Integrated Hip Fracture Care: Achieving Cost Effectiveness and Best Practice in 2009

Stryker UK recently teamed up with Professor Keith Willett to hold a seminar based around achieving cost effectiveness and best practice in Hip fracture care. Taking place at the Kassam Stadium, Oxford, the course focused on a number of different aspects relating to Hip fracture care, including the NHS changes in commissioning, the care pathway and case discussions on Displaced Intracapsular Hip Fracture and Unstable Pertrochanteric Fracture. Keith Willett, newly appointed National Clinical Director for Trauma Care for the Department of Health, was joined by Tim Chesser, a Consultant Orthopaedic Surgeon at the Frenchay Hospital in Bristol, as well as a number of other orthopaedic professionals to present the programme on behalf of Stryker UK.

The NHS: Policy and Perspective for Fragility Fractures

Willett and Cheeser began with an introduction to ‘The NHS: Policy and Perspective for Fragility Fractures’, outlining the National Context:

• Hip fractures made up 87% of total cost of all fragility fractures (Top 10 for Healthcare Resource Groups)
• 70,000 hip fractures in the UK in 2008
• £384m per year acute care
• £1.8bn total care cost

Proximal Femoral Fracture Oxford Audit. Of 2016 patients over 4 years (40 per month):

• Mean age 84 years, 75% female
• 20% unfit for surgery at presentation
• 30% dementia, 20% episode related delirium
• 30% mortality at one year
  • 3% die prior to surgery
  • 10% die within 30 days of surgery
• Two-thirds in hospital and one-third after discharge
• Median length of acute stay (spell) 12 days
• Mean total stay for community hospital 67 days
• 33% need more care support, 14% change residence

The introduction continued with a look at recent reports into the state of hip fracture care in the UK. NHS Institute for Health - Focus On: Fractured Neck of Femur

• There must be effective communication with the patient and/or family about treatment decisions.
• Surgical fixation should not be delayed more than 48 hours from admission unless there are clear reversible medical conditions.
• Multiagency team including bed managers, social services and intermediate care coordinators

BOA and BGS – The Care of Patients with Fragility Fracture

Preoperative assessment should follow local protocols agreed between the anaesthetists, orthogeriatricians and orthopaedic surgeons to address medical problems, identify high-risk patients and facilitate prompt fracture treatment.

Healthcare Commission – National Clinical Audit of Falls and bone health in Older People

Secondary prevention (anti-resorptive therapy) for osteoporosis and falls assessments are effective in reducing further fragility fractures and must be an integral part of the fracture care. PCTs should commission patient care pathways and risk assessments and PCTs and local providers should audit and share information.

Hip Fracture Database

Each hospital should submit data to the National Hip Fracture Database to monitor its performance against national benchmarks and quality standards.

The Changing National Perspective

Dr. Finbarr Martin looked at the changing national perspective within the Department of Health. It was said in April 2005 that all local and health care systems should have established:

• Rapid admission from A/E
• Assessment for purpose, ie for 80 year old frail woman
• Surgery by experienced surgeon within 24 -48 hours
• Mobilisation within 48 hours
• Formal liaison with geriatric medicine
• A ward as centre of clinical excellence
• Links to osteoporosis management
• Links to specialist falls service

But multiple sources have confirmed that care is sub –optimal. The key messages from Clinical audit, funded by Healthcare Commission, were that after discharge from A&E after a fragility fracture most were not offered a falls risk assessment, only 22% were referred for exercise training and by 16 weeks, only 20% were on appropriate bone treatment. Even after hip surgery, less than 50% were on appropriate bone treatment, whereas the 5% who attended Falls Clinic received better falls and bone assessments and treatment. According to Martin, The Department of Health’s Falls and Fragility Fractures Commissioning Toolkit aims to change this. It’s objectives are:

• Better commissioning
• Better services
• Better integration of services
• Raise public profile

The Toolkit contains a web based tool, examples of service level agreements, model job descriptions (for falls/osteoporosis nurses, fracture liaison services and exercise prescriptions), and clinical governance requirements like the National Hip Fracture Database.

The motivation to do it will come from peer pressure through benchmarking quality (National Audits from RCP and NHFD Reports), as well as achieving government targets and rewarding efficient quality through Payment by Results.

Best Hip Fracture Service Delivery

The second part of the programme looked at ‘Best Hip Fracture Service Delivery’. Dr. Kassim Javaid, Senior Lecturer in Metabolic Medicine at the University of Oxford, focused on bone health and secondary prevention of osteoporosis. He looked at the three stages of secondary prevention: Identification, Assessment and Treatment, and how they are being adapted for a piloted scheme, as well as the Falls and Bone Health Care Pathway. Javaid also spoke of the importance of trauma/falls/Fracture Liaison Service and ruling out secondary causes through assessment, as well as using effective therapy: ‘Multi-disciplinary approach is key’.

Intracapsular Hip Fracture

After lunch, the programme looked at three intracapsular hip fracture cases and the evidence for the different ways of treating them. Three surgeons were briefed to present the case for each treatment option. A multidisciplinary debate followed.

Rob Wakeman (Romford) stated the case for more fixation operations in the future with the following conditions:

• Good proximal hold
• Good distal hold (locking plate for extra strength)
• Allow for fracture collapse
• No backing out of implant
• Minimally invasive with alignment jig
• Made of titanium

With these implant improvements, he suggested that the case for fixation may be an easier one, even for those over 70 as the population become more active in later life. Next was Matthew Porteous, an Orthopaedic Surgeon from West Suffolk. He spoke about using Hemiarthroplasty for an intracapsular fracture on a patient who was fit, had a good prognosis and life expectancy above eight years. The advantages of Hemiarthroplasty is the quick operation time (1 hour), technically easier than THA (done by a junior SpR) and an inexpensive implant used (less than £200). However, there are complications, with acetabular erosion, infection, dislocation, pain, loosening and leg length inequality all potential problems. Porteous dismissed Bipolar implants, with acetabular erosion & migration reported up to 77%, which is worse than Unipolar (60%). However, Unipolar Hemiarthroplasty has relatively poor outcomes, with a study on 500 consecutive patients (Norrish Injury 2006) showing 81% dead within eight years and 25% revision in survivors. This can be improved with a cemented implant that is easy to convert to THA and with a proven stem design, but the overall cost makes THR a better option in this example. Finally, Keith Willett stated the case for THR, and why it should be considered. Improved bearing surfaces may translate to:

• less acetabular erosion
• less pain
• less loosening
• better mobility
• longer joint survival
• less redo surgery
• less social care costs
• better quality of life

Whereas more complex surgery may result in:

• Greater cost for no gain
• More complications
• Infection
• Dislocation
• Mortality
• Worse outcome

The lecture went on to discuss the comparative results of meta-analysis into revision and complications (Bhandari (2001):

	Hemiarthroplasty	THR
Revision surgery	7.5%	7.5%
Dislocation	3.5%	7.0%
Wound infection	8.0%	2.0%
Hip pain	23%	25%
Good function (at 2years)	54%	72%

Pooled treatment effect comparing THA and hemiarthroplasty:

	Relative Risk	p value	CI
1 yr Mortality	0.71	p=0.13	0.46-1.11
Dislocation	1.54	p=0.17	0.83-2.86
Wound Infection	0.69	p=0.46	0.26-1.85
Hip pain	0.76	p=0.03	0.59-0.9
Functional limit	0.90	p=0.13	0.76-1.06

81 mobile socially independent patients - randomised (3 years FU, mean age 75, 4:1 female to male). Baker & Bannister, 2007, mirrored results of Tidemark (Stockholm 2007) at 1 yr FU

	Hemiarthroplasty	THR	p value
Walking distance	1.2km	2.2km	0.04
Oxford Hip Score	22.3	18.8	0.03
SF 36 (physical)	38.1	40.5	0.36
SF 36 (mental)	55.3	52.0	0.35
Dislocation	0%	7.5%	0.12
Infection	2.5%	7.5%	0.30

A Rational Approach?

In summing up, Willett questioned what is the ‘Rational Approach’ to THR? Total Replacement should be used for the medically fit, mentally sound, independent community ambulator. But implant survival would exceed patient survival with 13 yr mortality at 80-90% (Ravikumar 2000) and even three year mortality was 25%, so patients should be chosen carefully.