August 1999 Bulletin

AAOS urges hip fracture care reform

The American Academy of Orthopaedic Surgeons and American Association of Orthopaedic Surgeons (AAOS) are urging the federal government and regulators to explore new models for hip fracture care that are more accountable to patients' needs.

A new Position Statement on Hip Fracture in Seniors: A Call for Health System Reform points out that hip fracture is a serious and costly health problem involving more than 300,000 hospital admissions each year and 60,000 nursing home admissions. More than 4 percent of hip fracture patients die during the initial hospitalization; 24 percent die within a year of the injury; and 50 percent lose the ability to walk.

The problem is expected to increase as the population ages in coming decades. But, cost-savings incentives by Medicare and hospital utilization management activities have created an immediate problem by 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 AAOS warns of the consequences of the current policies.

• Reducing the length of stay for hip fracture leads to a fragmentation in hip fracture care because the acute hospital phase is cut without enhancing and coordinating the post-acute phase, including rehabilitation and home support.
• The burden of care shifts to the nonhospital sectors of the system, and to families, at a tremendous cost.
• 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.

The AAOS believes that a coordinated approach to the prevention, treatment and rehabilitation of hip fracture patients is necessary to reduce morbidity, mortality, loss of independence and the overall costs to society. The AAOS says the health care the system can be more accountable to patient needs, by accomplishing the following:

1. Eliminate the current acute care hospital model, which provides a mix of services based on hospital utilization targets, and minimizes rehabilitation services.
2. Establish a patient care model, which is based on functional patient needs, and return of the patient to the highest possible activity level, after hip fracture.
3. Redefine the recovery and rehabilitation period, its length and the mix of appropriate therapies, based on patient functional goals.
4. Evaluate the cost-effectiveness of new treatment pathways. Measure patient outcome against total cost.
5. Increase the value of home health services and home physical therapy services to patients. Inform doctors and patients of the costs for specific home-based services.
6. Expand step-down hospital options.
7. 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. Minimize the degree to which the patient is removed from his/her health care team after discharge.
8. Expand comprehensive falls prevention programs, and programs to prevent and treat osteoporosis.

The AAOS believes hip fracture is a societal problem. While the repair of a fractured hip is essential, it is only one part of the process leading to optimal recovery. A comprehensive, coordinated and ongoing strategy, beginning with prevention, and reaching far beyond the acute hospital phase, is needed to ensure that recovery is optimized.