Saturday, March 18, 2000
Academy statement on hip fracture in seniors
The American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons (AAOS) believe that hip fractures in the senior population should be a public health priority and target of health system reform.
Hip fracture is a serious and costly health problem, affecting not only the individual, but also the entire family. Hip fractures account for 350,000 hospital admissions each year, and 60,000 nursing home admissions. More than 4 percent of hip fracture patients die during their initial hospitalization; 24 percent die within a year of the injury; and 50 percent lose the ability to walk.1,2,3.
Hip fractures will multiply, with the projected growth in the 65 and older population and, most dramatically, in people 85 years and older, our fastest growing population segment.4.
Women are affected in far greater numbers than men, but men are also at high risk, especially in the 85 years and older age group. Osteoporosis plays a role in 90 percent of all hip fractures.5,6.
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 persons age 65 years and older who live alone.
The AAOS believes that incentives 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 discriminatory to older Americans.
There is no data to demonstrate that shorter hospital stays for hip fracture lead to cost savings to society. There is a need to look at total cost, financial and societal, if hip fracture as a public health problem is to be overcome.
- 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 non-hospital 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 federal government, regulatory agencies and Congress are called upon to explore new models for hip fracture care which make the system more accountable to patient needs, by accomplishing the following:
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. The AAOS stands ready to assist the federal government in the development and implementation of such a strategy.7.
- Eliminate the current acute care hospital model, which provides a mix of services based on hospital utilization targets, and minimizes rehabilitation services.
- 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.
- Redefine the recovery and rehabilitation period, its length and the mix of appropriate therapies, based on patient functional goals.
- Evaluate the cost-effectiveness of new treatment pathways. Measure patient outcome against total cost.
- 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.
- Expand step-down hospital options.
- 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.
- Expand comprehensive falls prevention programs, and programs to prevent and treat osteoporosis.
- Rodrigues J, Sattin RW, Waxweiler RJ: Incidence of hip fractures, United States, 1970-83. Am J Prev Med 1989; 5:175-181.
- Ray NF, Chan JK, Thamer M, Melton LJ: 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.
- Wolinsky FD, Fitzgerald JF, Stump TE: The effect of hip fracture on mortality, hospitalization and functional status: A prospective study. Am J of Public Health 1997; 87:398-403.
- Melton III, LJ: Hip fractures: A worldwide problem today and tomorrow. BONE 1993; 14: S1-S8.
- Report on Older Women, U.S. Administration on Aging Fact Sheet.
- The Women's Health Initiative, National Institutes of Health, Bethesda, Md. 1995-98.
- Koval KJ, Aharonoff GB, Rosenberg AD, Schmigelski C, Bernstein, RL, Zuckerman, JD: Hip fracture in the elderly: The effect of anesthetic technique. Orthopedics 1999; 22: 31-34.
Last modified 28/February/2000 by IS