Improving the Management of Osteoporosis Hip Fractures Where by MikeJenny

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									        Improving the Management of Osteoporosis Hip Fractures:
                                  Where Are We Now?
                 Karalyn Church, Surgical Senior Major, Class of 2006
                                 Advisor: Elise Ames, MD


INTRODUCTION


Osteoporosis is an insidious bone disease characterized by microarchitectural
deterioration of bone structure, decreased bone mass and skeletal fragility. Currently 1 in
4 women and 1 in 8 men over age 50 have osteoporosis.(1) Osteoporosis is becoming
more prevalent in the US as the population ages. The first clinical indication of
osteoporosis is often a fragility fracture despite accurate noninvasive means of assessing
bone mass.


The World Health Organization (WHO) defines fragility fractures as those that occur
after a fall from standing height or less. In normal healthy bone this amount of
mechanical stress would be insufficient to cause significant bone injury. The fractures
occur most typically at the distal radius, proximal humerus, vertebrae or hip and they
often result in disability, pain, deformity and significant financial burden. Hip fractures in
particular usually occur late in the course of the disease and are associated with
substantial morbidity, loss of function and high one-year mortality rates.(2) Direct health
care costs related to osteoporotic fracture care exceed 17 billion dollars, with hip
fractures responsible for the majority of this sum.(3,4) A history of one hip fracture
significantly increases the risk for subsequent fractures.(5, 6, 7) Patients who present in this
manner are candidates for both surgical stabilization of the existing fracture and
therapeutic medical intervention to prevent other fractures from occurring.


The initiation of pharmacologic treatment is recommended for all patients with either a
vertebral or hip fracture or with BMD scores of either 1.5 or 2 standard deviations from
the mean, dependent on concurrent risk factor analysis.(3) Current standard of care for
suspected osteoporosis includes universal recommendations regarding calcium, vitamin
D and weight bearing exercise, evaluation for potential secondary causes, a central dual-
energy x-ray absorptiometry (DEXA) scan to obtain a BMD score and consideration for
pharmacologic treatment.(3) Numerous placebo-controlled, prospective, randomized
clinical trials have demonstrated a reduction in fracture risk through treatment with
Calcium, Vitamin D, raloxifene and the antiresorptive bisphosponates alendronate and
risedronate.(8, 9,10,11,12,13)


Recent research has repeatedly pointed out the failure of health providers to adequately
identify and treat patients at high risk for repeated osteoporotic fractures even with
established clinical guidelines for therapy. (4, 6, 14,15,16,17) Harrington et al. (6) reported that
in hip fracture patients an average of only 15% had a bone densitometry scan, 14% were
prescribed calcium and vitamin D supplements and only 21% were prescribed
antiresorptive therapy. Part of the problem may be a lack of consensus regarding who is
responsible for osteoporosis care. In hip fracture, the patient is acutely cared for by the
orthopaedic surgeon and often returned to the primary care physician without adequate
and appropriate osteoporosis management from either end.


Studies have recently demonstrated success in strategic, integrated plans to increase
treatment and management of osteoporosis following fragility fracture. Majumdar et al.
(18) used a nonrandomized controlled trial in Canada where fracture patients were
identified, screened and allocated to an intervention or a usual care group. Intervention
consisted of physician reminders with endorsed treatment guidelines and osteoporosis-
focused patient education. At 6 months, 62% of intervention patients had BMD testing
and 40% were being treated for osteoporosis versus 17% and 10% respectively for the
control group. Chevalley et al. (19) implemented a clinical pathway in Switzerland where
fracture patients were identified, diagnosed and treated. After 6 months 86% of patients
were taking Calcium and vitamin D and 67% had begun medical management. Most
recently in the US, Gardner et al. (20) showed that in a small, randomized prospective
trial, low energy hip fracture patients who were provided with information and questions
for their primary care physician about osteoporosis were twice more likely to receive
appropriate therapeutic intervention than were control patients.
The evidence that simple intervention may improve the quality of care for patients
diagnosed with a fragility fracture has led to interest in developing critical pathways and
other strategies at our institution. The logical place to develop protocols for this type of
care is during the acute inpatient stay associated with hip fracture. At Fletcher Allen
Health Care (FAHC) hip fracture patients are routinely cared for by a multidisciplinary
team including hospitalists, orthopaedic surgeons, physical therapists and outpatient
physicians. We currently treat over 200 patients with hip fractures per year and to date
there has been sporadic attention to overall osteoporosis management. The purpose of
this retrospective review was to evaluate of the current status of osteoporosis treatment
after hip fracture in this community. If the statistics at FAHC mirror current national and
international findings, we will likely identify a significant deficit in the effective
management of high-risk osteoporotic patients as well as characterize the demographics
of our hip fracture population. This information will help us to identify the effectiveness
of our current treatments and will allow us to move forward in the development of a
strategic plan to improve the quality and delivery of care for our hip fracture patients.


OBJECTIVE


The purpose of this study was to describe the demographics of the hip fracture population
at one Level 1 orthopaedic center (FAHC), to describe inpatient and operative
management of the population, determine the rate of pre-fracture medical management
for osteoporosis, and define the prevalence of the initiation of medical management for
osteoporosis during the acute inpatient stay.


Our long term objective is to use this information to design a long-term prospective study
to explore interventions to improve upon both inpatient and subsequent outpatient
management of osteoporosis and fracture risk in these patients.
METHODS AND MATERIALS


The following methods were reviewed and received approval from the Institutional
Review Board. Fletcher Allen Health Care (FAHC) is a Level One Trauma and Regional
Referral center that provides care for three New England states. This cross-sectional
study was a retrospective chart review of all patients admitted to FAHC with the
diagnosis of hip fracture (ICD9 codes 820.X and 733.X). The name, MRN and date of
admission for all patients admitted to FAHC from February 1, 2003 to September 30,
2004 with the appropriate ICD9 codes were gathered from administrative data. The
FAHC inpatient medical records for the corresponding admissions were reviewed by one
of the two primary investigators. A fragility fractures was defined as a hip fracture that
occurred after a fall from standing height or less. Hip fractures due to high energy trauma
or pathologic (metastatic) causes were not included in the data set. Fragility hip fractures
were then cataloged by their anatomic region, dividing them into three groups: femoral
neck, intertrochanteric and subtrochanteric. Femoral neck fractures were evaluated using
the Garden Classification system. Types I and II were defined as “non-displaced” and
types III and III “displaced”. Type I and II intertrochanteric fractures were catalogued as
“simple” and Types 3 or 4 as “complex”. Reverse obliquity fractures were the final
category for intertrochanteric fractures. The reverse obliquity subtype was chosen if the
major fracture line extended from the proximal-medial to distal-lateral through the
intertroch-subtrochanteric region. A subtrochanteric fracture was defined as a fracture
that occurs between the lesser trochanter and a point 5cm distal to the lesser trochanter.


A detailed data sheet was designed and then completed for each patient (see Appendix 1).
Investigators collected demographic data, pre-hospital health information, in-hospital
statistics, pharmacy data and discharge information. Pertinent past medical history and
current medication lists for patients were collected solely from the admission correlating
to the proper ICD9 code. Radiographs from the admission were reviewed by an
investigator when fracture type or subtype was in question or incomplete in the patient
hospital record.
Each patient subject was assigned a study ID number. The data sheets were then entered
by ID number into a Microsoft Access database where they were maintained for
statistical analysis. The data was entered by a single investigator with quality verification
by a second investigator. Data analysis was conducted using the Access database.




RESULTS


A total of 204 patient charts were reviewed. 66 patients were excluded for the following
reasons: 4 greater trochanter fractures, 2 pubic rami fractures, 1 acetabular fracture, 3
pathologic fractures, 28 high energy trauma related fractures, 22 improperly coded files,
5 insufficient records and one patient expired in the Emergency Department. 138 patients
met the inclusion criteria and formed the basis for the study population.


101 subjects (73%) were female. The mean age of both genders was 80.5 years with a
range from 38 to 100 years. The female mean age was 80.9, range 38 to 98 years. The
male mean age was 79.6, range 52 to 100 years. The mean BMI was available for 125
subjects (87% of females, 100% of males). The BMI of the patient population was 23.3
with a range from 14.5 to 45.4. The mean female BMI was 23.2 (range 14.5 to 45.4). The
mean male BMI was 23.4 (range 15.4 to 33.5).


Sixty-two fractures (44.9%) were on the left side and 76 (55.1%) were on the right side.
No bilateral hip fractures were found in this population. There were 71 (51.4%) femoral
neck fractures, 57 intertrochanteric fractures and 10 subtrochanteric fractures. Fifty-one
(71.8%) of the femoral neck fractures were displaced. Thirty-seven (64.9%) of the
intertroch fractures were complex and only one was defined as a reverse obliquity
fracture. See Figure 1.
Figure 1

                                  Fracture Type and Subtypes

  80

  70
             non-displaced (20)
                                                             reverse obliquity (1)
  60
                                             sim ple (19)
  50

  40          displaced (51)

  30                                        com plex (37)

  20

  10

   0
                  Neck                      Intertroch                    Subtroch




Fifteen subjects (10.9%) were noted to have additional injuries at the time of admission.
These injuries included fractures at alternate sites, lacerations, abrasions and one case of
severe rhabdomyolysis.


100 subjects (72.5%) were living in a private home prior to their injury, 21 (15.2%)
arrived from Full-time Nursing Care facilities and 16 (11.6%) from Assisted Living
facilities. One subject was homeless prior to the hip fracture. 89 subjects (64.5%)
experienced their injury in a private home setting. These injuries most commonly
involved a fall while in transition to either the bathroom or bedroom or while in the
kitchen. All 21 Nursing Care subjects fractured their hips at the Nursing facility. Over
half of these were un-witnessed falls resulting in the subjects being found down on the
floor by staff. Twenty-five subjects (18.1%) fractured their hip in a community setting, 2
with documented alcohol use at the time of the fall. One subject fell while a hospital
inpatient at FAHC and the location was unknown for the remaining 2 subjects.


Premorbid ambulatory status as described by the admitting physician indicated that 51
(37.0%) subjects were independent ambulators, 59 (42.8%) were community ambulators,
24 (17.4%) were household ambulators and 3 (0.2%) were non-ambulatory. Sixty-two
subjects (44.9%) were known to use assistive devices for ambulation (cane or walker) at
the time of injury.


Nineteen subjects were received as transfers from outside hospitals and the remainder
presented to the FAHC Emergency Department. Eleven subjects (8.0%) gave home
telephone exchange codes indicating that their primary residence was greater than 50
miles from our facility and 8 (6.8%) resided outside of the state. 106 subjects (76.8%)
lived within a 25 mile in-state radius and a total of 115 subjects (83.3%) were
encompassed within a 50 mile in-state radius from FAHC. No primary phone numbers
were listed for the remaining 4 subjects. The primary service population for this facility
can reasonably be defined within a 25 mile in-state radius.


118 (85.5%) of patients were admitted to our facility within one day from the time of
their acute injury. This figure also includes 15 of the 19 subjects transferred from outside
hospitals. Available reasons for delay in care included previous misdiagnosis and
increasing pain during ambulation in the days after a fall.


All subjects in this study were evaluated by the Orthopaedic Surgery service. 120
subjects (86.9%) were admitted to the Orthopaedic Surgery service, 13 to the Medicine
service, 3 to Family Medicine and 2 to the Cardiology service. Five patients were
transferred from the Orthopaedic service to either Medicine or Family Medicine and one
was transferred directly to the MICU during their hospital course. Of the 13 subjects
admitted to Medicine, one went directly to the MICU and 2 were initially monitored on
telemetry beds.


Of the total 138, 125 subjects (90.5%) had a Medicine or Family Medicine attending
involved through service care or by consult. 48 subjects (34.8%) were seen by Hospitalist
physicians based at our facility. Seventy-two subjects (52.9%) were seen by their primary
care physician or a covering physician from within a group practice. One subject was
cared for by the MICU, 6 had no primary care physician and 6 consult physicians’
signatures were illegible.


A Medicine consult was requested on 107 (89.2%) of the subjects admitted by
Orthopaedics. This consult occurred within one day of admission 92.6% of the time and
all consults were complete within four days. The 13 Orthopaedic service patients who did
not have a Medicine consult were younger than the total population acquiring a mean age
of 66.3 years (range 41 to 83). Only one subject had three significant risk factors for hip
fracture. Of the 13, this one particular subject experienced the only post surgical in-
hospital complication (pneumonia) was also the only one to be readmitted to FAHC
within a 3 month period (for altered mental status).


Records were screened for the major risk factors for low bone density, fall risk and hip
fracture. The results for each factor are listed in Table 1.


Table 1
Risk Factors             Yes       No        Unk
Current Smoker           17        112       9
Alcohol Use              23        105       10
Physical inactivity      23        114       1
Dementia                 30        108       0
Immune/Rheumatoid 4                134       0
Chronic Steroid Use      5         133       0
COPD                     21        117       0
Heart Disease            71        67        0
Previous MI              20        118       0
Arrhythmia               32        106       0
Renal Failure            23        115       0


46 (33.3%) had 3 or more risk factors. 28 subjects (20.3%) had none of the investigated
risk factors.
Medications on admission were recorded from the intake paperwork. Medications known
to affect bone density (e.g. antiepileptics, corticosteroids) were actively prescribed to 13
subjects (9.4%). Medications considered increasing fall risk (e.g. chronic narcotics,
sedatives) were prescribed to 33 subjects (23.9%) prior to their admission for hip
fracture.


In this data set, 133 subjects (93.4%) were managed operatively. The interval between
admission to operation is shown in Figure 2. Forty-three subjects (31.9%) had their hip
surgically repaired on the same day as their admission to our facility. Sixty subjects
(44.4%) were taken to the operating room the day following their admission and 15
(11.1%) on the second post admission day. The remaining 15 subjects (11.1%) received
surgical intervention between post admission days three and eight.


Figure 2

                      Interval from Admission to Operation




                                                                         Same Day
                                                                         Next Day
                                                                         2 Days
                                                                         3 Days
                                                                         4 Days
                                                                         5 Days
                                                                         8 Days




Of the 133 operative subjects, 117 (87.9%) received spinal anesthesia and 16 received
general anesthesia. One general anesthesia subject became hypotensive and later
pulseless after induction. Despite intubation and resuscitative efforts, this subject expired.
ASA scores were available for 132 subjects. Four subjects (3%) were ASA I, 40 (30%)
ASA II, 71 (53.8%) ASA III and 17 subjects (12.9%) were ASA IV.


Operative times ranged from 14 to 254 minutes. The mean overall operative time for this
data set was 75 minutes. The mean operative times specific to implant types are displayed
in Figure 3. Cannulated screws took an average of 43 minutes and hemiarthroplasty 83
minutes. Gamma Nail and CHS repairs together, had a mean operative time of 81
minutes (CHS mean 77 min and Gamma mean 103 min). One IM Nail and one flexible
nail were used for fixation in this study population. The IM Nail was reported at 62
minutes and the flexible nail repair at 104 minutes.


Figure 3

                                                            Mean Operative Tim e


                                  90
   Operative Duration (minutes)




                                  80
                                  70
                                  60
                                  50
                                  40
                                  30
                                  20
                                  10
                                  0
                                       Cannulated Screw s         CHS and Gamma    Hemi
                                                                   Im plant Type




Fixation choices for the femoral neck fractures included 40 hemiarthroplasties, 23
cannulated screws and 6 CHS implants. The intertrochcanteric fractures were repaired
with 51 CHS implants and 2 Gamma nails. Seven Gamma nails, 1 IM nail, 1 flexible nail
set and 1 CHS were used in fixation of the 10 subtrochanteric fractures.


The reported mean Estimated Blood Loss (EBL) intraoperatively was 228ml and ranged
from 10 to 850ml. The mean blood loss for cannulated screw fixation was 75ml (range 10
to 200ml). Hemiarthroplasty reports indicated a mean 285ml EBL (range 50 to 800ml).
Gamma Nail and CHS implants had a combined mean EBL of 251ml (range 50 to
850ml). Both the IM Nail and flexible nail fixations had reported EBL at 100ml.
Fifty-seven operative subjects (42.9%) received at least one transfusion of packed red
blood cells (pRBC). Two of these subjects received their transfusion intraoperatively and
the remainder post-operatively. 13 subjects (22.8%) received greater than 2 Units of
pRBCs and 5 (3.6%) received only 1 Unit. The measured hematocrit was available for 53
of the subjects. The mean first transfusion hematocrit was 24.3 and the range was 17 to
30.


DVT prophylaxis was evaluated based on the chart orders for the following interventions.
If the prophylactic methods were changed, all interventions are listed in the final totals. In
this subject population 128 (96.2%) of the 133 operative subjects had Venodynes ordered
and 127 (95.4%) had Ted stockings. Seventy-two (51.4%) of subjects took Aspirin
postoperatively. Heparin was utilized in the care of 15 subjects (11.2%), Lovenox 79
(59.3%) and Coumadin for 13 subjects (9.7%).


Postoperatively 130 subjects (97.7%) were seen in consult by the Inpatient Physical
Therapy team. Of the 3 operative subjects who were not seen by PT, two were discharged
to a Sub Acute Nursing facility and one had expired during anesthesia induction. Four
subjects (3%) had consults initiated prior to their surgery. Sixty-five (50%) were seen on
post-operative day number one and 40 (30.8%) on post-operative day two. The remaining
21 subjects (16.2%) had all been seen by PT by the sixth post-operative day.
Weight bearing restrictions as ordered by the surgical team were: weight bearing to
tolerance 64 subjects (49.2%); eggshell touchdown 49 subjects (37.7%); non-weight
bearing 17 subjects (13.1%). Figure 4 provides a breakdown of weight bearing status
based on fixation method.
Figure 4


                                   Weight Bearing Status by Fixation Method

                       70
                       60
  Number of Subjects




                       50
                       40

                       30
                       20

                       10
                        0
                            Cannulated   CHS         Gamma              IM Nail   Flexible
                             Screws                                                 Nail
                                            Fixation Method
                                          Non Weight Bearing
                                          Weight Bearing to Tolerence
                                          Eggshell Touchdown




Subjects were discharged as indicated in Figure 5. Ninety-two subjects (66.7%) of the
total data set were discharged to a sub-acute nursing facility (includes return to original
Nursing Care facility). An acute rehabilitation facility associated with our medical center
accepted 25 subjects (18.1%). Three subjects (2.2%) were discharged directly to home
and an additional 10 (7.2%) were discharged to their private home with assistance from
Visiting Nursing. Three subjects (2.2%) were discharged to Hospice care and 5 (3.6%)
expired during the course of their admission for acute fragility hip fracture.
Figure 5

                                                               Disposition Details

                        100         92
                        90

                        80
   Number of Subjects




                        70
                        60
                        50
                        40

                        30                           25

                        20
                                                                     10
                        10                                                            5       3       3
                         0
                                Sub-Acute        Acute Rehab    Home w ith VNA    Deceased   Home   Hospice
                              Nursing Facility
                                                                           Location




There were no documented in-hospital complications for 81 subjects (58.6%). The most
common complication was UTI at 16 (11.5%) of all subjects. Nine subjects (6.5%) were
diagnosed with pneumonia and 9 (6.5%) subjects experienced urinary retention as a
complication. Six (4.3%) were diagnosed with myocardial infarction, one of which
occurred preoperatively and 3 (2.2%) had acute renal failure. A graphic representation of
inpatient complications is provided in Figure 6.


Complications in the category “Other” included: wound drainage, wound infection,
wound hematoma, hypotension, decubitous ulcers, hematemasis, ileus, bacteremia,
respiratory failure, mental status changes, CDiff colitis, alcohol withdrawal and CHF.
Figure 6

                                          In-Hospital Complications

                        90
                              80
                        80
                        70
   Number of Subjects




                        60
                        50
                        40
                        30                                                             22
                        20          16
                                              9            9
                        10                                            6
                                                                            3
                        0
                             None   UTI   Pneumonia      Urinary      MI   ARF     Other
                                                        Retention
                                                      Complication




Five subjects (3.6%) expired during their admission for hip fracture. Four of these
subjects were treated operatively. As previously mentioned, one subject expired after
general anesthetic induction. Another subject expired two days post-op, no post-mortem
examination was conducted. The patient had an EBL of 200ml intraoperatively, was not
transfused and no other complications were listed in the medical record. The third expired
operative patient had a diagnosis of pneumonia prior to surgical management of the hip
fracture. This subject had declining respiratory status post-op and a family decision was
made to withdraw care. The subject expired on post-op day thirteen. The fourth expired
subject had a post-op course complicated by hypotension and acute renal failure. This
subject also had documented PE and MI postoperatively. Aggressive care was withdrawn
and the subject expired on post-op day three. A decision was made to forgo surgical
management and pursue comfort care measures for the fifth expired subject.


Five subjects (3.6%) were managed non-operatively. Three of these subjects were
discharged to Hospice care. One additional subject was transferred to the Medicine
service for palliative care and the final no-operative subject was discharged by the
Medicine service back to Nursing Home care with non-weight bearing status. For study
purposes, the five non-operative subjects will be considered to have expired from a direct
cause of their fragility hip fracture lending to a 7.2% mortality calculation for our 138
subjects. Six patients were readmitted to our facility within a 30 day period. Of these
patients one expired due to respiratory failure following a diagnosis of pneumonia.


On admission 103 subjects (74.6%) did not have osteoporosis listed as a medical problem
on their intake History and Physical. Two of these subjects had been actively prescribed
osteoporosis medications and therefore were assumed to have been previously diagnosed.
Thirty-five (25.4%) were identified as having osteoporosis and fourteen of this group
were taking osteoporosis medications (Calcitonin, Alendronate, Risedronate or
Raloxifene). Eighteen total subjects (13%) indicated that they were taking oral Calcium
and/or Vitamin D supplementation.


Five (3.7%) were taking corticosteroids, 17 (12.3%) were known to be current smokers,
and 4 (2.9%) held diagnosis of Rheumatoid Arthritis. Nineteen (14.9) patient records
clearly documented that the subjects had not had any previously known fragility
fractures. Twenty-three (16.7%) patient records indicated that the subject had previous
fractures compatible with possible fragility definitions. However, aside from spinal
compression fractures, the events surrounding these fractures were not documented and
thus a definition of a fragility cause would be speculative.


Osteoporosis screening was recommended by at least one hospital caregiver for 3 (2.2%)
of our subjects. Osteoporosis medications were recommended during the inpatient stay or
in the discharge summary for 6 subjects (4.4%). Osteoporosis medications were ordered
and administered during the admission for 2 subjects (1.4%). Osteoporosis supplements,
in the form of Calcium and Vitamin D were recommended, primarily by nutrition
consultation services, for 29 of our subjects (21%).
DISCUSSION
This study was limited by its design as a retrospective chart review. The quality of
documentation was variable between subjects and poor documentation was encountered.
Chart availability was problematic for 5 potential subjects in this population. Those
subjects did not meet inclusion criteria for the study. Our facility serves a predominantly
Caucasian population. Though no race or ethnicity information was collected in this
study, it is safe to presume that this study population was overwhelmingly of Caucasian
origin.


Surgical and anesthetic complications included one death immediately following
induction. There were no other immediate surgical or anesthetic complications reported
in the patient records. There was evidence of one non-union of fracture and one hardware
complication (patient discomfort) necessitating re-operation.


In-hospital complication rates are commonly believed to be very high, especially for
DVT and pneumonia, but improvements in medical management and early surgical
intervention have resulted in much improved outcomes. It is important to remember that
often hip fracture patients represent a predominantly older age group of patients with a
mix of co-morbidities at the time of admission. In our population 58.6% of subject had no
complications during their admission. Aside from UTI, no single complication exceeded
10% and none were elevated dramatically above the age related risks already associated
with this population.


Five subjects, 3.6% expired after surgical intervention and an additional 5 subjects were
discharged non-operatively to palliative care. Typically hip fracture mortality is described
in dramatic fashion with 1 year mortality rates. In-hospital mortality has been quoted as
high as 12% although the literature is highly variable.(21) Our mortality rates seem to be
consistent with quoted rates within the limits of our study. We were not able to account
for additional deaths if the patient was not readmitted to our facility as we did not have
access to outpatient records.
At FAHC 90.5% of subjects were cared for by a Medicine care provider and 97% were
seen additionally by Physical Therapy. Nutrition consultation services were also utilized
frequently in the care of these patients. Our subjects had a mean age of just over 80 years
and came with a large list of comorbid health conditions. The literature repeatedly shows
that focused care for these complicated patients leads to better outcomes and fewer
complications. The numbers clearly represent a solid commitment to interdisciplinary
care for the hip fracture patient at our facility.


Perioperative blood transfusion rates were determined to be at 42.9% for this population,
within commonly quoted ranges in the literature. Poses et al. (22) found hospital
transfusion rates for hip fracture surgical patients at 19 centers had a range from 31.2 to
54% and in 2003, Halm et al. (23) found the overall rate between four centers to be
54.4%.


All fracture patients were seen by the Orthopaedic service and of those, 76.3% of
operative patients had their hips surgically repaired by the day immediately following
their admission and 87.4% by the second post admission day. Studies on the timing of
surgical repair of hip fracture provide conflicting evidence as to the effect of prolonged
delay before operation for morbidity and mortality.23,24 One recent large prospective
study has shown that patients waiting over 48 hours for surgical repair (for non-medical
reasons) had a mean hospital plus convalescence stay significantly longer than those
patients with earlier surgical intervention (32.5 days versus 21.6 days).25 Of the 3628
patients in their study, 95% were surgically treated prior to the 48 hour mark. There is
often a desire to provide definitive surgical treatment in a timely manner, but for this
population of patients early treatment may significantly decrease the financial cost of care
and improve the rate of return to prior living situation.


Only 15.2% of our population arrived from full time Nursing Care facilities but a striking
84.8% of our subjects were discharged to a Nursing Care facility (acute or sub-acute).
Osteoporotic fracture care is known for its significant health care costs, extended out-of-
home Nursing Care costs rapidly increase the total financial burden. Despite rapid
Physical Therapy consultation, the vast majority of patients do not attain independent
functioning levels during their acute stay and are unable to return to private homes or
assisted living. It would be appropriate to consider developing a dedicated step-down or
extended stay unit within our facility.


In normal healthy bone, a fall from standing height provides insufficient force to cause
significant bone injury. A good working definition of osteoporosis is a loss of bone
density to a level at which the bone can not withstand normal mechanical forces. Using
this definition, a patient who sustains a fragility fracture can be diagnosed with
osteoporosis on the basis of the fracture alone. Literature suggests that the medical
community is failing to utilize proven therapies to reduce fracture risk even in patients
with the greatest need for intervention, those who have already sustained a fragility
fracture. From our measures, we found that only 25.4% of these subjects had been
diagnosed with a bone fragility problem. We also showed that osteoporosis screening was
recommended for only 3 of our subjects and that medical management was recommended
for only 6 subjects (4.4%). Recommendations for vitamin supplementation were at 21%,
which was approaching previously studied discharge intervention initiation values of 11,
13, 24 and 29% found in consecutive years by Gardner et al. (20). Despite excellent
surgical care, inpatient medical management and rapid physical therapy, osteoporosis
care for these patients remains suboptimal.


Currently in hospital medical management is limited due to FAHC policy (new since
the collection of the study data) to not administer bisphosphonate medications in-house
because of the difficulty of ensuring that patients remain in upright positioning for 30
minutes to prevent esophageal and gastric injury. This does not preclude treatment with
calcitonin (a bone resorption inhibitor), raloxifene (a selective estrogen receptor agonist)
or vitamin supplementation options. Initiating treatment with teriparatide may also be an
option, although cost-benefit analysis for this drug is not yet available and its availability
on an outpatient basis may also be problematic. Optimizing the inpatient management of
osteoporosis is an area for significant quality improvement that remains wide open for
debate.
The evidence that simple intervention may improve the quality of outpatient care for
patients diagnosed with a fragility fracture has led to interest in developing critical
pathways and other strategies at our institution. Presentation with a fragility hip fracture
should be an automatic trigger to initiate coordinated care to ensure that patients are
appropriately diagnosed, educated and provided with appropriate discharge instructions
for further management of osteoporosis.


Viable options for improvement begin with the alteration of preprinted Orthopaedic
service consultation and post-surgical forms. This could dramatically increase attention
towards the identification and treatment of osteoporosis. Consultation forms could easily
include the question “Did this patient present with a fragility fracture” or “Has this
patient been previously diagnosed or treated for osteoporosis”. Orthopaedic post
surgical order forms should also include supplementation options for Calcium and
Vitamin D. A continued dedication to interdisciplinary care is required for good
outcomes in hip fracture patients. Communications between in-hospital providers and
out-patient providers must include recommendations for follow-up care of osteoporosis
following a fragility hip fracture admission. A number of successful clinical pathways
and successful interventions have already been demonstrated in the literature.


Our facility provides timely interdisciplinary care and prompt surgical attention with low
complication rates to patients admitted for fragility hip fractures. Unfortunately, we lack
strength in the diagnosis, management and follow-up for this population of patients
presenting in likely advanced stages of osteoporosis. In order to improve care, our facility
should consider a well designed osteoporosis education program for patients, a
coordinated care plan for their inpatient stay, a strategic method for communication of
this diagnosis and recommendation for screening and treatment to outpatient care
providers.
                                       APPENDICES


Appendix 1: Hip Fracture Study - Data collection sheet.

MRN:                    ID
DOB:            / /                                      Medicine Consult MD:
Gender:        F M                                       Consult Date      / /
Phone prefix:                                            Previous Fx:
Living: PH AL NH UNK                   Admission Meds:
Admit Date:    / /
Service: Ortho Med     Other:
Disch Date:     / /
Alive:         Y N                               OP on prob list Y N
Primary MD:                                      OP Meds                 Y N
Comments on Admission:                           Calc/Supplements        Y N
                                                 Risk Factor Meds   Y N
                                                                  Name Risk Meds:
Date of Injury: /    /
Type of Fx:                                      OP Screen Recommended?      Y          N
Subtype:                                         OP Meds Recommended? Y N
Fx Side: R L                                     OP Meds Started?        Y N
Other Injuries : Y N                             OP Supplements Started? Y N
          Describe:
Circumstances:                                   DVT Prophylaxis:   Venodynes
Inj locale:                                                              Teds
Home Safety Issue:       Y N                                             ASA
Comments on Injury:                                                      Heparin
Premorbid Ambulatory status: Independent                                Lovenox
                                     Community                          Coumadin
                                     Household
                                     None             Transfusion Units:
Assistive Devices:       Y N                           Hct:
                                                       Date of transfusion          /       /
Nonoperative:          Y N                       Comments on Inpt Course:
ASA Category: 1 2 3 4
Anes:           Spinal General                           Smoker Y N
Ht:                                                      Etoh        Y N
Wt:                                                      Phys inac Y N
OR Date:        / /                                      Dementia Y N
OR Attending:                                            Imm/RA Y N
Start Time:                                              Steroids Y N
End Time:                                                COPD       YN
EBL:                                                     Heard Dis Y N
Implant Type:                                            Prev MI Y N
Implant Company: Smith Howmedica Synthes                 Arryth      YN
Comments on Operation:                                   Renal Fail Y N
                                                                 Comments on Risk Factors:
PT Consult Date       / / NWB WBTT ESTD
Disp: Home, Home-VNA, SANF, Hospice, Deceased
Complications (list):                                       Readmission (list):
                                          REFERENCES


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