Hip Fracture: Can We Do Better?

Hip fractures impair the quality and duration of lives of many older adults. Outcomes for individuals with these fractures have not improved like those of other conditions. Heart disease, stroke, and cancer mortality in the United States decreased by 67.5%, 77%, and 17.9% respectively from 1969 to 2013.1 Although 1-year hip fracture mortality in the United States declined from 1986 to 2004 for men and women (men, 40.6% to 32.5%; women, 24% to 21.9%), all of this improvement occurred from 1986 to 1995. There was no improvement in mortality from 1995 to 2004.2 All-cause mortality for hip fracture is substantially greater than for myocardial infarction or stroke, and hip fracture has a major effect on function, mobility, and the need for nursing home placement. In this issue of the Journal of the American Geriatrics Society, Cram and colleagues have traced changes in the frequency of different surgical approaches to hip fracture in the Canadian province of Manitoba from 1990 to 2014. Surgeons increased their use of total hip arthroplasty from 0.6% to 5.3% and hemiarthroplasty from 19.3% to 29.7% while decreasing nonoperative management from 8.3% to 5.1%.3 Despite these changes in technique, overall mortality and loss of function in this Manitoba cohort were substantial. One-year mortality ranged from a low of 18.7% for individuals with total hip replacement to 41.8% for those who were managed nonoperatively.4 The rates of nursing home placement were 26.4% for those undergoing hemiarthroplasty, 26.6% for those undergoing internal fixation, and 18.9% for those undergoing total hip replacement.5 Individuals who underwent total hip replacement were significantly younger than other participants. In previous studies using the same hip fracture registry in Manitoba, the authors reported no significant change in 1-year mortality from 1986 to 2006 and an increase in the percentage of individuals aged 75 and older who were permanently placed in nursing homes.5 Although changes in surgical techniques did not appear to affect mortality or the need for nursing home placement, they decrease complications and, in high-functioning individuals, may improve results.6, 7 Individuals with displaced femoral neck fractures treated with hemiarthroplasty have a much lower incidence of reoperation than those treated using operative reduction and internal fixation. Similarly, studies have shown that younger adults (average age 75) with normal mental status and good prefracture function had less pain and better mobility when they were treated with total hip arthroplasty rather than hemiarthroplasty.6 In the United States and Canada, the prognosis for individuals with hip fracture has not improved significantly in the past 2 to 3 decades. Why is this the case, and what might we do to improve the outcomes of these individuals? One of the challenges in the care of these individuals is the substantial effect that individual characteristics have on outcomes. Mortality of individuals with underlying dementia is 3 to 4 times as high as that of those with normal mental function. Poor prefracture mobility and multiple chronic conditions are associated with high mortality and poor functional outcomes.8 Studies have shown that the mortality of individuals living in a nursing home before sustaining a hip fracture exceeds that of those residing in the community.9, 10 In some surgical centers, the combination of severe dementia and bed-bound status is an indication for nonoperative management. It is not clear that hip fracture itself is the primary reason for loss of function and mortality. Many feel that hip fracture may be a marker of frailty because many individuals appear to lose function before the fracture. A recent article supports this theory.11 Smith and colleagues followed 857 Health and Retirement Study participants with hip fracture from 1992 to 2010 and found that the percentage of individuals with disability increased significantly in the 10 months before the hip fracture, exceeding 40% in the last month before the fracture. This was substantially higher than the disability levels of those who did not experience a fracture. Most studies of medical and geriatric management of individuals with hip fracture have focused on care in acute hospitals. A number of trials have evaluated the effect of geriatric consultation on older adults hospitalized for hip fracture. Although inpatient geriatric consultation for individuals with hip fracture results in a decrease in the number who experience delirium, there is no difference in mortality, admission to a skilled nursing facility, or readmission.12, 13 The comanagement model for individuals with hip fracture was developed in England in 1950 in a collaboration between orthopedic surgeons and geriatricians. Studies of this model in Europe have shown a reduction in in-hospital complications, length of stay, readmission rate, and mortality and improved function and higher levels of individual and provider satisfaction.14, 15 A meta-analysis of U.S. studies demonstrated a reduction in hospital complications but no change in in-hospital or 30-day mortality.16 Other studies have demonstrated a trend toward reduction in 1-year mortality and hospital cost savings with comanagement strategies.17-19 Although comanagement programs and geriatric consultations show promise for improving outcomes during acute hospitalization, the brief hospital stay that these individuals have may limit the long-term effect of these models of care in the United States. The prospective payment system has encouraged hospitals to discharge these individuals as soon as possible, resulting in a decrease in the length of stay for hip fracture in the United States from 18.6 days in 1982 to 6.6 days in 2002. In the United States, 90% of individuals with hip fracture are transferred to acute rehabilitation facilities or skilled nursing facilities, where the remainder of their care is provided.20, 21 To improve the rehabilitation process, care must be well coordinated with medical and surgical specialists, primary care physicians, and clinicians in the rehabilitative setting. Integration of care for these individuals is essential, and communication between acute and long-term providers must be excellent. Guidelines and clinical pathways in the rehabilitation setting may aid in this process, allowing for all clinicians to share goals and processes. The outcomes of care of individuals with hip fracture can be improved only if surgeons and programs track their progress, including factors that might have influenced outcomes. Programs must assess outcomes such as mortality, mobility, living site, ability to perform activities of daily living, and the amount of care required 3 to 6 months after surgery. Programs should determine which characteristics, surgical approaches, and processes of rehabilitation care are associated with positive (living at home with good mobility, limited need for care) and negative (mortality, need for nursing home placement, poor function, need for substantial care) outcomes. U.S. medicine can do a better job in the care of older adults with hip fracture. Improving care begins with learning the outcomes of care. Investigators must determine which individual characteristics, surgical approaches, medical interventions, and rehabilitative care methods contribute to positive outcomes of care. Which interventions and processes result in the most-successful outcomes must be determined before care of these individuals can be improved. Conflict of Interest: None. Authors Contributions: Ouellet, Cooney: study concept and design, preparation of manuscript. Sponsor's Role: No sponsor.

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