Rising costs of hip fractures

Early, intensive intervention may complement fall prevention in reducing the personal and financial costs

The most rapidly growing age group in Australia is that of people aged 65 or more, and those over 85 years of age make up an increasing proportion of this group. While we celebrate longevity, it appears that low trauma fractures, most of which result from a fall and poor bone quality, remain a major problem, both for older people and for the health systems that care for them.

According to a report published by Osteoporosis Australia in 2013,1 there will be about 26 000 hip fractures in Australia during 2016, with estimated total costs of $1 billion. Treatment of hip fractures consumes about 44% of total fracture-related health care expenditure, and accounts for 36% of all hospital beds occupied by patients with low trauma fractures.

Hip fracture patients are the most complex and frail people in our hospitals, and care is most effectively delivered when orthopaedic surgeons and geriatricians work in partnership with other key health professionals involved in hip fracture care.2 The surgery itself comprises a tiny fraction of the total time spent in hospital, but this period is critical for affording pain relief and optimising the chances of a functional recovery.

The Australian and New Zealand Guideline for hip fracture care recommends early and regular mobilisation to achieve this goal.2 However, it remains unclear how much therapy should be offered.

High intensity physiotherapy may be one way to improve outcomes for patients and reduce their length of stay in hospital. The study by Kimmel and colleagues3 published in this issue of the MJA specifically examined the potential benefits for hip fracture patients of high intensity physiotherapy in the acute setting. Using a randomised controlled trial design, the authors compare usual care physiotherapy (30 minutes each day) with intensive physiotherapy (30 minutes, three times per day) in a busy trauma hospital. The primary outcome for which the study was powered was a change in the modified Iowa Level of Assistance Scale (mILOA) score, measured 5 days after surgery.

A total of 170 patients were screened for participation and 92 were ultimately randomised to control and intervention groups. The authors tried to ensure blinding of the assessors, but it was naturally impossible to blind the patients to their allocation, and perhaps difficult to be certain that the assessors remained unaware of who was in the treatment arm. The 46 patients in each group were reasonably matched in terms of demographic characteristics and morbidity. Discharge from the acute ward occurred when the patient was deemed medically stable, and their destination depended on their functional status. If they were not ready to be discharged home, they were transferred to fast or slow stream rehabilitation; no information is provided by the study authors about the intensity of therapy in these facilities.

The results of this study are surprising. Although there was no statistically significant difference between the two groups in mILOA scores at Day 5, there was a substantial and statistically significant difference in the median total length of stay, with a saving of 10.6 days for patients receiving high intensity physiotherapy. Twice as many people in the intervention group went directly home from the acute ward, and those referred to rehabilitation were more likely to be directed to fast stream rehabilitation. Whether these differences were related to the pre-morbid functional status of the patients or were a direct result of the intervention is uncertain. This study also highlights the importance of looking at total length of stay when evaluating the impact of an intervention such as early and higher intensity therapy in the acute setting.

If these results could be replicated on a national basis, there could potentially be major reductions in the number of bed-days associated with hip fractures. Further work for better defining the optimal approach to restoring function and expediting discharge after hip fracture surgery is necessary. While randomised controlled trials provide a robust methodological approach for addressing a particular research question, they are expensive to undertake.

Registries offer an alternative mechanism for evaluating systems, processes and outcomes of care. The new Australian and New Zealand Hip Fracture Registry collects data at both the patient and facility levels, with the specific intention of using it to inform clinicians, to drive change, and to evaluate the impact of such change.

In view of the projected increase in the number and costs of hip fractures over the next 25 years, it would be remiss to ignore the results of the study by Kimmel and colleagues. While the focus in the future must be on fall and fracture prevention, it is incumbent upon us to explore different approaches to hip fracture care, looking for models that are effective and efficient, and which deliver better outcomes for patients.