Position Statement 1144

Hip Fracture in Seniors: A Call for Health System Reform

This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

The American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons (AAOS) believe that hip fractures should be a public health priority and target of health system reform given the increasing burden of disease.

Hip fracture is a serious and costly public health problem. According to the 2004 Surgeon General’s Report on Bone Health and Osteoporosis, “The bone health of Americans appears to be in jeopardy.” One of every two women and one of every four men over age 50 will suffer a fracture related to osteoporosis.² In 2002, it was estimated that over 44 million Americans over age 50 suffer from osteoporosis or low bone mass, putting them at risk for fragility fracture, namely a fracture caused by minimal trauma such as falling from a standing height. It is estimated that over 61 million people will be at risk by the year 2020 if current trends continue.²

The burden of disease, disability, and pain from abnormal bone health and osteoporosis is significant. In the United States alone, the economic burden of caring for osteoporosis-related fractures is estimated at $17 billion. The cumulative economic cost over the next twenty years is estimated at $474 billion.²

Among adults 65 and older, fragility fractures are the primary cause of hospitalization or death.² Hip fractures account for 350,000 hospital admissions each year, and 60,000 nursing home admissions. Hip fractures are the most ubiquitous type of fragility fracture; 44% of nursing home admissions due to fracture are hip fractures.² More than 4% of hip fracture patients die during their initial hospitalization; 24% die within a year of the injury; and 50% lose the ability to walk.^{7, 10, 13}

People are also living longer. 2006 data from the World Health Organization (WHO) predicts the average life expectancy of American men to be 75 and that of women to be 80 years.¹⁵ Consequently, with the projected growth in the 65 and older population, the number of hip fractures will increase. The most dramatic increase will be in the fastest growing segment of the populations, those people 85 years and older.⁴ While women are affected in far greater numbers than men, men are also at high risk - especially in the 85 years and older age group. Studies have shown that the proportion of men with hip fracture is increasing.¹² Osteoporosis plays a role in 90 percent of all hip fractures.^{8, 14} 45% of all adults who present with hip fracture have had a prior fracture.^{5, 6} Many of these fractures occur in women who have been undiagnosed and untreated for osteoporosis and many of these fractures can be prevented.

Hip fracture is an even greater crisis for those who live alone. By 2005, 17 percent of men 65 years and older, and 43 percent of women in this age group, will live alone. By 2010, 45 percent of those 85 years and older will be living alone. By 2020, women will account for 85 percent of people aged 65 years and older who live alone.

The AAOS believes that flat fee based reimbursements created by the Medicare payment system and hospital utilization management activities are causing medical care organizations and hospitals to reduce the lengths of stay for hip fracture patients in an effort to control health care costs. The impact of this reduction is disproportionately negative and impacts patient care.

Reducing the length of stay for hip fracture leads to fragmentation in hip fracture care as the acute hospital phase is decreased without enhancing and coordinating the post-acute phase, which includes rehabilitation and home support, DEXA and metabolic screening regimens for fragility fracture investigation. Increased time available for evaluation and initiation of treatment may lead to a decreased risk of subsequent fracture. There is often a sudden loss of follow up care after hospital discharge. The patient is cut off from his day-to-day relationship with the primary care doctor, surgeon and physical therapist. During the immediate recovery period where readmission rates for related complications and co-morbidities may be significant. ^{17, 18, 19}

The addition of including rehospitalization and cost of caring for complications as a bundled reimbursement will further shift the care of these patients to tertiary and state and local government funded hospitals for fear of the economic impact caring for the patient may have on private systems.

Those hospital systems that have incorporated multidisciplinary care pathways with orthopaedic and medicine services, and decreased the time to operative treatment have shown benefit to the patient by reducing long and short term morbidity and mortality. Implementation of these pathways and abolishment of delays for surgical care should be emphasized. ^20-25

The AAOS calls upon the federal government, regulatory agencies and Congress to explore new models for hip fracture care which make the system more accountable to patient needs, by accomplishing the following:

• Eliminate the current acute care hospital model, which provides a mix of services based on hospital utilization targets, and minimizes rehabilitation services.
• Follow the recommendations of the 2004 Surgeons General’s Report on Bone Health and Osteoporosis for a public health approach to this problem, recognizing how it affects all racial/ethnic groups and both sexes.
• Establish a patient care model, which is based on functional patient needs, uncovering and treatment of co-morbidities that have contributed to osteoporosis and return of the patient to the highest possible activity level after hip fracture.
• Redefine the recovery and rehabilitation period, its length and the mix of appropriate therapies, based on patient functional goals and co-morbidities.
• Evaluate the cost-effectiveness of new treatment pathways. Measure patient outcome along with readmissions against total cost. ^{21, 22, 24}
• Increase the economic value of home health services and home physical therapy services to patients. Inform doctors and patients of the costs for specific home-based services.
• Increase the coordination, cooperation and communication among health and medical professionals along the continuum of hip fracture care. Extend the involvement of the primary care doctor and the surgeon with a focus on needs of the patient with regard to co-morbidities and treatment of diseases that affect the quality and quantity bone mineral density. This may include tailoring treatment with regard to the differences for men and women both in anatomy, risk factors, and morbidity and mortality after hip fracture.
• Creation of incentive based programs for decreasing time from admission to surgery as well as care pathways which involve primary care based and orthopaedic based services which have shown to decrease mortality and morbidity rates in these patients, while recognizing the increasing number of co-morbidities with which hip fracture patients present.^20,23,25
• Minimize the degree to which the patient is removed from his/her health care team after discharge.
• Expand comprehensive falls prevention programs and programs to prevent and treat osteoporosis early in the continuum of basic health care and screenings.
• Emphasize sex and gender specific care. Since mortality and co-morbidities in men are greater when compared to women, the best care for a patient would be sex and gender specific care. This optimizes better bone quality to prevent osteoporosis, early return to function and a return to expected quality of life if a hip fracture is sustained. Examples include:
1. Basic best bone care with calcium/ vitamin D and weight bearing exercise is recommended for all patients, both male and female. While the National Osteoporosis Foundation (NOF) treatment guidelines recommend calcium/vitamin D and pharmacology agents for women who have a history of fracture in the hip or vertebral body, recommendations for prevention and treatment for osteoporosis in men should also include these measures.⁵
2. Attention to secondary causes of osteoporosis in both men and women. There is a greater number of co-morbidities in men, and men are more likely to have secondary causes of osteoporosis. Men may have a different health status at the time of fracture than women as supported by the fact that men appear to be younger and sicker when hip fracture occurs.⁶
3. Appropriate attention to prevention of future subsequent fractures for all patients. A first fragility fracture is one of the greatest indicators of risk for a second fragility fracture.¹
4. Psychosocial factors (ex. depression is greater in both men and women who sustain a hip fracture, but most research has been on women).⁶
5. Use of pharmacologic agents for treatment of osteoporosis before and after hip fracture (most treatment options have only been recommended for women).
6. Prevention of mortality after hip fracture (greater in men emphasizing the need to promptly diagnose and treat co-morbidities).

The AAOS believes that hip fracture is a significant problem. While the repair of a fractured hip is essential, it is only one part of the process leading to optimal recovery. A comprehensive, sex and gender-specific, coordinated and ongoing strategy, beginning with prevention, and reaching far beyond the acute hospital phase, is needed to ensure optimal recovery and prevention of subsequent fragility fractures. The AAOS stands ready to assist the federal government in the development and implementation of such a strategy.³

References:

1. Bouxsein et al: Recommendations for optimal care of the fragility fracture patient to reduce the risk of future fracture. J Am Acad Orthop Surg 2004 12: 385-395
2. Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost. Rosemont, IL, American Academy of Orthopaedic Surgeons, February 2008.
3. Koval K, Aharonoff G, Rosenberg A, Schmigelski C, Bernstein R, Zuckerman J: Hip fracture in the elderly: The effect of anesthetic technique. Orthopedics 1999; 22: 31-34.
4. Melton III, LJ: Hip fractures: A worldwide problem today and tomorrow. BONE 1993; 14: S1-S8.
5. National Osteoporosis Foundation. www.nof.org
6. Orwig DL, Chan J, Magaziner J: Hip fracture and its consequences: Differences between men and women. Orthop Clin North Am. 2006; 37: 611-622.
7. Ray N, Chan J, Thamer M, Melton L: Medical expenditures for treatment of osteoporotic fractures in the United States in 1995. Report from the National Osteoporosis Foundation. J Bone and Miner Res 1997; 12: 24-35.
8. Report on Older Women, U.S. Administration on Aging Fact Sheet. Available at: http://www.aoa.dhhs.gov/press/fact/fact.asp.
9. Rockwood CA, Green DP (eds): Fractures in Adults, ed2. Philadelphia, PA, JB Lippincott, 1984.
10. Rodrigues J, Sattin R, Waxweiler R: Incidence of hip fractures, United States, 1970-83. Am J Prev Med 1989; 5:175-181.
11. Tosi LL, Boyan BD, Boskey AL: Does sex matter in musculoskeletal health? J Bone Joint Surg AM July 2005: Vol. 87-A, No. 7: 1631-1647.
12. Vestergaard P, et al: Has mortality after a hip fracture increased? J Am Geriatr Soc November 2007; Vol. 55, No. 11: 1720-1726.
13. Wolinsky F, Fitzgerald J, Stump T: The effect of hip fracture on mortality, hospitalization and functional status: A prospective study. Am J Public Health 1997; 87:398-403.
14. Women’s Health Initiative, National Institutes of Health, Bethesda, MD. 1995-98.
15. World Health Organization. World health statistics 2008.
16. Bone Health and Osteoporosis: A Report of the Surgeon General (2004), United States Department of Health and Human Services, available at http://www.surgeongeneral.gov/library/bonehealth/content.html.
17. van Balen R, Steyerberg EW, Cools HJ, Polder JJ, Habbema JD: Early discharge of hip fracture patients from hospital: transfer of costs from hospital to nursing home. Acta Orthop Scand 2002 Oct;73(5):491-5.
18. Ottenbacher KJ, Smith PM, Illig SB, Peek MK, Fiedler RC, Granger CV: Hospital readmission of persons with hip fracture following medical rehabilitation. Arch Gerontol Geriatr 2003 Jan-Feb;36(1):15-22.
19. Al-Ani AN, Samuelsson B, Tidermark J, Norling A, Ekström W, Cederholm T, Hedström M: Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am 2008 Jul;90(7):1436-42).
20. Novack V, Jotkowitz A, Etzion O, Porath A: Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care 2007 Jun;19(3):170-6.
21. Olsson LE, Karlsson J, Ekman I: The integrated care pathway reduced the number of hospital days by half: A prospective comparative study of patients with acute hip fracture. J Orthop Surg 2006 Sep 25;1:3.
22. Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM: Outcomes for older patients with hip fractures: The impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 2006 Mar;20(3):172-8; discussion 179-80.
23. 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.
24. Koval KJ, Chen AL, Aharonoff GB, Egol KA, Zuckerman JD: Clinical pathway for hip fractures in the elderly: The Hospital for Joint Diseases experience. Clin Orthop 2004 Aug;(425):72-81.
25. Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, McLaughlin M, Halm EA, Wang JJ, Litke A, Silberzweig SB, Siu AL.

May 1999 American Academy of Orthopaedic Surgeons.
Revised December 2008.

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.

Position Statement 1144

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