June 2001 Bulletin

40 organizations seek to improve hip fracture care

More than 40 national organizations, representing a broad spectrum of patient care, are working to build consensus on how to improve the continuum of care for hip fractures patients.

Orthopaedic surgeons, internists, nurses, physical therapists and others in the patient care chain met at the two-day national conference in May to review the current strengths and weaknesses in the delivery of care to hip fracture patients–from hospital admission to a six-month episode of care–and to develop a consensus report and a set of recommendations for policy-makers.

The report will likely address the following four main areas:

There are now 350,000 hospital admissions for hip fractures each year and 60,000 nursing home admissions. Given the projected growth of the 65-plus population and most dramatically in people 85 years and older–the fastest growing population section–the incidence of hip fracture will soar in the years ahead.

But while the incidence of hip fractures is increasing, the chain of patient care has been fragmented. Incentives in the Medicare payment system and hospital utilization management have forced medical care organizations and hospitals to reduce lengths of stay for hip fracture. The acute hospital phase of care has been reduced without enhancing and coordinating the post-acute phase, including rehabilitation and home support.

The burden of care is shifting to nonhospital sectors of the system, and to families. In the sudden loss of follow up care, the patient is cut off from the day-to-day relationship with the primary care doctor, surgeon and physical therapist.

"As big a problem as hip fracture is now, it’s only going to get worse," said Joseph D. Zuckerman, MD, conference co-chair. "The development of a coordinated approach to the prevention, treatment and rehabilitation of hip fracture patients is necessary to reduce morbidity, loss of independence and the overall costs to society. The health care delivery system needs to better serve this vulnerable and growing population, and to be more accountable to patient needs."

"This is a quality of care, coordination of care and quality of life issue," said Alan H. Morris, MD, conference co-chair, adding, "the bottom line is that there needs to be a better way to address the needs of these patients."

Joseph Melton III, MD, professor of epidemiology, Mayo Clinic, Rochester, N.Y., emphasized the magnitude of the problem. "Hip fracture is a disease with a ‘universal propensity’, which means everybody in the population is at risk," Dr. Melton said. "The lifetime risk for risk for hip fracture from age 50 onward in a white woman is about 18 percent. That’s the same as the lifetime risk in a white woman of breast cancer and endometrial cancer and ovarian cancer, all added together.

"At any given age, the incidence of hip fracture is about twice as much in women as it is in men. Lifetime risk of a hip fracture in a white man is about 6 percent, but the proportion of men is increasing as the number of elderly men increase.

"Calculations done in Sweden–taking into account the improving life expectancy that we’re observing right now–estimate that in the future, the lifetime risk of hip fracture will rise to an incredible 35 percent of women and 17 percent of men."

The conference stemmed from the Academy’s identification of hip fracture patients as one of those groups in the U.S. with unique "access to care" problems, who can "fall through the cracks," and are in need of advocacy. The AAOS position statement, "Hip Fracture in Seniors: A Call for Health System Reform," describes the magnitude of the hip fracture patient population and recommendations for change. Proposing and facilitating this national meeting was the next phase of the Academy’s advocacy work on behalf of hip fracture patients.

Organizations represented at the conference included, among others, the American Hospital Association, the American Academy of Physical Medicine and Rehabilitation, the Association of Rehabilitation Nurses, American Nurses Association, National Association of Orthopaedic Nurses, National Osteoporosis Foundation, American Society of Physicians Assistants, American Association of Home and Services for the Aging, American Congress of Rehabilitation Medicine, American Academy of Physician Medicine and Rehabilitation, American Physical Therapy Association, American Academy of Physician Assistants, National Institute of Arthritis and Musculoskeletal and Skin Diseases, and Agency for Healthcare Research and Quality.

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