Volume 170 Issue 10

Research Health burden of hip and other fractures in Australia beyond 2000 Projections based on the Geelong Osteoporosis Study Kerrie M Sanders, Geoffrey C Nicholson, Antony M Ugoni, Julie A Pasco, Ego Seeman, and Mark A Kotowicz MJA 1999; 170: 467-470 For editorial comment, see Morris et al; see also Pocock et al. Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Author's Detials - - More articles on Public and environmental health Abstract Objective: To calculate the expected increase in the number of fractures in adults attributable to the predicted increase in the number of elderly Australians. Data sources: All fractures in adult residents (> 35 years) of the Barwon Statistical Division (total population, 218 000) were identified from radiological reports from February 1994 to February 1996. The Australian Bureau of Statistics supplied predictions of Australia's population (1996 to 2051). Main outcome measure: The projected annual number of fractures in Australian adults up to 2051 (based on stable rates of fracture in each age group). Results: The number of fractures per year is projected to increase 25% from 1996 to 2006 (from 83 000 fractures to 104 000). Hip fractures are projected to increase 36% (from 15 000 to 21 000) because of a substantial rise in the number of elderly aged 85 years and over. Hip fractures are expected to double by 2026 and increase fourfold by 2051. Conclusions: In contrast to Europe and North America, where numbers of hip fractures are expected to double by 2026 and then stabilise, in Australia hip fractures will continue to place a growing demand on healthcare resources for many decades. These projections can be used for setting goals and evaluating the costs and benefits of interventions in Australia. Introduction Australia's population is ageing. Thus, diseases such as osteoporosis are affecting a greater proportion of the population. Cost-effective prevention and treatment of fractures will become increasingly important, as the proportion of the "prime working" population (aged 15 to 64 years) is expected to decrease by 7% between 1996 and 2051.1 Estimations of the annual number of fractures will facilitate effective allocation of limited healthcare resources. Previously, fracture rates in Australia have been extrapolated from rates in Dubbo and Busselton,2,3 populations that may not be representative of the national population as they are both fairly isolated towns with small numbers of men and women in the oldest age groups. Lord et al investigated changes in hip fracture admissions in New South Wales between 1979 and 1990 using International Classification of Diseases hospital discharge codes.4 Although frequently used for ascertaining hip fractures, the limitations of this method are well documented.5,6 The Geelong Osteoporosis Study is a population-based study of age-, sex- and site-specific fracture rate(s) within a well-defined geographic region sufficiently large to establish reliable rates of fracture. It is the largest Australian epidemiological study of adult fractures, identifying 2184 fractures over two years in people aged 35 years and over. Data from the 1996 national census confirm the findings of an earlier study7 that the regional population is typical of the nation in age distribution and socioeconomic range. The Australian Bureau of Statistics publishes projections of the size, structure and distribution of Australia's population into the next century.1 Assuming stable age- and sex-specific rates of fracture, we have projected annual numbers of fractures by anatomical site in adults over the next 50 years. Methods Population The Barwon Statistical Division is a region of southern Victoria7 defined by the Australian Bureau of Statistics which includes urban, semi-urban and rural residents and has a population of 218 000 (109 923 aged 35 years and over). Fracture ascertainment Using radiological reports from the two medical imaging practices in the region, we identified all fractures in adults (aged 35 years and over) residing within the Barwon Statistical Division over the two-year ascertainment period (17 February 1994 to 16 February 1996). Fractures were identified by a weekly computerised keyword search of all radiological reports. Although radiological services are available at several sites throughout the region, these sites are under the auspices of two medical imaging practices. Only reports of definite fractures were included as "cases". Reports referring to "likely" or "possible" fracture were not included unless radiologically confirmed at a later date. Vertebral fractures were included in the study on the basis of the radiological report, provided there was no previous record of a fracture at that level. The initial x-ray demonstrating each fracture was sought and the date of fracture was the date of the radiological diagnosis. As the region is well provided with medical facilities, few fractures would not have been assessed or followed up by services within the region. The standing orders for the ambulance service are to transport patients from residences within the study region to The Geelong Hospital. The study was well advertised and adults who may have sustained fracture(s) while outside the region were asked to contact study coordinators. Non-residents and patients with pathological fractures (metastatic cancer, Paget's disease and multiple myeloma) were excluded. We have previously reported that the exclusion of high trauma fractures may underestimate the prevalence of bone-fragility fractures in the community,8 so we did not exclude fractures on the basis of trauma classification. The method of fracture ascertainment has been previously described9 and validated, using hip fracture as a model.10 The study was approved by The Geelong Hospital Human Research and Ethics Advisory Committee. Projections We calculated the predicted number of fractures in each five-year age group for men and women as: Predicted number of fractures = Number of fractures in the study region Study region population X Projected Australian population X 0.5 (2 year ascertainment) The study region population was determined from the 1996 Australian Bureau of Statistics census. Annual population projections were also provided by the Australian Bureau of Statistics.1 This method of projection assumes that the fracture rate in each age group will remain unchanged over time. Confidence intervals around the projections were calculated by the bootstrap method.11 Results The number of fractures identified in the study population is shown in Table 1. Projections for all fractures During the ascertainment period, 2184 adults sustained fractures, producing an age- and sex-adjusted incidence of 102 per 10 000 person-years. In 1996, we estimate that about 83 000 Australians aged 35 years and over sustained fractures. We predict that by 2006 the total number of fractures per year will increase by 25%, to 104 000 (Figure 1). Projections for hip fractures Over the two-year ascertainment period, 428 people sustained hip fractures, producing an age- and sex-adjusted incidence in people aged 35 years and over of 17.2. The number of hip fractures in Australian women is projected to increase from 11 300 per year in 1996 to 44 700 in 2051. In men, the number is projected to rise from 4 000 to 15 300. Figure 2 shows the projection for all people aged 35 years or over. The number of Australians sustaining hip fractures each year is projected to increase by 15% every five years until 2036, then by about 10% every five years until 2051. A fourfold increase in hip fractures is expected by 2051, when about 23% of Australia's projected population will be aged 65 years and over (compared with 12% in 1996) and over 8% of the population will be aged 85 years and over (compared with 2% in 1996). Hip fractures are likely to increase more than fractures at other sites because the greatest population growth is expected in the oldest age groups, where the hip is the most common site of fracture.9 Projections for fractures at sites other than the hip During the ascertainment period, 1756 adults aged 35 years and over sustained fractures at sites other than the hip, producing an age- and sex-adjusted incidence of 77 per 10 000 person-years. We estimate that in 1996 about 68 000 Australians aged 35 years and over sustained fractures at sites other than the hip, and that the number of non-hip fractures is likely to increase by 9% every five years until 2036, and then by 4% every five years until 2051 (to 147 645 non-hip fractures per year). Projections for vertebral, Colles, humeral and pelvic fractures (the most common sites of fracture after the hip) are shown in Figure 3. Fractures at these sites are likely to increase more than fractures at other sites where fracture rates do not increase substantially with age.9 Population projections suggest that vertebral, humeral and pelvic fractures will increase by 12% every five years to 2036, then by 6% every five years to 2051. Colles fracture rates increase with age in women, but not in men,8 and the overall number of adults sustaining a Colles fracture will increase by 10% every five years until 2036, then by 5% every five years until 2051. Fractures other than hip, vertebral, Colles, humeral and pelvic fractures are predicted to increase at about half the rate predicted for these sites (6% every five years until 2036, then 3% every five years until 2051). Projection of fracture numbers by age group The number of fractures in adults aged 35 to 59 years is not predicted to change substantially over the projection period, as only a small population increase in this age group is anticipated. By contrast, among those aged 60 years and over, the number of fractures is predicted to increase by at least 10% every five years, and by almost 20% every five years among those aged 85 years and over (Table 2). Figure 4 shows the projected distribution of hip fractures across age groups for selected years from 1996 to 2051. Discussion The ageing of the Australian population is increasing the demand for health resources. Health expenditure per person aged 65 years and over is nearly four times higher than for younger individuals ($4900 v $1300).12It is likely that hip fracture, which becomes increasingly common with advancing age, contributes significantly to this higher expenditure. Almost all people with a fractured hip are hospitalised, with an average length of stay of 13 days.13 Studies in other white populations suggest that 50% of patients who survive hip fracture are discharged to nursing homes, and 25% remain institutionalised one year later.14,15 Comparable Australian data are not available, although the increased mortality after hip fracture has been confirmed.16 We estimate that hip fractures accounted for 0.9% of total government health services expenditure for 1995/96.12 Based on the number of Australian salary earners in 1998 (Australian Bureau of Statistics) and an average cost of $16 000 per hip fracture,17 treatment alone costs salary earners an average of $28 per year. In current dollar terms, this may escalate to $120 per salary earner per year by 2051 if the projected increase is realised. The number of adults sustaining a hip fracture is likely to more than double from 15 000 in 1996 to 34 000 in 2026, then almost double again by 2051. Fractures at other sites are expected to increase by 70% from 1996 to 2026, then by a further 26% to 2051. These rates of increase are far above the expected growth in total healthcare costs due to the ageing of the Australian population, which is estimated to be 4% every five years for the next 30 to 40 years.18 For the number of hip fractures to remain stable, their incidence (per 10 000 population per year) would need to decline from 17.2 in 19969 to 15.6 in 2001, 14.3 in 2006 and 11.3 in 2026. In the United States, an 18% reduction in hip fracture rates between 1988 to 2000 has been targeted by public health strategists.19 Current therapies (such as hormone replacement therapy and bisphosphonates) may reduce fracture rates by 50%, but their cost-effectiveness remains controversial.20,21 In most white populations the number of hip fractures is predicted to double between 1990 and 2025, and then plateau as the growth in the aged population ceases.22 However, in contrast with Europe and North America, the aged population and the number of hip fractures in Australia and New Zealand are likely to continue to increase from 2025 to 2050.22 Current trends suggest that almost three times as many women as men will sustain a hip fracture (Table 1). Largely for this reason, efforts to prevent hip fracture have focused on osteoporosis in women. However, mortality and rate of institutionalisation after hip fracture is higher in men,23 and increasing hip fracture rates among men, but not women, have been reported.24,25 The projected increased longevity in men suggests that osteoporosis will affect a growing number of Australian men, yet there are no data concerning efficacy of any drug treatment to prevent hip or vertebral fractures in men.26 Our projected number of vertebral fractures is likely to be an underestimate because our ascertainment relied on clinical indications for medical imaging. Between 50% and 75% of vertebral fractures do not come to medical attention.27,28 However, our data are likely to include some previously undiagnosed vertebral fractures that occurred before the ascertainment period. Nevertheless, the predicted number of vertebral fractures represents the number likely to come to medical attention each year. Excluding vertebral fractures does not alter the projected rate increase of all fractures. The validity of these projections is dependent upon reliable and stable incidence rates and accurate population projections. The major strength of our study was the comprehensive ascertainment of all fractures among adult residents of a defined region representative of Australia.9 A decline in hip fracture rates has recently been reported,19 but other studies have pointed to stable age-specific rates in women and younger men and increasing rates in older men.24,25,29,30 These projections highlight the need to decrease fracture rates among the elderly and can be used for setting goals and evaluating the costs and benefits of interventions in Australia. Acknowledgements This study was supported by the Victorian Health Promotion Foundation. We acknowledge the invaluable contributions of the radiologists (D Barry, JM Cameron, PJ Carman, WP Holloway, V Mercuri, PM Motterdam and DB Robertson) and staff at the Geelong Radiological Clinic, as well as the radiologists (NJ Ferris, DO Lun, CB Styles) and staff of the Medical Imaging Department at the Geelong and Colac hospitals. We also wish to thank Biljana Skoric and Soheila Panahi. References McLennan W. Projections of the populations of Australia, States and Territories, 1995-2051. Canberra: Australian Bureau of Statistics, 1996: 128. (Catalogue no. 3222.0.) Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA. Symptomatic fracture incidence in elderly men and women: The Dubbo osteoporosis study (DOES). Osteoporos Int 1994; 4: 277-282. Prince RL, Knuiman MW, Gulland L. Fracture prevalence in an Australian population. Aust J Public Health 1993; 17: 124-128. Lord SR. Hip fractures: changing patterns in hospital bed use in NSW between 1979 and 1990. Aust N Z Surg 1993; 63: 352-355. Bacon W, Maggi S, Looker A, et al. International comparison of hip fracture rates in 1988-89. Osteoporos Int 1996; 6: 69-75. Maggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in the elderly: a cross national analysis. Osteoporos Int 1991; 1: 232-241. Ross KN. The development of the 1984 "Indicator of Disadvantage" and its application to resource allocation decisions for the "Disadvantaged Schools Program" in Australia. Geelong: School of Education, Deakin University, 1984. Sanders K, Pasco J, Ugoni A, et al. The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: The Geelong Osteoporosis Study. J Bone Mineral Res 1998; 13: 1337-1342. Sanders K, Seeman E, Ugoni A, et al. The age- and gender-specific rate of fractures in Australia: a population based study. Osteoporos Int 1999. In press. Pasco JA, Henry MJ, Gaudry TM, et al. Identification of incident fractures: Geelong Osteoporosis Study. Aust N Z J Med 1999; 29: 203-206. Efron B, Tibshirani R. The introduction to the bootstrap. New York: Chapman & Hall, 1993. Australia's health 1998: the sixth biennial health report of the Australian Institute of Health and Welfare. Canberra: AGPS, 1998. Abraham B, d'Espaignet E, Stevenson C. Australian health trends 1995. Canberra: Australian Institute of Health and Welfare, 1995. Orwoll ES. The special problem of hip fracture. In: Favus MJ, editor. Primer on the metabolic bone diseases and disorders of mineral metabolism. 3rd ed. Philadelphia: Lippincott-Raven, 1996: 272-282. Keene G, Parker M, Pryor G. Mortality and morbidity after hip fractures. BMJ 1993; 307: 1248-1250. Center J, Nguyen TV, Schneider D, et al. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 1999; 353: 878-882. Randell A, Sambrook P, Nguyen T, et al. Direct clinical and welfare costs of osteoporotic fractures in elderly men and women. Osteoporos Int 1995; 5: 427-432. Gray R. Insurance: the long term funding of aged care. National Healthcare 1998; 8(4): 32-33. Melton L, Atkinson EJ, Madhok R. Downturn in hip fracture incidence. Public Health Rep 1996; 111 (March/April): 146-150. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 1996; 348: 1535-1541. Jonsson B, Christiansen C, Johnell O, Hedbrandt J. Cost-effectiveness of fracture prevention in established osteoporosis. Osteoporos Int 1995; 5: 136-142. Cooper C, Campion G, Melton LJ III. Hip fractures in the elderly: A world-wide projection. Osteoporos Int 1992; 2: 285-289. Sernbo I, Johnell O. Consequences of a hip fracture: A prospective study over 1 year. Osteoporos Int 1993; 3: 148-153. Melton LJI, O'Fallon WM, Riggs BL. Secular trends in the incidence of hip fractures. Calcif Tissue Int 1987; 41: 57-64. Bacon W. Secular trends in hip fracture occurrence and survival: Age and sex differences. J Aging Health 1996; 8: 538-553. Seeman E. Osteoporosis: trials and tribulations. Am J Med 1997; 103 (2A): 74S-87S. Kanis JA, McCloskey EV. Epidemiology of vertebral osteoporosis. Bone 1992; 13 Suppl 2: S1-S10. Cooper C, Atkinson EJ, O'Fallon M, Melton L. Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989. J Bone Min Res 1992; 7: 221-227. Falch JA, Kaastad TS, Bohler G, et al. Secular increase and geograpical differences in hip fracture incidence in Norway. Bone 1993; 14: 643-645. Agnusdei D, Camporeale A, Gerardi D, et al. Trends in the incidence of hip fracture in Siena, Italy, from 1980 to 1991. Bone 1993; 14: S31-S34. (Received 13 Nov 1998, accepted 13 Apr 1999) Author's Detials University of Melbourne Department of Medicine, Barwon Health-The Geelong Hospital, Geelong, VIC Kerrie M Sanders, MNutrition, PhD, Research Fellow; Geoffrey C Nicholson, PhD, FRACP, Professor of Medicine; Julie A Pasco, PhD, Study Coordinator; Mark A Kotowicz, FRACP, Senior Lecturer in Medicine. Department of General Practice and Public Health, The University of Melbourne, Melbourne, VIC. Antony M Ugoni, BSc(Hons), Lecturer in Biostatistics. Austin and Repatriation Medical Centre, Melbourne, VIC. Ego Seeman, MD, FRACP, Associate Professor of Medicine, The University of Melbourne. Reprints will not be available from the authors. Correspondence: Dr M A Kotowicz, University Department of Medicine, Barwon Health-Geelong Hospital, PO Box 281, Geelong, VIC 3220. Email: m.kotowiczATmedicine.unimelb.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Back to textBack to textBack to textBack to textBack to textBack to text

Kerrie M Sanders · Geoffrey C Nicholson · Antony M Ugoni · Julie A Pasco · Ego Seeman · Mark A Kotowicz

For Debate The potential effect on hip fracture incidence of mass screening for osteoporosis Nicholas A Pocock, Nicole L Culton and Neil D Harris MJA 1999; 170: 486-488 For editorial comment, see Morris et al; see also Sanders et al. With ageing of the Australian population, treatment of osteoporosis-related hip fractures will impose an increasing burden on the healthcare system. Based on current age-adjusted hip fracture incidence and population projections for New South Wales, we estimated a 90% increase in hip fractures by the year 2021. Contributing significantly to this increase will be the number of men reaching the high risk age group for osteoporotic hip fractures. A suggested solution -- screening and appropriate therapy for individuals at high risk of osteoporosis -- may have only a modest impact. Our calculations show that, even with optimistic screening and therapy compliance rates, hip fractures could still increase by over 50%. Other approaches need to be further explored. Introduction - Discussion - References - Authors' details - - More articles on Public and environmental health Introduction Osteoporosis-related hip fractures are a high-cost item in the Australian healthcare budget, and place considerable demands upon the limited resources of the public health system. This burden will increase in the first quarter of the next century as the projected Australian population over 65 years of age increases from the current level of 2.25 million to between 4.02 and 4.05 million by 2021.1 To avoid this impending healthcare crisis, several reports have suggested a screening program to identify individuals at high risk of osteoporosis, followed by appropriate intervention to reduce the number of hip fractures.2-6The possible introduction of a mass-screening program for osteoporosis raises a number of issues. Cost effectiveness is of major importance, and there are reports to indicate that screening for osteoporosis may well be cost effective.3,5,6 However, few data exist on the impact of a screening program on the healthcare system, and, in particular, on the demand for acute-care hospital beds, which has important implications for healthcare planning. To assess the impact of screening on the demand for hospital beds for hip fracture treatment, we have used available population projections for New South Wales (NSW) to calculate the likely number of hip fractures in people aged 65 years or older by the year 2021. We then assessed the potential of a screening program, coupled with effective therapy, to reduce hip fracture incidence using available data on population capture rates of current large screening programs, and data on therapy compliance and drug-efficacy rates. Our methods and the results we obtained are shown in the Box. Discussion Current costs of osteoporotic hip fractures in Australia exceed $400 million annually,15 and hip fracture treatment is making great demands on an already overstretched hospital infrastructure.2,7,16,17In 1994-95, there were 52017 admissions to NSW hospitals of patients over 65 years of age with major hip fractures. Without further intervention, our calculations show that, even with a low population growth model, this figure may rise by the year 2021 to 9800 hip fracture admissions annually in this age group, an increase of about 89%. A major cause will be the increase in the number of men reaching the high risk age group for osteoporotic hip fractures. In 1997, the population of men in NSW over 80 years of age numbered about 60 300.1 This is projected to increase to about 123 900 by 2021,1 an increase of 106%. A 65% increase in the number of women over 80 years of age is expected in the same interval. Our calculations show the limited preventive effect on increasing hip fracture incidence of an active interventional screening and therapy program for osteoporosis. Even with a relatively optimistic 60% screening and therapy compliance rate, hip fractures may still increase by about 55% compared with 1994-95. In view of the age of the target population (the average age of hip fracture patients in NSW is 82 years7), 40% capture and therapy compliance rates may be more realistic, suggesting that hip fractures may increase by 74% compared with 1994-95. It is also possible that capture and therapy compliance rates in the target population might not even achieve these levels. We also used the lowest of a number of population growth models.1 If faster population growth occurs, the increase in hip fractures will exceed our predictions, with correspondingly more serious implications for the healthcare system. We assumed the screening technique would identify all patients at increased risk of hip fracture and all would be offered therapy. This optimistic assumption is almost certainly incorrect and thus our calculations overestimate the benefits of a screening program. On the other hand, compared with current drug regimens, advances in therapy may decrease fracture risk. Moreover, therapies with minimal toxicity and which have demonstrated benefit, such as vitamin D and calcium, could be applied widely to high risk patients in nursing homes and other institutions.2,13 However, the potential benefit of such an approach is limited, as, at present, only 29% of hip fracture patients are admitted from nursing homes and an additional 9% from hostels.7 Our analysis does not address the cost efficacy of a screening program for osteoporosis. Nor does it address the possible role of population education in preventing osteoporosis. Recent raised community awareness of osteoporosis may translate in the future into consumer-driven demand for preventive action from healthcare providers and more self- initiated prevention. The recent increased demand for acute-care hospital beds in NSW has been partly met by reducing the average length of stay in hospital and increasing the number of day-only procedures. However, there is a limit to how much of the demand for hospital services can be met by these means. The average length of stay for hip fracture treatment in NSW has already been reduced from 31.5 days in 198018 to 11 days in 1995,7 and there is likely to be only limited additional gain from future efforts to reduce hospital stay for these patients.7 The increased number of hip fractures by 2021 will require considerable additional hospital resources, and, in view of the seasonal variation in hip fracture incidence,18 may impose an extreme burden on hospital services at certain times of the year. To cope with this, health service providers need to address the issue of future hospital bed availability for hip fractures. Failure to plan adequately may result in delay in treating other, less urgent, patients. In conclusion, Australia, like other Western countries, must cope with the health problems of an ageing population in the early part of the next century, with osteoporotic hip fractures likely to be a major component of the expected increased demand for acute-care hospital services. A preventive program based on mass screening for osteoporosis and treatment of high risk individuals may have only a limited impact. While potentially of benefit, this approach would be insufficient by itself, and additional or alternative approaches to this problem, such as education of the community, need to be further explored. References Australian Bureau of Statistics. Population projections for New South Wales 1997 to 2051. Canberra: ABS, 1998. (Catalogue No. 3222.0.) Wark JD. Osteoporosis: the emerging epidemic. Med J Aust 1996; 164: 327-328. Garton MJ, Cooper C, Reid D. Perimenopausal bone density screening -- will it help prevent osteoporosis? Maturitas 1997; 26: 35-43. Kanis JA. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int 1994; 4: 368-381. Tosteson AN, Rosenthal DI, Melton LJ, Weinstein MC. Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy. Ann Intern Med 1990; 113: 594-603. Black DM. Why elderly women should be screened and treated to prevent osteoporosis [review]. Am J Med 1995; 98 Suppl 2A: 67S-75S. March L, Chamberlain A, Cameron I, et al. Prevention, treatment and rehabilitation of fractured neck of femur. Health Outcomes Project 1996. Sydney: Public Health Unit, Northern Sydney Area Health Service, 1996 (ISBN 07310 9633 9). Updated information provided by personal communication. Also on the internet <http://www.mja.com.au/public/issues/iprs2/march/fnof.pdf> Barratt AL, Cockburn J, Redman S, et al. Mammographic screening: results from the 1996 National Breast Health Survey. Med J Aust 1997; 167: 521-524. Salzman C. Medication compliance in the elderly. J Clin Psychol 1995; 56 Suppl 1: 18-22. McElnay JC, McCallion CR, al-Deagi F, Scott M. Self-reported medication non-compliance in the elderly. Eur J Clin Pharmacol 1997; 53: 171-178. Wren BG, Brown L. Compliance with hormonal replacement therapy. Maturitas 1991; 13: 17-21. Rozenberg S, Vandromme J, Kroll M, et al. Compliance to hormone replacement therapy [review]. Int J Fertil Menopausal Stud 1995; 40 Suppl 1: 23-32. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 1996; 348: 1535-1541. Seeman E. Osteoporosis: trials and tribulations [review]. Am J Med 1997; 103 Suppl 2A: 74S-87S. Randell A, Sambrook PN, Nguyen TV, et al. Direct clinical and welfare costs of osteoporotic fractures in elderly men and women. Osteoporos Int 1995; 5: 427-432. Lord SR. Femoral neck fractures: admissions, bed use, outcomes and projections. Med J Aust 1996; 145: 493-496. Lord SR. Hip fractures: changing patterns in hospital bed use in NSW between 1979 and 1990. Aust N Z J Surg 1993; 63: 352-355. Lau EM, Gillespie BG, Valenti L, O'Connell D. The seasonality of hip fracture and its relationship with weather conditions in New South Wales. Aust J Public Health 1995; 19: 76-80. (Received 13 Nov 1998, accepted 13 Mar 1999) Authors' details Department of Nuclear Medicine and Bone Densitometry, St Vincent's Hospital, Sydney, NSW. Nicholas A Pocock, MD, FRACP, Senior Staff Specialist. Nicole L Culton, BAppSc, Research Officer. Neil D Harris, BA(Comm), RN, Research Officer. Reprints will not be available from the authors. Correspondence: Associate Professor N A Pocock, Department of Nuclear Medicine and Bone Densitometry, St Vincent's Hospital, Sydney, NSW 2010. Email: n.pocockATunsw.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> How many hip fractures can we prevent in New South Wales Methods To determine the predicted NSW population of those aged 65 years and over in 2021, we used the most recent Australian Bureau of Statistics population projections (low population growth model).1 To calculate the likely absolute numbers of hip fractures in 2021, we assumed similar age-adjusted hip fracture rates to those currently found in NSW.7 In women, the annual incidence of hip fractures in NSW (based on figures for 1995-96) ranges from 1.77/1000 in the 65 to 69 years age group, to 33.21/1000 in the over-85 group.7 In men, the respective rates are 1.01/1000 and 18.45/1000.7 These hip fracture incidences were applied to the NSW population predictions to derive the expected number of hip fractures in 2021 for the low population growth model. It is difficult to estimate the likely capture rate of an osteoporosis screening program (ie, the proportion of the target population using the service), as the population at risk of osteoporotic fractures is generally older than those targeted by current screening programs (eg, mammographic screening for breast cancer). In addition, an osteoporosis screening program would need to include men, and no comparable screening programs for men currently exist in Australia. In the absence of a more suitable model, a recent study of the data from the 1996 National Breast Health Survey reported that about 50% of the target population have participated in the Program within the past two years.8 For our analysis we have made projections using 10%, 20%, 40%, 60% and 80% population capture rates. There is no current consensus on the best osteoporosis screening program. For our study, however, we assumed a hypothetical best-case scenario in which the screening technique would identify all patients at increased risk of fracture, and therapy would be offered to all at-risk subjects. Reported compliance rates for long term medical therapy vary widely.9 While figures of up to 80% have been reported,10 particularly with medications which have few side effects, lower compliance rates are more common for medications with adverse or unpleasant side effects (eg, hormone replacement therapy).11,12 There are few data available on long term compliance with therapy for osteoporosis, such as bisphosphonates, calcitriol or the latest generation of selective oestrogen receptor modulators. The possible efficacy of a screening and treatment program was calculated separately for compliance rates of 20%, 40%, 60% and 80%. The efficacy of a treatment program targeted at high risk individuals depends not only on compliance with therapy, but also on drug efficacy. Available data suggest that current therapies for osteoporosis may have about 50% efficacy in reducing fractures.13,14 While it is possible that more effective therapeutic regimens will become available in the future, we used a value of 50% drug efficacy. Results In 2021, the projected age-specific NSW population for men and women over the age of 65 years (low population growth model) is shown in Table 1.1 Based on these population figures, and on recent data on age-specific admission rates for hip fractures,7 by 2021 we predict there will be about 9800 hip fracture admissions annually in NSW in subjects aged 65 years and older (Table 2). This is an increase of about 89% above current levels and compares with an expected 14% to 22% increase in the entire NSW population during the same period.1 In Table 3 the impact of an osteoporosis screening program and effective therapy in 2021 is shown for NSW men and women over 65 years at different capture rates and therapy compliance levels. The potential efficacy of a screening program would vary widely depending on population capture rates and therapy compliance. With an optimistic 60% population capture rate and 60% long term therapy compliance, with the low population growth model, a screening program might potentially prevent 1767 admissions for hip fractures. In this situation, hip fracture admissions in NSW in 2021 would still be 55% higher than in 1994-95. Back to text

Nicholas A Pocock · Nicole L Culton · Neil D Harris

Lynette M March, Anne C Chamberlain, Ian D Cameron, Robert G Cumming, Alan J M Brnabic, Terrence P Finnegan, Susan E Kurrle, Jennifer M Schwarz, Sydney M L Nade, Tom K F Taylor, and members of the Fractured Neck of Femur Health Outcomes Project Team* MJA 1999; 170: 489-494 Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details This article was first published in an unedited form after internet peer review. Click here to read the unedited version and the transcript of the review process. - - More articles on Orthopaedic surgery Abstract Objectives: To develop evidence-based guidelines for the treatment of proximal femoral fractures to optimise functional outcome while minimising length of stay in hospital. Data sources: Systematic literature search of MEDLINE and CINAHL computer databases, bibliographies, and current contents of key journals for 1966-1995. Study selection: English-language randomised controlled trials of all aspects of acute-care hospital treatment of proximal femoral fracture among subjects aged 50 years and over with proximal femoral fractures not due to metastatic disease. Data extraction: Two independent reviewers, blinded to authors, institution and study results, followed a standard Cochrane Collaboration protocol and assessed study quality and treatment conclusions. When necessary, a third review was performed to reach consensus. Results: Of the 120 articles published between 1966 and December 1995, 97 met the inclusion criteria. Fifteen clinical interventions were reviewed. Five were supported by National Health and Medical Research Council (NHMRC) level I evidence (prophylactic anticoagulants, prophylactic antibiotics, regional anaesthesia, pressure-relieving mattresses, and internal surgical fixation), two had no supporting randomised controlled trial evidence (time to surgery, time to mobilisation after surgery) and the remainder were classified as having Level II evidence. A review of current practice (1993-94) identified wide variability in these interventions across five acute-care hospitals in the Northern Sydney Area Health Service. Conclusions: Randomised controlled trial evidence (NHMRC Levels I and II) exists for many, but not all, aspects of hip fracture treatment. There is a need for changes to be made to some aspects of practice in accordance with evidence-based guidelines. Introduction Each year, fractures of the proximal femur (hip fracture) affect 4% of women and 2% of men aged 85 years or more. In 1995, this led to about 15 000 hospital admissions across Australia. Given current age-specific hip fracture rates1 and the expected ageing of the population,2 we calculated that by the year 2021 admissions for hip fracture will more than double. Conservative estimates of the current costs of acute inpatient care for these patients are $7.8 million in the Northern Sydney Area Health Service and $46.3 million for the whole of New South Wales (NSW).1 This does not include other costs, such as rehabilitation, support services, residential care, family assistance and changes in quality of life. The death rate in the 12 months after hip fracture is about 25%, four times greater than for community-living age-matched controls.3 Most survivors do not return to their prefracture level of independence and physical abilities.4The main objective of this study was to answer two questions about treatment of proximal femoral fractures: "What is the right thing to do?" and "Are we doing the right thing?", and then to develop evidence-based clinical guidelines for hip-fracture treatment. A systematic approach was taken, with a focus on health outcomes;5 we aimed to make recommendations that would optimise functional outcome while minimising length of stay in hospital. Methods What is the right thing to do? We performed a systematic review of randomised controlled trials (RCTs) and meta-analyses that included patients over 50 years with proximal femoral fractures. In the absence of an RCT (there were none published for "time to surgery" and "time to mobilisation after surgery"), we searched for observational studies. The main literature source was English language articles identified from MEDLINE and CINAHL from 1966 to December 1995. Search words used were "hip fractures", "proximal femoral fractures", "fractured neck of femur", together with specific interventions and clinical indicators (Box 1). The searches were limited to English language, RCTs, meta-analyses, age 50 years or over, and proximal femoral fractures not due to metastatic disease. In addition, manual searches were conducted of current issues of key specialty and general journals, our personal literature, libraries, bibliographies of the published articles and personal contact with those working in areas relevant to hip fracture, including the Cochrane Collaboration Musculoskeletal Injuries Group. Articles were distributed randomly to the assessors by the use of a random numbers table. The assessors, who were all experienced in the critical appraisal of scientific literature, were blinded to the authors, institutions and journal of publication of the articles. Articles were read independently by two assessors. Disagreements were resolved by a third assessment and a consensus meeting. Results and data on study quality were recorded according to Cochrane Collaboration guidelines for the assessment of study quality.6 Guidelines for ranking the level of evidence were those devised by the National Health and Medical Research Council (NHMRC).7 Are we doing the right thing? The study population for the medical audit came from the five acute-care Northern Sydney Area Health Service public hospitals during the 1993-94 financial year. All admissions for proximal femoral fracture in the 12 months were included. Patients with multiple injuries or fractures due to metastatic cancer were excluded. Data were extracted by trained medical record reviewers. A second audit, conducted by an independent reviewer in a 10% random subsample, showed more than 90% agreement. Patients were identified by ICD-9 code 820 (fracture of neck of femur) and by the following procedural codes: 79.15 Closed reduction of fracture with internal fixation -- femur 79.35 Open reduction of fracture with internal fixation -- femur 81.51 Total hip replacement 81.52 Partial hip replacement 81.53 Revision of hip replacement Development of evidence-based guidelines The key steps in the process of care for the acute management of hip fracture were identified by discussion with clinical staff and review of medical records (Box 1) and a specific clinical question was asked for each (eg, "Do low pressure mattresses reduce the number and severity of pressure sores?"). All supporting trial evidence was summarised in table format with author, year, interventions tested, number of subjects, ranking of bias (low, moderate, high), adequate concealment of allocation to groups (yes/no), summary of results of the individual articles with odds ratios and 95% confidence limits and, where possible, a calculation of the number needed to treat.6 Data were in a suitable format for meta-analysis for "prophylactic antibiotics" and "type of anaesthesia", but summary statistics were not generated for the other treatment modalities. Full details of all articles and these summaries are available from the authors and are on the Internet.1 From these tables, a one-page summary was generated for each clinical intervention, together with recommendations for clinical practice and suggestions for future study. These were circulated among the review team and the orthopaedic clinical groups. The results of the medical literature review and medical record audit were presented to medical and nursing staff in each hospital in oral and written form. Local practice was compared with practice in the other hospitals and to evidence-based best practice. After all these steps, a single page of draft guidelines was developed with NHMRC levels of evidence listed for each clinical recommendation. These were circulated and presented for further discussion before being adopted. Results The right thing to do Of the 120 articles published between 1966 and December 1995, 97 met the inclusion criteria. Articles were excluded if they did not report randomised trials, if they had insufficient numbers of patients with hip fracture, or if they were judged to be of poor quality by two independent assessors.1 Our conclusions from the literature review addressed 15 issues, and what we found, on the basis of available evidence, is given in Box 1. Box 2 presents the evidence-based clinical guidelines and average practice (1993-94) for each of the clinical interventions (as well as for acute-care-hospital length of stay) among the five acute-care hospitals audited. Average practice is given as unweighted averages across all five hospitals of the frequency of adherence to evidence-based best practice, plus the range from lowest to highest frequency. The guidelines can be applied to most, but not all, patients who sustain a proximal femoral fracture. Individual circumstances and comorbidities will always influence decision-making. These guidelines should be updated as new evidence becomes available. What we are doing In all, 729 consecutive admissions were audited and will be the subject of a more detailed report evaluating the implementation of the guidelines. No significant variation was shown among the five acute-care hospitals with respect to the patients' age (mean, 82.4 years; 18% were 90 years or older), sex (81% female), admissions from nursing homes (28.7%) and fracture type (51% intracapsular, 43% extracapsular, 6% unknown). All patients had at least one comorbidity, 71.7% had two or more and almost a third had five or more. Mortality at 12 months was 18%1 for non-nursing-home patients and 38% for nursing-home patients. At the four-month follow-up, 16% of patients required a new nursing-home admission. There was considerable variation in the clinical interventions (Box 2), particularly evident for "time to surgery", "preoperative traction", "pressure gradient stockings", "type of anaesthesia" (spinal) and "urinary catheterisation". Prophylactic antibiotics (intravenous) were used in the majority of patients in all five hospitals, but most continued their use longer than evidence and basic principles require. Giving additional oral antibiotics, for which there is no supporting evidence, was also common practice (lowest hospital rate, 32%; highest hospital rate, 83%). Surgical wound drains were used almost universally, with most remaining in place beyond 24 hours. Delay in mobilisation after surgery was associated with an increased length of stay. The hospital with the longest time to mobilisation also had the longest acute-care stay (median, 13 days v. overall median, 9 days). Three-quarters of patients who were admitted from their own home were discharged to a rehabilitation facility. Acute-care stay for these patients (median, 11 days) was considerably longer than for those returning to a nursing home (median, 6 days). The day of the week on which a patient was admitted was also found to be associated with length of stay, and this effect occurred both between and within the five hospitals. Patients admitted on a Thursday were likely to spend an extra two days in the acute-care facility (median, 11 days) compared with those admitted on other days (median, 9 days). Discussion Our study reports the completion of a project which followed a structured approach to health-outcomes research, as advocated by the NSW Health Department.5 We developed evidence-based guidelines for the management of proximal femoral fractures. The method we used adhered closely to the guidelines for the development of guidelines published by the NHMRC.7 To our knowledge, this is the first time evidence-based guideline development has been performed within the context of clinical practice, ensuring that the recommendations for best-practice interventions are realistic. The levels of evidence for each recommendation were made explicit, with all the supporting evidence available for discussion. Clinical staff were involved throughout the process, and each step was systematically developed and evaluated. Thus, the support for our conclusions is robust. Current practice, identified by medical record audit, was compared with evidence-based best practice and areas of care requiring modification were identified. A number of steps in patient treatment were supported by high level evidence, but wide variability in the routine use of these treatments was seen among the five participating hospitals. There was little or no supporting evidence for some common practices, including preoperative traction and the extended use of wound drains. Although not measured systematically, we observed great variability in clinicians' response to this information, ranging from relief to frank disbelief, and many showed considerable reluctance to drop a "time-honoured practice". Prevention strategies involving medical therapies, such as prophylactic anticoagulants and antibiotics, were in widespread use and compared favourably with other audits.105,106 However, non-pharmaceutical prevention strategies, including pressure-decreasing mattresses, oxygen saturation monitoring and nutritional supplements, were not in routine use in any hospital. Despite high level evidence for the use of prophylactic anticoagulants, the exact timing of initial administration of anticoagulation remained in doubt, with surgical and anaesthetic staff expressing concern about its use in combination with regional anaesthesia. There is an extremely small, but nevertheless serious, risk of spinal haematoma with this combination. On the balance of available evidence, the benefits appear to outweigh the risk of harm, but it remains a controversial area, suggesting that further trials on types and timing of anticoagulants are required. The evidence that regional anaesthesia was associated with reduced mortality and morbidity compared with general anaesthesia also met with a mixed response, with anaesthetists being completely polarised in their views. The published meta-analysis on this topic41 did have flaws (duplication of patients, not all RCTs), but our review team reassessed the original articles according to the Cochrane Collaboration protocol and performed a repeat analysis, excluding studies which appeared to be duplicated, and reached the same conclusion, albeit with a more conservative estimate of benefit (summary odds ratio for mortality, 0.68; 95% CL, 0.49, 0.96). The optimum time from admission to surgical operation has long been a vexed question. Only observational studies,8-12 with their inherent biases and conflicting results, were available to guide recommendations. Longer time to surgery is likely to increase the risk of complications and the total length of stay, and early surgery on patients who are medically stable has not been shown to cause any harm. We found considerable variability in time to surgery, with up to 20% of patients waiting longer than 72 hours. This may reflect the lack of availability of out-of-hours surgical facilities and, to a lesser extent, the achievement of medical stability, but these patients continue to be "poor surgical relations" and are not given the priority they deserve. Earlier mobilisation also has resource implications and is dependent, in part, on the availability of physiotherapy staff, but also on a patient's general condition. While there are no randomised controlled trials to indicate the optimal time for mobilisation, a review of all trials of surgical treatment showed that ambulation on the first or second day after surgery had no adverse effects,56-88,98 and a cohort study has now reached the same conclusions.107 The day of admission appeared to influence both delay to surgery and overall acute length of stay, suggesting that the practice of adding these patients to a routine list, rather than making special arrangements for them, may be a factor in prolonging length of stay. Patients requiring transfer to rehabilitation facilities generally stayed several days longer in the acute-care ward compared with those discharged to nursing-home care. This suggests a need to address difficulties with the process of assessment for rehabilitation and/or the availability of rehabilitation beds. Costs could be reduced by earlier transfer to rehabilitation from the more expensive acute-care ward, but whether this would mean longer-term cost savings remains to be determined. Our study identified considerable variation in current management of patients who have sustained hip fractures. It has some limitations, being restricted to English language articles and to evidence published up to January 1996. As a result, a few relevant references may have been missed. However, we recommend that these guidelines be applied to most elderly patients admitted with hip fracture, as we have shown that sufficient information now exists to challenge treatments based solely on tradition or individual perceptions. The current "epidemic" of proximal femoral fractures108 makes it essential that the best possible use is made of scarce resources to achieve optimal outcomes. Acknowledgements We acknowledge the support and assistance of the NSW Health Department's Health Outcomes Program Grants Scheme, the Cochrane Musculoskeletal Injuries Group, the staff and administration of the five acute-care public hospitals, the Northern Sydney Public Health and Health Service Development Units and the Swedish Hip Fracture Group. This study would not have been possible without the help of the other members of the Project team: Dr Don Holt, Mr Wayne Salvage, Mr John Skinner, Dr Krishna Hort, Mr Peter Whitecross, Mrs Barbara Carfrae, Ms Bronwyn Christiansen, Ms Loray Dudley, Ms Catherine Ferry, Ms Jill Makaroff, Ms Sarah Michael, Ms Melanie Saunders, Ms Katherine Scott, Ms Julia Sweeney, Ms Lorraine Heaslett, Mrs Carolyn Cole, Mr Terry Black. References March L, Chamberlain A, Cameron I, et al. Prevention, treatment and rehabilitation of fractured neck of femur. Report from the Northern Sydney Area Health Service Fractured Neck of Femur Health Outcomes Project, 1996. 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Accelerated rehabilitation after proximal femoral fracture. Disabil Rehabil 1993; 15: 29-34. 100. Fordham R, Thompson R, Holmes J, et al. A cost-benefit study of geriatric-orthopaedic management of patients with fractured neck of femur. Discussion paper. York: Centre for Health Economics, University of York, 1986. Gilchrist WJ, Newman RJ, Hamblen DL, Williams BO. Prospective randomised study of an orthopaedic-geriatric inpatient service. BMJ 1988; 297: 1116-1118. Kennie DC, Reid J, Richardson IR, et al. Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women: a randomised clinical trial. BMJ 1988; 297: 1083-1086. Oyewole MF, Moloney A. A randomised, controlled trial of a high-support hospital discharge team for elderly people. Age Ageing 1994; 23: 228-234. Reid J, Kennie DC. Geriatric rehabilitative care after fractures of the proximal femur: one year follow-up of a randomised, clinical trial. BMJ 1989; 299: 25-26. Todd CJ, Freeman DJ, Camilleri C, et al. Differences in mortality after hip fracture: The East Anglia audit. BMJ; 1995; 310: 904-908. Tallis G, Balla JJ. Critical path analysis for the management of fractured neck of femur. Aust J Public Health 1995; 19: 155-159. Koval KJ, Friend KD, Aharonoff GB, et al. Weightbearing after hip fracture: a prospective series of 596 geriatric hip fracture patients. J Orthop Trauma 1996; 10: 526-530. Cooper C, Campion G, Melton LJ. Hip fracture in the elderly: a word-wide projection. Osteoporos Int 1992; 2: 285-289. (Received 28 Jul 1998, accepted 19 Mar 1999) Authors' details Northern Sydney Area Health Service Public Health Unit, Hornsby Ku-ring-gai Hospital, Sydney, NSW. Lynette M March, Associate Professor; and Senior Staff Specialist in Clinical Epidemiology. Alan J M Brnabic, Statistician. Fractured Neck of Femur Health Outcomes Project, Health Services Development, Royal North Shore Hospital, Sydney, NSW. Anne C Chamberlain, Project Officer; Jennifer M Schwarz, Research Assistant. University of Sydney Rehabilitation Studies Unit, Royal Rehabilitation Centre, NSW. Ian D Cameron, Associate Professor; and Director. Department of Public Health and Community Medicine, University of Sydney, NSW. Robert G Cumming, Associate Professor. Department of Aged Care and Rehabilitation, Royal North Shore Hospital, Sydney, NSW. Terrence P Finnegan, Senior Staff Specialist. Rehabilitation and Aged Care Services, Hornsby Ku-ring-gai Hospital, Sydney, NSW. Susan E Kurrle, Staff Specialist. Department of Surgery, University of Sydney, NSW. Sydney M L Nade, Emeritus Clinical Professor of Orthopaedics. Department of Orthopaedics and Traumatic Surgery, University of Sydney, Royal North Shore Hospital, Sydney, NSW. Tom K F Taylor, Professor; and Head. Reprints: Associate Professor L M March, Department of Rheumatology, The Royal North Shore Hospital, St Leonards, NSW 2065. Email: lmarcATdoh.health.nsw.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> 1: Systematic literature review of 15 aspects of treatment of proximal femoral fracture--conclusions and evidence level1. Time to surgery (Level III)8-12 No randomised-trial evidence is available and observational studies give a range of conclusions. Early surgery (within 24-36 hours) is recommended for most patients once medical assessment has been made and the patient's condition stabilised appropriately. Undue delay to surgery inevitably increases length of stay and may lead to more complications, including more pressure sores, pneumonia and confusion. 2. Preoperative traction (Level II)13-15 Routine use of preoperative skin and tibial pin traction should be abandoned. Pain should be adequately controlled with narcotic analgesia and/or nerve block. 3. Prevention of pressure sores (Level I)16,17 Patients should be nursed on one of a range of foam-based low pressure mattresses rather than standard hospital mattresses. Patients at very high risk of pressure sores should ideally be nursed on a large-cell, alternating-pressure air mattress or similar pressure-decreasing bed. 4. Oxygen therapy (Level II)18,19 Some evidence supports its routine use for the first 72 hours after surgery. All patients should have oximetry assessment from the time of emergency admission to 48 hours after surgery and oxygen administered as necessary. 5. Prophylactic anticoagulants (Level I)20-39 Unless there is a specific contraindication, patients should receive unfractionated low dose heparin (LDH) or low molecular weight heparin (LMWH), with a preference for the latter. This should commence as soon as possible after admission. 6. Pressure gradient stockings (Level II)40 Patients should be wearing these as soon as possible after admission. 7. Type of anaesthesia (Level I)41 Regional anaesthesia (spinal or epidural) appears to be associated with reduced short-term mortality and morbidity (confusion and thromboembolism) when compared with general anaesthesia and is recommended for most patients. 8. Type of analgesia (Level II)42,43 Pain should be adequately controlled with narcotic analgesia before and immediately after surgery. Femoral nerve blocks are useful in selected cases. 9. Prophylactic antibiotics (Level I)44-55 Prophylactic intravenous antibiotics should be given at induction of anaesthesia. Prolonged antibiotic use is of no proven benefit for prophylaxis of wound infection. 10. Type of surgery Extracapsular (trochanteric) fractures (Level I)56-74 should be treated surgically. A compression hip screw and plate has less chance of failure, leading to reoperation, compared with a fixed device and may prove to be more cost-effective in the long term. Undisplaced intracapsular fractures (Level I)75-88 should have internal fixation with a widely used method that is familiar to the surgeon (cancellous screws or compression screw and plate). Displaced intracapsular fractures (Level II)75-88 have no clearly superior surgical treatment. The options for surgical treatment of this fracture are internal fixation or arthroplasty. Internal fixation is associated with a higher risk of implant failure than hemiarthroplasty (femoral head replacement). At present the choice of treatment is best determined by patient factors (including age, presence of arthritis, availability and cost of the different types of treatment, surgeon experience and preference). 11. Surgical wound drains (Level II)89-91 May not be required as often as currently used and early removal is advised (around 24 hours after insertion). 12. Urinary catheterisation (Level II)92 Avoid indwelling catheters (where possible). Intermittent catheterisation is preferable and has been shown not to increase the incidence of urinary tract infections. 13. Nutritional status (Level II)93-97 All patients should have a nutritional assessment so that protein supplementation can be given as indicated. 14. Mobilisation (Level III)56-88,98 No randomised controlled trial evidence was available. A review of studies related to types of surgery1 concluded that almost all patients should be mobilised on the first or second day, taking as much weight on the fractured leg as the patient can tolerate. 15. Rehabilitation (Level II)99-104 Early assessment by a specialist team (within three days of admission) and active rehabilitation as soon as patient is mobile on a support frame is recommended for those who were independent before their fracture. Back to text 2: Evidence-based guidelines for acute management of proximal femoral fractureAverageRecommendation1993-94 practiceClinical intervention(level of evidence)(min-max)*1. Time to surgery8-12Within 24 hours of admission (Level III-3)15% (6%-24%)2. Preoperative traction13-15Not necessary -- adequate analgesiashould be given (Level II)57% (41%-64%)3. Prevention of pressure sores16,17Pressure care mattress to be used assoon as possible after admission (Level I) Not routine4. Oxygen therapy18,19O2 saturation monitored from timeof admission (Level II)Not routineO2 administered for 48 hours after surgery and if O2 saturation < 95% (Level II)Not routine5. Prophylactic anticoagulants20-39To commence as soon as possibleafter admission (Level I)87% (82%-98%)6. Pressure-gradient stockings40To be worn as soon as possible afteradmission (Level II)40% (16%-70%)7. Type of anaesthesia41Regional anaesthesia recommendedfor most patients (Level I)54% (14%-75%)8. Type of analgesia42,43Femoral nerve block in selected cases(Level II)Not routine9. Prophylactic IV antibiotics44-55At induction of anaesthesia (Level I)95% (86%-98%)10. Type of surgeryExtracapsular and undisplacedintracapsular fractures: compression screw device (Level I)56-7494% (83%-100%)Displaced intracapsular fractures:hemiarthroplasty (Level II)75-8861% (52%-67%)11. Surgical wound drains89-91Remove as soon as possible -- consider from 24 hours (Level II) Not recorded12. Urinary catheterisation92If possible, avoid indwelling catheters(Level II)66% (40%-90%)13. Nutritional status93-97Routine assessment -- provision of protein supplements as needed (Level II) Not routine14. Mobilisation56-88,98Early assisted ambulation -- by 48 hoursMedian Day 3after surgery (Level III)(Days 2-5)15. Rehabilitation99-104Early assessment by specialist team(Level II)Not routine16. Acute hospital length of stayEarly discharge to nursing home (Day 5)Median Day 6(Level IV)(Days 5-9)Early transfer to rehabilitation unit (Day 7)Median Day 11(Level II)(Days 8-16)Level of evidence -- National Health and Medical Research Council (Australia) 7I:Evidence obtained from a systematic review of all relevant randomised controlled trials (RCTs). II:Evidence obtained from at least one properly designed RCT. III - 1:Evidence obtained from well-designed controlled trials without randomisation. III - 2:Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or research group. III - 3:Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence. IV:Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.* Unweighted average across all five acute-care hospitals of the frequency of adherence to evidence-based best practice in 1993-94. (min-max) = range of values from lowest rate (min) to highest rate (max). Back to text

Lynette M March · Anne C Chamberlain · Ian D Cameron · Robert G Cumming · Terrence P Finnegan · Susan E Kurrle · Jennifer M Schwarz