With a rapidly expanding elderly population, orthopaedic surgeons are likely to see increased numbers of hip fractures, noted Susan V. Bukata, MD, of UCLA, during her presentation for the Orthopaedic Trauma Association’s Specialty Day. Improving outcomes for these patients, she said, will require quality measures.
“We all want to provide high-quality, cost-effective care. Treatment of hip fractures is one area where we can show we are providing quality care, because there are some standards,” said Dr. Bukata. Scorecards include the Surgical Care Improvement Project (SCIP) measures and the Physician Quality Reporting System measures. However, she noted, physicians “may have different ideas about what constitutes quality care than patients, payers, and hospitals.”
In hip fractures, for example, patient event-related issues include infections, pressure sores, falls, and 30-day and 1-year mortality numbers.
“We can spend an infinite amount of money on things that make no difference in outcomes,” Dr. Bukata said. “How nice the room is and how many nurses are following the patient may not make any difference, but taking the Foley catheter out within 24 hours can make a huge difference.”
Various parties from different vantage points are attempting to define which outcomes are important. Regulatory agencies, hospitals, insurance carriers, and patients all have a say, but physicians also need to be involved in the process.
“We don’t yet have functional quality measures,” she said. “However, we can report on event-related issues, such as geriatric or comedicine management, time to surgery, length of stay, in-hospital mortality, 30-day mortality, and osteoporosis education. These are all areas where improvements can result in better quality care for our patients.”
The value of comanagement
Dr. Bukata said that care coordination among orthopaedic, geriatric, and internal medicine professionals is an important component in the effort to improve outcomes. At UCLA, she said, “Our core goal is to get at least 50 percent of our patients comanaged with geriatrics and medicine. This provides a medicine partner who can help decrease delirium, get the patient optimized for the operating room (OR), help with medical questions or any ‘bumps’ after surgery, and make sure patients are given the correct medications.
“Everybody is admitted to the geriatric service. Orthopaedics is a consultation service, but we have partner management and very defined roles in terms of who orders what. Everybody has the same goal of getting the patient to the OR as efficiently as possible,” she continued.”
Among those goals, is a time to surgery of 36 hours or less; this threshold is based on literature that shows that once a patient is medically optimized, rapid surgery decreases complications. “Chronic problems can’t be fixed rapidly, so we shouldn’t waste money or time trying to fix them before surgery,” she said.
Acute events, however, require medical stabilization. “It is important to know whether we should be operating on these patients,” Dr. Bukata said. “This is where gathering other data such as 30-day mortality is important. What happens to those patients on discharge? It is very difficult to ‘sit’ on a hip fracture patient past 36 hours, because we have been trained to go very quickly. But patients who had an acute heart attack must be medically optimized before going to the OR.”
In measuring the time to surgery, “the clock begins when the patient is taken to the (emergency department) ED, and it stops when anesthesia is administered,” Dr. Bukata said. “To meet that 36-hour number requires multiple services to coordinate smoothly: the ED gets them out quickly; they have a proper diagnosis and admission; and orthopaedics does its consultation and takes them to the OR quickly, with geriatrics and medicine providing the preoperative and perioperative support that is needed. In many places, the roadblock is OR availability.”
The goal for length of stay after hip fracture surgery in the United States is 6.4 days, although this standard can vary by county as well as by community. In communities without rehab facilities, patients have to stay in the hospital. “The family needs to understand what is going to happen with the patient, and then early mobilization is important, getting them out of bed right away and figuring out where they need to go postoperatively and what they need for physical therapy,” she said.
Dr. Bukata noted that the mortality standard after hip fracture is currently less than 3.1 percent in the hospital; 30-day mortality is less than 10 percent. One-year mortality varies dramatically by age, sex, and prehospital function status.
“We know that on average, mortality within 1 year after a hip fracture is 25 percent for women and 37 percent for men,” Dr. Bukata said. “The older the patient is, the higher that number is. If the patient comes from a nursing home and/or has dementia, the mortality rate is even higher. But getting data on those patients can be difficult.”
The education deficit
The degree to which osteoporosis and bone-health education is provided to hip fracture patients is so low that the current goal is to provide such education to a modest 15 percent of them, Dr. Bukata said, although she emphatically described that number as a starting point. She noted that 8 percent to 10 percent of all hip fracture patients will break the other hip and that a hip fracture doubles a female’s risk of sustaining other fragility fractures and more than doubles a male’s risk.
According to Dr. Bukata, a fragility hip fracture is now recognized as a diagnosis of osteoporosis. Patients should be educated about the condition, prescribed calcium and vitamin D, and provided osteoporosis medication management.
Gather the data!
Dr. Bukata encouraged attendees to leverage hospital electronic medical records in collecting outcomes data. Starting with a list of standards, hospitals and physicians must decide whether internal collection or an outside contractor is more cost-effective.
She advised reviewing reports regularly, and eliminating information that is not useful. Armed with solid information, orthopaedic surgeons and their colleagues can lobby for improvement.
Dr. Bukata noted that geriatric fracture certification programs are available to help physicians and institutions develop and meet standards and make improvements. The AAOS has issued a Clinical Practice Guideline on management of hip fracture and is developing an Appropriate Use Criteria algorithm for it.
Details of Dr. Bukata’s disclosures may be accessed electronically at www.aaos.org/disclosure
Terry Stanton is a senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org
- Measuring outcomes for hip fracture is essential for improving care.
- Event-related issues for hip fracture patients include infections, pressure sores, falls, and 30-day and 1-year mortality.
- Approximately 8 percent to10 percent of all hip fracture patients will break the other hip; a hip fracture doubles the risk of sustaining other fragility fractures for females and multiplies it even more for males.
- Important, measureable goals include time to surgery of 36 hours or less for eligible patients and length of stay of 6.4 days or less; comanagement with medicine/geriatrics for 50 percent of patients is also a goal.
- Hip fragility fracture alone is diagnostic of osteoporosis.
AAOS CPG on management of hip fractures in the elderly
AAOS Position Statement on Osteoporosis/Bone Health in Adults as a National Public Health Priority