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Broken hips - background

Hip fracture is an important cause of death and morbidity in the over 65s, especially in women. About 57,000 people are affected every year, accounting for 20% of all orthopaedic beds, with an average cost of stay of £5,000 and a total cost to the NHS of hospital care alone of about £280 million [1].

As the population over 65 increases, and with declining levels of exercise, the problem will get bigger. Several recent reports by the Royal College of Physicians [2], the study of Population Health Outcome Indicators [3] and an Audit Commission report [4] have examined hip fractures. It is likely to be a topic which will demand more attention from purchasers and providers.

Who is most at risk?

Of patients admitted with hip fracture, 87% are over the age of 65, and 82% of these are women. The most common underlying pathology is loss of bone density - osteoporosis.

Risk factors for osteoporosis are many, and include :
  • genetic predisposition
  • poor nutrition in childhood and adolescence
  • early age of onset of menopause
  • decreased exposure to sunshine and low vitamin D intake
  • low dietary calcium
  • alcohol and cigarette use
  • caffeine consumption
  • low weight
  • lack of regular exercise

How big is the problem?

The lifetime risk that a woman will suffer a hip fracture before age 85 years is 12%. For a man it is 5%.

In the population 65 years and over in 1990 there were 249 men and 743 women admitted to hospital for each 100,000 population (age-standardised hospital episode rates).

What is the outcome?

More than 95% of patients have surgery to repair the fracture [5]. Most patients do very well, but in England and Wales in 1990 fracture of neck of femur was responsible for 1,155 deaths, with an additional 416 deaths due to other unspecified similar fractures [3]. Other adverse events, such as infection, thrombo-embolism in the leg and pressure sores cause many problems.

The East Anglian Audit

An audit comparing differences in mortality in East Anglia between eight different hospitals investigated the importance of various factors [5]. There were 580 consecutive admissions, and patients admitted to each hospital were similar in terms of age, sex, pre-existing illnesses and activities of daily living before fracture.

The report showed that 97% of admissions were treated surgically (range 88 - 100%), that 45% received thromboembolic prophylaxis (range 10 - 91%), and 93% pre-operative antibiotics (range 81 - 99%). Mortality at 90 days was 18%, but there was a wide range between hospitals from 5% to 24%.

Being older, having a lower level of day activity, being male, and having a history of cardiovascular disease emerged as important determinants of mortality.

One hospital stood out as having a much higher survival rate. There was no single factor to which this could be ascribed, and the authors concluded that the hospital's performance appeared to be due to the "overall package of care".

The hospital with the best performance judged by 90-day mortality had a high proportion of patients receiving pharmaceutical thromboembolic prophylaxis (86%), had more than 50% of patients mobilised by the first postoperative day (compared with 2-3 days for the other hospitals), and had the shortest median length of hospital stay at 13 days, compared with 16 - 28 days for the other seven hospitals).

Postoperative thrombosis was diagnosed in 22 of 305 patients who did not receive thromboembolic prophylaxis compared with 9/261 who did. Fatal pulmonary embolism occurred in 12 patients who did not receive prophylaxis, but none in those who did (NNT 25; 95%CI 16 - 52).

The authors of the report paid particular attention in their discussion to thromboembolic prophylaxis. They make the point that patients with a fractured hip are at high risk, with 40 - 80% developing a deep vein thrombosis, 10 - 30% a proximal vein thrombosis, and 1 - 10% having a fatal pulmonary embolism if prophylactic measures are not taken. They conclude that written policies that include prophylaxis should be developed and implemented for this vulnerable group of patients if mortality is to be improved.

Reducing mortality and morbidity

Primary prevention

Primary preventative approaches focus on reducing the prevalence of osteoporosis and the number of falls in the elderly (see Bandolier 3 and 20 ).

Secondary and tertiary prevention

This focuses on interventions following admission and measures taken on discharge. Areas that might be covered are shown in the box.

Delays in intervention can occur at a number of stages. In spite of guidelines issued by the Royal College of Physicians recommending that patients with hip fracture wait no more than one hour in A&E, most appear to wait longer [4]. There is also evidence that discharge planning for patients is poorly documented. Areas that could be covered might include specification of a target discharge date, assessment and planning of support needed at home in conjunction with other agencies, and involvement of the patients themselves, and their relatives.

Dr Steve Kisely, University of Manchester

References:

  1. W Hollingworth, CJ Todd, MJ Parker. The cost of treating hip fractures in the twenty first century. Journal of Public Health Medicine 1995 17:269-76.
  2. Royal College of Physicians. Fractured neck of femur, prevention and management: Summary and recommendations of a report of the Royal College of Physicians. Journal of the Royal College of Physicians 1989 23:8-12.
  3. AJ McColl, MC Gulliford. Population Health Outcome Indicators for the NHS: a feasibility study. London: Faculty of Public Health Medicine, 1993.
  4. Audit Commission. United they stand: co-ordinating care for elderly patients with hip fracture. London: HMSO, 1995.
  5. CJ Todd, CJ Freeman, C Camilleri-Ferrante et al. Differences in mortality after fracture of the hip: the East Anglian audit. British Medical Journal 1995 310:904-8.



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