If you’re elderly, falling and breaking a hip is a major health risk. More than 35,000 Canadians suffer from hip fractures every year, and most of them are over 60. For many of those people, it will mark the beginning of serious health issues. Many will suffer complications such as a heart attack, stroke, pneumonia, blood clot or major bleeding. Within three months of a hip fracture, 6% to 8% will die. Within a year, 12% to 37% will die, with numbers reflecting ranges in the studies.
Surprisingly, many of those complications are not repercussions of the injury itself. Rather, they’re a result of the time patients spend bedridden waiting to get surgery. “These people are lying in bed, they don’t eat [because they’re fasting for surgery], they’re on strong medication, their circulation deteriorates … there’s a myriad of complications that can happen as a result of that,” explains Don Dick, an orthopedic surgeon and senior medical director of Alberta’s Bone and Joint Strategic Clinical Network.
Which brings us to the good news: getting surgery for a hip fracture sooner – within 48 hours – can significantly reduce the risk of negative outcomes. Canada has done well on pushing towards that two-day goal, but there remains significant variation across the country. In some parts of Ontario, only 75% of patients get their surgery within 48 hours. In some parts of Alberta, rates dip down to 62%.
And a major trial in Ontario is now testing whether doing surgery even sooner would result in even better outcomes. Called HIP ATTACK, it looks at whether treating patients in six hours or less will help reduce complications and death. The trial’s six-hour line sprung out of a finding by UK researcher Martyn Parker, who was stratifying outcomes data by wait times, and found that patients who happened to wait less than six hours did considerably better than others who waited longer.
“HIP ATTACK treats hip fractures almost like a heart attack: if someone shows up with this problem, you do something for them right away,” explains James Waddell, chair of the Expert Panel for Orthopaedic Surgery for Health Quality Ontario. “Yes, we’re better than we were, but I’m hopeful that we can make wait times even shorter.”
Working to fix unequal access
Across the country, we’ve done much better at hitting the 48 hour benchmark for hip surgery, with 87% of people getting surgery within that time in 2015, up significantly from 79% in 2011. That puts us close to the target of 90%. It also means we rank fairly well against other OECD countries on this issue, coming in fifth of 23 countries in 2013.
It’s clear that early surgery is important. A 2005 study looked at 57,000 hip fracture patients in Ontario and found that surgical delay was a major predictor of death, with every day of delay increasing the odds of dying in hospital by 13%. The same trends held three months, six months and a year after surgery, and they were even more pronounced in younger, healthier patients. A more recent systematic review published in the Canadian Medical Association Journal found similar results. It looked at 16 studies that encompassed 13,500 patients over 60, with cutoffs at 24, 48 or 72 hours, and found that earlier surgery was associated with a lower risk of death, lower rates of pneumonia and fewer pressure sores.
A 2005 study found that every day of delay before surgery increased the odds of dying in hospital by 13%.
So it’s concerning that there are still differences in wait times depending on where you live. Interestingly, unlike many health care inequities, “it doesn’t really fall in the rural-urban divide,” says Tracy Johnson, Director of Health System Analysis & Emerging Issues at the Canadian Institute for Health Information. She points out that 88% of people in Ontario’s South West LHIN get surgery within 48 hours, while the more urban Mississauga-Halton one is only at 81%. The lowest rates in Ontario are 75% in the North Simcoe Muskoka LHIN; the highest are in the Central West LHIN, where 94% do.
Alberta has a similar spread, and the province has started a Fragility and Stability Working Group to try and address it. While rural areas can face delays around transferring patients, in the end the group found that hospitals in larger cities posed a challenge. “Those organizations had to change the mindset of how they managed these patients,” says Dick.
To make improvements, the group brought the surgeons, administrators and operating room staff together to emphasize the magnitude of the problem and to collaborate on how to streamline the process. “[This kind of surgery] just has to get priority,” says Dick. “Does a fractured ankle go before a fractured hip? Everybody has to come together and make a conscious decision that hip surgery is a priority, that the evidence says that needs to be done first.”
That’s important to emphasize, because too often hip repair surgery falls into a grey area. “You’re not a planned surgery, and you’re not super urgent like a trauma,” says Johnson. “This is one area where more money isn’t necessarily going to improve your wait times, because doing more isn’t going to change your wait list, like it is with elective surgeries. This is about process improvement, and coordination of care.”
Over the long term, improving time to surgery can actually reduce costs, says Dick. “The cost of all these complications are enormous – these people get pneumonia, they end up in the ICU… It costs the system $30,000 for [the average] fractured hip, and if we can decrease the complications, then we can significantly decrease the costs.” The HIP ATTACK trial will also analyze the potential cost benefit of very early surgeries.
Is a 48-hour benchmark still too long?
Last winter, Lee Lin-Rogano slipped outside of her daughter’s house in Dundas, Ont., and broke her hip. The 73-year-old ended up being recruited for the HIP ATTACK trial, and got her surgery about five hours later.
As an ex-nurse, she understands why it is hoped that the expedited surgery means she’s less likely to have complications. But as a patient, she was also happy because she didn’t like waiting. “The pain is terrible – they gave me pain medications, but no matter how much they give you, you’re still going to have pain,” she explains. “The worst part is you cannot move without help. Every time you move it hurts. Then you have to go on the bedpan – it’s awful for a patient. The sooner it’s fixed, the better.”
The trial, which includes 1,200 participants, hopes to prove that faster surgery will lead to a lower risk of major complications within 30 days. “The mission is to reduce that time to get people in the OR to address that fracture,” says Michael McGillion, director of patient engagement for this trial.
“The pain is terrible. Every time you move it hurts. The sooner it’s fixed, the better.” – Lee Lin-Rogano, who recently had hip surgery
The HIP ATTACK group has completed its pilot trial, where it found it was possible to accelerate care. To do so, it sped up the initial medical clearance by hiring dedicated medical specialists who assessed patients in the emergency department and did the medical clearance. It also asked hospitals to give hip surgery patients priority over previously scheduled elective surgeries. The group also educated staff around the need to prioritize patients with hip fractures who were waiting in the emergency department.
The group paid for extra OR space for bumped elective surgeries to be completed later that day, but even with that, it was often difficult to find space or staff for hip surgery where Waddell works at St. Michael’s Hospital in Toronto, he says. “We are a Level 1 Trauma Centre, we’re a kidney transplant centre, and we have a very busy Neurosurgical Service looking after significant numbers of critically ill patients, so finding an available operating room and time to operate on these patients is a real challenge,” he says.
Patients who aren’t well enough to receive anaesthetic within six hours are not included in the HIP ATTACK trial. And for patients like that, waiting longer may be beneficial. If doctors can improve their health before the operation – by managing preexisting conditions like diabetes or anemia, for example – it decreases the risk of complications for that group.
The final piece: rehab
A year after her surgery, Lin-Rogano is feeling much better. “Thank god my health was good,” she says. “Because of my age I have always been healthy and active, and I’m a grandmother of five – they keep me very busy.” An important part of her recovery was doing outpatient rehab afterwards. “I loved rehab,” she says. “The people were excellent, really professional and very kind. And they really understand pain.”
Health Quality Ontario is working to improve hip fracture care, and access to rehab after surgery is a key component of that. “One of the things that we’re recommending to the ministry as an additional quality indicator is access to rehab after discharge,” says Waddell. They’ve seen improvements by simply prioritizing rehab, as they did surgery. “We used to be sending all our elective joint replacements to rehab, and hip fracture replacements were having a difficult time getting in,” he says. “We’ve decreased the use of elective rehab for elective joint replacement, and increased it for hip fracture replacement.” Access can also be improved by encouraging the use of community-based rehab in clinics or through home care instead of inpatient beds.
Meanwhile, in Alberta, they’ve also made a concerted effort to increase the number of people who get rehab. “As an example, we use recreational therapists to work with these patients in groups, working on simple range of motion exercises and falls prevention training,” says Dick, adding that they’re also working on prevention through better osteoporosis management. “To give these patients comprehensive, good care does require managing all parts of the continuum.”
The issue of hip fractures will affect more and more people as our population ages. “If you look at some jurisdictions, like Scandinavia and the UK, where they have a much older population than we do, the volume is staggering,” says Waddell. But if we manage them well – by preventing hip fractures through osteoporosis treatment, operating on them promptly and ensuring access to rehab afterwards – we can change what it means to break a hip.
“It was always sort of assumed that if you had a hip fracture you’d either die or be disabled,” says Waddell. “With good treatment, the prognosis isn’t what it used to be.”
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I am an osteoarthritis patient who does research with others with OA and those patients would whole-heartedly agree that hip surgery needs to happen sooner rather than later. However this not a new problem. In the late 1980s my elderly mother died of pneumonia after hip surgery. She waited a long time for her surgery and became dehydrated and confused before she finally got to the OR. She developed a post-op wound infection as well as pneumonia. Prior to her hip fracture she was physically and mentally in good health. I wrote a letter to the hospital administrator and spoke to the unit staff about the fact she was kept waiting too long for a woman her age. While they shared by concern it’s taking a long time for the system to put priority on hip fractures in older people. While I commend the work the Bone and Joint Health Strategic Clinical network has done and continues to do, as a citizen it is discouraging to see this situatuion that impacts well-being and tax dollars has not been resolved.
So there are a few issues here. Firstly, we are dealing with an EMERGENT condition, not one that can be planned for and this creates a lot of complexity. If I (as a general surgeon) am trying to get a patient with a perforated appendix to the operating room, with at the same time, a patient of a orthopedic colleague getting close to the 6 (or 48) hour mark post hip fracture, who should go first? This article implies the hip fracture and it is not nearly so simple a decision in busy after hours operating rooms, with many competing surgical specialties jostling for time for their patients’ surgeries. In a publicly funded system, when one problem gets attention and funding, often to the detriment of patients with other problems that administration is not focused on. Operating room time is wildly expensive- who is going to pay for the extra staffing (hint big $$$) required if this becomes mandated? Would you want your hip fracture surgery done at 2 am by an exhausted surgeon to get under the 6 (or 48) hour mark, or would you prefer it be done at 8 am by a surgeon with a full night’s sleep? It really bothers me to see the statement “this type of surgery just has to get priority”. All urgent cases, ie gangrenous gallbladder, kidney transplants, etc all deserve our attention. A fair system to prioritize all after hours cases is needed. Orthopedics often get access to trauma time for these type of cases (elective time scheduled to be filled on a semi-urgent basis with fractures), which is a good solution. But if 6 hours is mandated, there will be fireworks in operating rooms across the province (or country). I like the idea that we should just do everything faster, but it would be unfair to rob Peter to pay Paul, which seems likely to happen in our financially stretched system.
What about the availability and supply of trained orthopedic surgeons. Does that not affect the timeliness and waiting periods. I believe that on a/capita basis the US has about 35% more surgeons.
Also OR time, is that not a variable as well?
Hip fractures should be aggressively treated. At least within 48 hours and maybe even less if the evidence is there. Key is to set metrics and hold administrators and physicians accountable to meet these metrics. If can’t achieve the metrics finds others who can.