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.
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Very well-written and inciteful. Thank you for sharing your opinion and perspectives.
Thank you for your article. I think the data supporting cost-savings and improved outcomes demand that we take a close look at implementing shared-care centres for hip fractures.
It is important to keep patients close to their home communities. But if 10 percent of these patients are dying within 30 days and more than 30 percent dying within 1 year, prioritizing their location is of diminishing relevance. Most patients undergoing surgery value good outcomes over anything else.
A shift in our approach to hip fracture care is necessary, and we must do our best to make decisions based on the best available evidence. You have done a great job promoting this idea in your article.
As a retired GP, let me make a few comments.
First, I agree with the previous comment that these patients need to be treated as close as possible to their homes. Involvement of family and their ongoing GP (who will be managing their care once they return to the community) is facilitated by local care, not (more) specialized care. Having a centre of excellence would only move these patients further from where they come.
Second, the more the number of people involved in their care, the more likely there will be a scary and perhaps fatal communications error between them; and the more likely time will be spent on meetings for the care-givers rather than in direct, needed, patient care. GP’s have been doing wholistic care for generations, and could still, if they were not being actively discouraged from in-hospital care.
In summary, I think the money could be better spent on patient advocates, more and better nursing, and supports for the family doc who want to work with his/her patients in the hospital.
So I really dislike the idea that yet another “Centre of Excellence” for yet another specific condition is going to save money and be better for patients. We need more generalist care and this is a perfect example of creating yet another silo with the accompanying demand for extra resources to do so. These frail elderly patients need to be treated in their communities, close to their spouses and remaining support systems of friends and family. Transferring these patients is often a logistical nightmare for hospitals like mine and can only delay care. Want to have hip fractures repaired in under 6 hours? Adding in a transfer is one sure way to make sure no hip fractures get fixed in that time frame. The idea that orthopedic surgeons in small hospitals are managing these cases on their own is ridiculous and shows a lack of understanding of how small community hospitals work. Hospitalists, internists and family doctors with admitting privileges (an unfortunately small number but these are the people who already know these often complex patients well) are often the ones managing these patients medical issues from admission to discharge. Hip fractures are common- we need more funding to strengthen access to appropriate generalist care where our patients live, not pour more resources into ever more siloed subspecialized care in larger centres.
Thank you for citing the BC Hip Fracture Redesign Project!
Prognostic and prescriptive analytics transform hip fracture care in BC, Canada and globally. At its core are personalized treatment pathways. Ultimately, we *envision* a health care system in which predictive analytics routinely recommends treatments and predicts outcomes using clinical histories of patients and their past encounters with the health system.
Using advances of Data Science, we develop, implement and evaluate algorithms that predict likely treatment outcomes, health services use, the odds of failure to regain mobility and independence, the odds of readmission, and the odds of death, after sustaining hip fracture.
In addition to predicting high-risk and high-use patients, we develop, implement and evaluate algorithms that rank treatment pathways through hospital and rehabilitation phases of hip fracture care. For each patient, our recommendation models suggest personalized care pathways that most likely lead to improved survival, mobility and independence.
Our recommendation algorithms answer the question that policymakers, hospital administrators and caregivers tell us matters most in hip fracture care – how to identify patients at risk of hospital readmission or failure to regain mobility, so that the health system can intervene to prevent this transition earlier?