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 1. Juby AG, De Gues-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporos Int. 2002;13:205-210. 2. Gardner MJ, Flik KR, Mooar P, Lane JM. Improvement in the undertreatment of osteoporosis following hip fracture. J Bone Joint Surg Am. 2002;84-A:1342-1348. 3. Physicians’ Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 1999. Accessed at Http://www.nof.org/physguide.html on 18 January 2005. 4. Kamel HK, Jussain MS, Tariq S, Perry HM, Morley JE. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000;109:326-328. 5. Siris ES, Bilezikian JP, Rubin MR, Black DM, Bockman RS, Bone HG, et al. Pins and plaster aren’t enough: a call for the evaluation and treatment of patients with osteoporotic fractures. J Clin Endocrinol Metab. 2003;88(8):3482-6. 6. Harrington JT, Broy SB, Derosa AM, Licata AA, Shewmon DA. Hip fracture patients are not treated for osteoporosis: A call to action. 2002;47:651-654. 7. Klotzbuecher CM, Ross PD, Landsman PB, Abbott III TA, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000;15:721-739. 8. Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med. 1992;327:1637-1642. 9. Ettinger B, Black DM, Mitlak BH, Knickerbocker RK, Nickelsen T, Genant HK, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple outcomes of raloxifene evaluation (MORE) investigators. JAMA. 1999;282-637-645. 10. Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M, et al. Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral efficacy with risedronate therapy (VERT) study croup. JAMA. 1999;282:1344-1352. 11. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, et al. Effect of risedronate on the risk of hip fracture in elderly women. Hip intervention program study group. N Engl J Med. 2001;344:333-340. 12. Cummings SR, Black DM, Thompson DE, Applegate WB, Barrett-Connor E, Musliner TA, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA. 1998;280:2077-2082. 13. Ensrud KE, Black DM, Palermo L, Bauer DC, Barrett-Connor E, Quandt SA, et al. Treatment with aledronate prevents fractures in women at highest risk: results from the Fracture Intervention Trial. Arch Intern Med. 1997;157:2617-24. 14. Hajcsar EE, Hawker G, Bogoch ER. Investigation and treatment of osteoporosis in patients with fragility fractures. CMAJ. 2000;163:819-22. 15. Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis. 1998;57:378-9. 16. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy. 2003;23:190-198. 17. Simonelli C, Chen YT, Morancey J, Lewis AF, Abbott TA. Evaluation and management of osteoporosis following hospitalization for low-impact fracture. J Gen Intern Med. 2003;18:17-22. 18. Majumdar SR, Rowe BH, Folk D, Johnson JA, Holroyd BH, Morrish DW, et al. A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture. Ann Internal Med. 2004;141;5:366-373. 19. Chevalley T, Hoffmeyer P, Bonjour JP, Rizzoli R. An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. Osteoporos Int. 2002;13:450-455. 20. Gardner MJ, Brophy RH, Demetrakopoulos D, Koob J, Hong R, Rana A, et al. Interventions to Improve Osteoporosis Treatment Following Hip Fracture. J Bone Joint Surg Am. 2005;87:3-7. 21. Moran, WP, Chen GJ, Watters C, Poehling G, Millman F. Using a Collaborative Approach to Reduce Postoperative Complications for Hip-Fracture Patients: A Three-Year Follow-Up. Joint Commission Journal on Quality and Patient Safety; Volume 32, Number 1, January 2006, pp. 16- 23(8). 22. Poses RM, Berlin JA, Noveck H, Lawrence VA, Huber EC, O'Hara DA, Spence RK, Duff A, Strom BL, Carson JL: How you look determines what you find: severity of illness and variation in blood transfusion for hip fracture. Am J Med 1998; 105: 198–206. 23. Halm EA, Wang JJ, Boockvar K, Penrod J, Silberzweig SB, Magaziner J, Koval KJ, Siu AL: Effects of blood transfusion on clinical and functional outcomes in patients with hip fracture. Transfusion 2003; 43: 1358–1365. 24. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am. 2005 Mar;87(3):483-9 25. Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br. 2005 Mar;87(3):361-6. 26. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005 Aug;87(8):1123-6.
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