Orthogeriatric medicine and fracture liaison going from strength to PDF

[PDF] Guidelines to compliment the Integrated Care Pathway for Hip - HSE

British Orthopaedic Association/ British Geriatric Association Blue Book Standards ▫ 1) All patients with hip fractures should be admitted to an acute

Orthogeriatric medicine and fracture liaison going from strength to

[PDF] Fragility Fracture Network Website Fracture Care Resources Section

Orthopaedic-geriatric co-care models and Fracture Liaison Services mobilisation88 British Orthopaedic Association – British Geriatrics Society Blue Book

[PDF] CAPTURE THE FRACTURE - International Osteoporosis Foundation

British Orthopaedic Association – British Geriatrics Society 'Blue Book'22 in figure 8 on next page illustrates how UK-based Fracture Liaison Services (FLS)

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Age and Ageing2016;45:180-181

doi: 10.1093/ageing/afw008© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.

EDITORIALS

Orthogeriatric medicine and fracture liaison

going from strength to strength The management of patients sustaining a low trauma fracture has changed remarkably over recent years with the acute care of older trauma patients improved by pre-operative as- sessment, safe anaesthesia and timely surgical intervention. This has been complemented by the British Orthopaedic Association (BOA) Standards for Trauma care for hip frac- ture (BOAST 1) which synthesise the relevant guidance from the National Institute for Health and Care Excellence (NICE) and the BOA/BGS'Blue Book'on hip fracture management [1,2]. Since September 2007, the National Hip Fracture Database (NHFD) has been collecting data, with thefirst annual report (for 2007-8) published in 2009 on core standards of acute and rehabilitative care. In 2010, the best practice tariff (BPT) was introduced to provide extra funding to meet some of these quality standards for the care of hip fracture patients. The national audit of individual patients'care has reportedly improved standards, with evi- dence of better clinical outcomes. Even within 4 years (2007-

11), as the number of participating hospitals increased from

11 to 175, the rate of early surgery increased from 54.5 to

71.3% and 30-day mortality fell from 10.9 to 8.5% [3].

Whether these changes in practice and outcome were a result of better definition of optimal care by the'Blue Book',the impact of the NHFD audit, the introduction of BPTor (more likely) all three cannot be discerned from the available data.

BOAST 1 and the'Blue Book'highlight a number of

factors defining exemplary care and the common sense of prompt admission to an orthopaedic bed, rapid MDT assess- ment and minimal delay to surgery are standards worth moni- toring to reflect improved care likely to result in better outcomes. It is less straightforward to evaluate the accuracy and quality of surgery using simple audit tools, although NICE have cited data from the most recent NHFD report [4], to highlight poor compliance with its recommendations on the indications for total hip replacement in hip fracture [5]. The benefits of prompt mobilisation, MDT rehabilitation and early supported discharge should have contributed to the modest shortening of the average length of stay (LOS) by 0.5 days between 2013 and 2014 [4]. More worrying, perhaps, is the continued variation between hospitals and particularly between nations, as the mean LOS in England, Northern Ireland and Wales was 19.3, 22.4 and 35.2 days, respectively. Explanations for this variation may lie outside hospitals, with variable access

to intermediate care, supported hospital discharge and socialcare. Moreover, we should beware of pushing for ever shorter

LOS, as Scandinavian data suggest that early discharge (at least within the range of LOS up to 10 days) may be associated with a n in c r e a se d r is k o f e a r l y m ort a l i t y [6]. The National Osteoporosis Society, Royal College of Physicians and Royal College of Surgeons have strongly advocated the development of orthogeriatric and fracture liaison services. While previous studies have shown that both orthogeriatric [7] and multidisciplinary [8] models of care appear to be cost-effective, Dr Hawleyet al.[9] present data in this edition ofAge and Ageinglooking at the effects of introducing these models of care in a real world setting, using routine Hospital Episode Statistics (HES) data. The

authors assessed the impact of the introduction or expansionof orthogeriatric and nurse-led fracture liaison service

models on post hip fracture mortality and second hip frac- ture in 33,152 hip fracture patients from 11 acute hospitals. Orthogeriatric and nurse-led FLS were associated with improved 30-day and 1-year mortality of around 15-30%, al- though there was no significant impact on time to second hip fracture (after 2 years of monitoring). These results give no clear evidence on the best model of care and it is little disap- pointing that they do not present data on LOS, as a decrease would add to a health economic argument for these services. While it is important to target the health cost of acute management and rehabilitation, secondary prevention, in- cluding falls assessment, and the prescribing of drugs to treat osteoporosis are important components of any package of care. With previous studies seeing second hip fractures in 2-

3% patients per annum and 10% of patients overall [10-12],

follow-up for just 2 years was unlikely to show any effect of pharmacological intervention, although more immediate effects of fall and fracture prevention might have been antici- pated. Nationally, the most recent NHFD data show rates of osteoporosis assessment and bone protection prescription of

80.1% and falls assessments performed in 96.1% of patients.

Evidence that this results in a decrease in second hip frac- tures would have also been welcome. However, gathering evidence on such a complex intervention was a difficult chal- lenge, potentially compounded (and confounded) by back- ground noise from the NHFD and BPT, for which there is growing national evidence of some benefit. It is reassuring to see the study results map to the national picture provided by

data from the NHFD and, as arguments for cuts to health180Downloaded from https://academic.oup.com/ageing/article/45/2/180/2195376 by guest on 15 August 2023

budgets may be anticipated in the NHS over the next few years, evidence that mortality is so significantly decreased by simple service developments will be crucial in protecting them in the future!

Key points

The introduction of Orthogeriatric care and Fracture Liaison Services (FLS) has been associated with decreased mortality 1 month and 1 year after hip fracture. Unfortunately, we have no clear evidence for the best model of care (orthogeriatric or FLS). The introduction of the National Hip Fracture Database, BPTand the BGS/BOA'Blue Book'has probably contrib- uted to an improvement in outcome. Early placement on a surgical ward with prompt MDT assessment and timely surgery results in better outcomes. Evidence for medical intervention to reduce risk in second hip fractures up to 2 years is disappointing.

Conflicts of interest

None declared.

BELGINOZALP

1 ,TERRYJ. ASPRAY 1,2, 1 Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne, UK 2 Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK Address correspondence to: T. J. Aspray. Tel: (+44) 191 213 7975; Fax: (+44) 191 223 1291. Email:T.J.Aspray@newcastle.ac.uk

References

1.British Orthopaedic Association. BOAST 1 Version 2 -

Patients Sustaining a Fragility Hip Fracture. London: British Orthopaedic Association, 2012.2.British Orthopaedic Association and British Geriatrics Society. The Care of Patients With Fragility Fracture. London: British

Orthopaedic Association, 2007.

3.Neuburger J, Currie C, Wakeman Ret al. The impact of a na-

tional clinician-led audit initiative on care and mortality after hip fracture in England: an external evaluation using time trends in non-audit data. Med Care 2015; 53: 686-91.

4.Royal College of Physicians. National Hip Fracture Database

annual report 2015. London: RCP, 2015.

5.National Institute for Health and Care Excellence (NICE).

Hip Fracture: Management (Review Decision). London: National Institute for Health and Care Excellence, 2015.

6.Nordstrom P, Gustafson Y, Michaelsson K, Nordstrom A.

Length of hospital stay after hip fracture and short term risk of death after discharge: a total cohort study in Sweden. BMJ

2015; 350: h696.

7.Prestmo A, Hagen G, Sletvold Oet al. Comprehensive geriatric

care for patients with hip fractures: a prospective, randomised, controlled trial. Lancet 2015; 385: 1623-33.

8.McLellan AR, Wolowacz SE, Zimovetz EAet al. Fracture

liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision.

Osteoporos Int 2011; 22: 2083-98.

9.Hawley S, Javaid KM, Prieto-Alhambra Det al. Clinical effect-

iveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study. Age Ageing 2016; 45: 236-42.

10.Chapurlat RD, Bauer DC, Nevitt M, Stone K, Cummings SR.

Incidence and risk factors for a second hip fracture in elderly women. The Study of Osteoporotic Fractures. Osteoporos Int

2003; 14: 130-6.

11.Lawrence TM, Wenn R, Boulton CT, Moran CG. Age-specific

incidence offirst and second fractures of the hip. J Bone Joint

Surg Br Vol 2010; 92: 258-61.

12.Omsland TK, Holvik K, Meyer HEet al. Hip fractures in

Norway 1999-2008: time trends in total incidence and second hip fracture rates: a NOREPOS study. Eur J Epidemiol 2012;

27: 807-14.

Age and Ageing2016;45:181-183

doi: 10.1093/ageing/afw006© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.

Pharmacists and prevention of inappropriate

prescribing in hospital The art of prescribing for older people depends not so much on merely knowing when drugs are indicated for certain conditions, as knowing when they areappropriate, particularly in the context of multi-morbidity. The presence of potentially

inappropriate medications (PIMs) is a highly prevalent problemamong older people in hospital [1]. Equally common are

potential prescribing omissions (PPOs), that is, instances of po- tentially inappropriate omission of potentially beneficial medi- cations that are indicated but omitted for irrational or ageist reasons [2]. Data from hospitalised older people indicate that