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Hip fracture outcomes best if guidelines followed: Study

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Quality hip fracture care and adhering to related care standards is linked with improved survival for patients, according to fresh research published in the MJA.
 
But there is still room for improvement for delivery of this care and follow up with osteoporosis assessment.
 
Based on an analysis of data linked with the Australian and New Zealand Hip Fracture Registry (ANZHFR), the study uses the Australian Commission on Safety and Quality in Health Care’s Hip Fracture Clinical Care Standard as the baseline measure to determine its impact in improving patient outcomes.
 
For the study, the outcomes of participating patients aged 50 years or older – with a mean age of 83 years – with hip fractures who underwent surgery across 21 New South Wales hospitals were tracked over a four-year period.
 
Data relating to adherence to clinical care indicators were available for 7951 fractures, and adherence to these indicators was high for 5135 (64.6%), moderate for 2249 (28.3%), and low for 567 fractures (7.1%).
 
Short- and long-term mortality was lower among people who received a high level of adherence to clinical care than for those who received low-adherence care. However, secondary fracture prevention was the most poorly achieved quality indicator at less than 20%.
 
Key quality indicators from the ANZHFR were used in the study:

• Orthogeriatric model of care – 92.8% met
• Timing of surgery – 75.9% met
• Mobilisation and weight bearing – 88.5% met
• Unrestricted weight‐bearing status immediately after hip fracture surgery – 95.8% met
• Minimising risk of another fracture – 18.6% met

Patients who received hip fracture care that met all of the quality indicators had a 60% lower short-term mortality risk, while those meeting four indicators saw a 40% reduction.
 
But a third of hip fracture patients are still not receiving care with a high level of adherence to the indicators.
 
Dr Anthony Marinucci is Chair of RACGP Specific Interests Aged Care. He told newsGP while the study illustrates the benefits of quality indicators, many of which are ‘dependent on and delivered in the tertiary setting’, there is a need for improvement, particularly in the primary care setting.
 
‘Adherence to certain clinical quality indicators has a significant survival benefit for people aged 50 years or older who undergo surgery after a hip fracture,’ he said.
 
‘But importantly from a primary care perspective, secondary fracture prevention was the most poorly achieved quality indicator.
 
‘Only around 20% of all fractures are followed up with treatment for osteoporosis post-discharge, despite strong evidence for the value of treating.’
 
The quality indicator of minimising risk of another fracture includes the patient receiving bone protection medication prior to discharge from hospital at which they underwent surgery.
 
Providing patients with treatment for osteoporosis on discharge from acute care was recorded for only 29% of high indicator adherence fractures.
 
Patient‐related factors, such as low vitamin D levels, and the reluctance of hospitals to fund treatments are identified by the ANZHFR as some reasons behind a lack of secondary fracture prevention, the authors note, indicating the ‘need for greater awareness of the survival benefits and importance of initiating timely treatment’.
 
Dr Marinucci said this is the predominant message for GPs, and points to the RACGP’s Red Book and Silver Book as important resources.
 
‘[GPs can] ensure primary prevention with falls and fracture risk screening and furthermore, if required, ensuring secondary fracture prevention with appropriate management of osteoporosis is in place.’
 
The RACGP has also recently updated its guidelines for osteoporosis management and fracture prevention. 
 
In Australia, hip fracture rates are rising closer to 20,000 each year, and 3% of first hip fracture patients have a second within one year.
 
Usually occurring after a fall, hip fractures are associated with substantial morbidity and mortality, reduced quality of life, and loss of independence.
 
The ANZHFR reports around 25% of people die within twelve months, 50% do not regain their previous level of function, and 11% are admitted to residential care.
 
And while survival after hip fracture has improved in Australia in recent years, the study authors say, it is unknown whether the national Hip Fracture Clinical Care Standard has contributed to this improvement.
 
‘The findings emphasise the significant cumulative impact of adhering to multiple care processes and underscore the importance of a multidisciplinary approach to delivering high-quality hip fracture care,’ lead study author Dr Lara Harvey said.
 
‘[But] we would like to see more patients continue to receive this high level of care in line with the Clinical Care Standard, which was updated last year.’
 
Meanwhile, co-author and ANZHFR co-Chair Professor Jacqueline Close echoes Dr Marinucci’s calls that follow-up care for osteoporosis prevention needs to be on healthcare providers’ radar.
 
‘Whilst initiation of treatment for osteoporosis has improved this year, the rate remains poor and many people leave hospital without treatment that we know can reduce the risk of future fractures,’ she said.
 
‘We still face challenges in ensuring people get timely access to surgery and more work needs to be done in getting people out of bed and up on their feet the day after surgery – both of these indicators are strongly linked to better outcomes for patients.’
 
The Hip Fracture Care Clinical Care Standard was revised in late 2023, and reporting of new indicators in the ANZHFR Annual Report will begin from next year.
 
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aged care bone health clinical care standards fracture risk hip fracture osteoporosis preventive health

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