue that much of this lack of progress has to do with demographics. The vast majority of the 32,000 hip fractures that occur in Canada each year are sustained by the very elderly. Many of these patients suffer from cognitive decline or dementia. Many are physically frail. Many reside in assisted-living or nursing homes. Most are women. Patients with hip fracture are among the most vulnerable and disenfranchised in modern society. The ability for them to self-advocate is limited.
Yet we have the knowledge to do better. “Shared care,” for example, has been shown to improve some of the worst outcomes after hip fracture. In this model, the care of patients is assumed not by a lone orthopaedic surgeon (which is currently the dominant model in Canada), but by a multidisciplinary team. Patients are admitted to a hip fracture ward where specialists in geriatrics, orthopaedic surgery and rehabilitation co-manage their care. Several high-quality randomized controlled clinical trials (which have collectively studied over 9,000 patients) have shown that when a shared care model is used, the risk of dying while in hospital with a hip fracture is reduced by 40 percent; the risk of dying in the long term is reduced by 17 percent. Other clinical studies have shown impressive reductions in preventable medical complications (such as pneumonia and delirium), lengths of hospital stay, and quicker return to mobility.
In addition to immediate improvements in outcomes and patient experience, shared care also offers an opportunity to more easily research how best to treat hip fractures. For instance, an ongoing international randomized clinical trial is underway evaluating whether accelerated medical clearance and surgery (i.e. within six hours of diagnosis as opposed to the current standard of 48 hours) can decrease medical complications and improve mortality rates. Similarly, a growing body of research literature is showing that in a subgroup of patients with specific fracture characteristics, a total hip replacement may be better than more widely offered treatment options. Researching both of these protocols would be greatly facilitated by having the concentration of both patients and specialized staff that shared care would provide.
As a result of the evidence, many health care providers—including myself—have advocated for hip fracture “centres of excellence” Though these centres are costly to set up, reductions in length of hospital stays and medical complications may ultimately end up saving the system money. One U.S. study demonstrated that hospitals that implement hip fracture co-management programs are able to break even once the number of patients treated annually reaches 54; after that, they save money.
If the research evidence is so strong, and the changes are potentially cost-saving, why have such models not been widely adopted? Although the concept of shared care has been floating for years within medical and surgical communities, the high-quality clinical and observational data confirming its effectiveness is relatively recent. Moreover, knowledge translation—the adoption of innovative research to routine clinical practice and policy—is often slow, especially when the innovation is a complex system change. Still, in Canada, there has been some recent movement. For example, the British Columbia Hip Fracture Redesign Project, which offers a streamlined, standardized and multidisciplinary approach to care, was initiated in several hospitals in 2013. The project demonstrated impressive improvements in hip fracture mortality and other outcomes, and prompted a province-wide implementation initiative.
There is no debate as to whether multidisciplinary teams have improved the care of patients who have cancer or multi-system trauma; there is little doubt that hip fracture patients would similarly benefit. Care could be consolidated to regional academic medical centers and larger community hospitals, where multidisciplinary teams would include geriatricians, internists, orthopaedic surgeons, palliative care clinicians, physiotherapists, nurses, and rehabilitation specialists (among others), all with expertise in the care of patients with hip fracture, working collaboratively. Care pathways could be streamlined and based on the best available—and ever-evolving—evidence.
It’s unlikely that there will be any single drug or surgical procedure in the near future that will drastically improve outcomes for those suffering from a hip fracture. Meanwhile, a system-level reorganization to benefit those who are among the most vulnerable in our society may be a daunting endeavour, requiring advocacy, political will, and resources. However, the present-day alternative is simply unacceptable.
Dr. Harman Chaudhry is an orthopaedic surgeon and clinical fellow in hip and knee arthroplasty at McMaster University. His research interests are in the creation and dissemination of high quality evidence to inform surgical practice and policy.