Pre-Hip Fracture Falls: A Missed Opportunity for Intervention

Recommendations made by patients, caregivers, providers, and decision-makers to improve transitions in care for older adults with hip fracture: a qualitative study in Ontario, Canada

Background

Older adults frequently experience fall-related injuries, including hip fractures. Following a hip fracture, patients receive care across a number of settings and from multiple different providers. Transitions between providers and across settings have been noted as a vulnerable time, with potentially negative impacts. Currently, there is limited research on how to improve experiences with transitions in care following a hip fracture for older adults from the perspectives of those with lived experienced. The purpose of this study was to explore service recommendations made by patients, caregivers, healthcare providers, and decision-makers for improving transitions in care for older adults with hip fracture.

Methods

This descriptive qualitative study was part of a larger longitudinal qualitative multiple case study. Participants included older adults with hip fracture, caregivers supporting an individual with hip fracture, healthcare providers, and decision-makers. In-depth, semi-structured interviews were conducted with all participants, with patients and caregivers having the opportunity to participate in follow-up interviews as they transitioned out of hospital. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically.

Results

A total of 47 participants took part in 65 interviews. We identified three main categories of recommendations: (1) hospital-based recommendations; (2) community-based recommendations; and (3) cross-sectoral based recommendations. Hospital-based recommendations focused on treating patients and families with respect, improving the consistency, frequency, and comprehensiveness of communication between hospital providers and between providers and families, and increasing staffing levels. Community-based recommendations included the early identification of at-risk individuals and providing preventative and educational programs. Cross-sectoral based recommendations were grounded in enhanced system navigation through communication and care navigators, particularly within primary and community care settings.

Conclusions

Our findings highlighted the central role primary care can play in providing targeted, integrated services for older adults with hip fracture. The recommendations outlined have the potential to improve experiences with care transitions for older adults with hip fracture, and thus, addressing and acting on them should be a priority.

Own the Fall: AOA Critical Issues

Falls are the most common cause of injury to older patients, resulting in >3 million emergency room visits per year and 290,000 hip fractures annually in the United States. Orthopaedic surgeons care for the majority of these patients; however, they are rarely involved in the assessment of fall risk and providing prevention strategies. Falls also occur perioperatively (e.g., in patients with arthritis and those undergoing arthroplasty). Preoperatively, up to 40% of patients awaiting joint arthroplasty sustain a fall, and 20% to 40% have a fall postoperatively. Risk factors for falls include intrinsic factors such as age and comorbidities that are not modifiable as well as extrinsic factors, including medication reconciliation, improvement in the environment, and the management of modifiable comorbidities that can be optimized. Simple in-office fall assessment tools are available that can be adapted for the orthopaedic practice and be used to identify patients who would benefit from rehabilitation. Orthopaedic surgeons should incorporate these strategies to improve care and to reduce fall risk and associated adverse events.

Barriers and Resources to Optimize Bone Health in Orthopaedic Education: Own the Bone (OTB): Bone Health Education in Residency

Osteoporosis is a critical public health issue with substantial morbidity and healthcare costs. Resident education on osteoporosis is not standardized. Little is known about the barriers to osteoporosis treatment and the usefulness of educational programming from the perspective of orthopaedic residency program directors (PDs).

Higher Readmission Rates After Hip Fracture Among Patients With Vestibular Disorders

OBJECTIVE

Falls in older adults are associated with high morbidity and mortality. Patients with vestibular disorders may have an increased risk. The purpose of this study was to examine the outcomes among patients with underlying vestibular disorders who have hip fractures and identify predictors of increased morbidity and mortality.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic medical center.

PATIENTS

Two hundred one adults diagnosed with a vestibular disorder and hip fracture due to a ground-level fall were compared to 327 age- and sex-matched controls with fractures due to ground-level falls without vestibular diagnoses. Patients were treated between 2013 and 2019.

MAIN OUTCOME MEASURES

Length of hospital stay, 30-day readmission rate, and 30-day mortality rate.

RESULTS

Thirty-day readmission rate after hip fracture was significantly increased in patients with vestibular disorders compared to matched controls (p < 0.001), odds ratio 3.12 (95% confidence interval 1.84-5.39). Reasons for readmission in the vestibular patient group included higher rates of repeat falls, infections, and recurrent vestibular symptoms. Use of medication classes associated with falls or hip fractures was not significantly different between groups, except for lower rates of antihypertensive use in the vestibular group (54.0% vs. 67.7%, p = 0.002). No significant difference was found for length of hospital stay (7.34 ± 4.95 vs. 8.14 ± 20.50 days, p = 0.51) or 30-day mortality rate (5.0% vs. 4.6%, p = 0.99). No significant differences were found between groups for age, sex, race, rate of surgical treatment for hip fracture, or disposition at discharge.

CONCLUSIONS

Patients with vestibular disorders are at a significantly higher risk of hospital readmission within 30 days after discharge for treatment for hip fracture.

Preventing Fragility Fractures: A 3-Month Critical Window of Opportunity

Introduction:

Low-energy falls are the leading cause of injury-related morbidity and mortality in the elderly. In the past, physicians focused on treating fractures resulting from falls rather than preventing them. The purpose of this study is to identify patients with a hospital encounter for fall prior to a fracture as an opportunity for pre-injury intervention when patients might be motivated to engage in falls prevention.

Materials & Methods:

A retrospective analysis of all emergency room and inpatient encounters in 2016 with an ICD10 diagnosis code including “fall” across a tri-state health system was performed. Subsequent encounters with diagnosis of fracture within 2 years were then identified. Data was collected for time to subsequent fracture, fracture type and location, and length of stay of initial encounter.

Results:

There were 12,382 encounters for falls among 10,589 patients. Of those patients, 1,040 (9.8%) sustained a subsequent fracture. Fractures were most commonly lower extremity fractures (661 fractures; 63.5%), including hip fractures (447 fractures; 45.87%). Median time from fall to fracture was 105 days (IQR 16-359 days).

Discussion:

Falls are an important, modifiable risk factor for fragility fracture. This study demonstrates that patients are presenting to the hospital with one of the main modifiable risk factors for fracture within a time window that allows for intervention.

Conclusions:

Presentation to the hospital for a fall is a vital opportunity to intervene and prevent subsequent fracture in a high-risk population.

Injury Mechanisms of Hip Fractures in India

Purpose

Hip fractures are a major cause of morbidity and mortality in the elderly; however, the current literature on the injury patterns of hip fractures in India is lacking. Understanding the injury profile of these patients is important to develop targeted interventions to prevent hip fractures.

Materials and Methods

This was a prospective study of all hip fracture patients aged 50 years or older admitted from February 2019 to December 2019. Details about the injury were recorded by an in-person interview. Multivariate logistic regression analysis was used to identify the factors associated with any particular injury mechanism.

Results

Two hundred and eighty-three hip fractures were included. The mechanism of injury for the majority of patients was a fall from a standing height (n=217, 76.7%) while 60 patients (21.2%) were injured as the result of a road traffic accident (RTA). Slipping on a wet floor (n=49, 22.6%) and change in posture (n=35, 16.1%) were the most commonly reported reasons for falling. Pedestrian injuries were the most common form of RTA (n=29, 48.3%). Increasing age (P<0.001) and female sex (P=0.001) were associated with fall as the mode of injury while sustaining another fracture in addition to hip fracture (P=0.032) was associated with RTA as the mode of injury.

Conclusion

A fall from standing height is the predominant mode of injury among elderly hip fractures especially among women. Environmental hazards and postural changes are responsible for the majority of falls while pedestrian accidents contribute to a majority of the RTAs.

Survival analysis after hip fracture: higher mortality than the general population and delayed surgery increases the risk at any time

PURPOSE

To estimate survival curves in patients with hip fracture according to gender, age, type of fracture, and waiting time for surgery and to compare them with the life expectancy of the general population. The study hypothesis is that survival after hip fractures is significantly lower than in the general population, especially in cases that underwent delayed surgery, regardless of age and gender.

METHODS

A survival analysis study was designed and approved by our institutional ethics review board. All patients who were coded with a diagnosis of hip fracture from 2002 to 2018 were included in the study. A total of 1176 patients were included, and the median age was 81 years (18-105 years). Kaplan-Meier curves and log-rank tests were performed to compare survival curves between those who underwent surgery on time and those with surgical delays. An exponential multivariate regression model was estimated, and a hazard ratio (HR) was reported for age, gender, and wait time for surgery. A significance of 5% was used, and a confidence interval level of 95% was reported.

RESULTS

The Kaplan-Meier curves for delayed surgery (log-rank, p = 0.00) and the age group (log-rank, p = 0.00) were significantly different. Exponential regression estimated an HR 1.05 (1.05-1.07) for age, HR 1.80 (1.51-2.13) for men, and HR 1.93 (1.61-2.31) for each day of wait for surgery.

CONCLUSIONS

The 2 significant findings of this study are that hip fracture patients over 40 years old have a higher risk of dying at any time compared to the general population and that the waiting time for surgery (a modifiable factor) decreases survival rates at any time.

Incidence, risk factors and case fatality rate for hip fracture in Chile: A cross-sectional study based on 2017 national registries

Purpose

To describe the incidence of hip fracture in Chile during 2017, identify risk factors for in-hospital mortality, and estimate annual case fatality rate.

Method

The study design was cross-sectional and analytical. We obtained the registries of all patients from the Chilean Ministry of Health who were treated for hip fracture between January 1, 2017, and December 31, 2017. We used multivariate logistic regression to estimate the risk factors for in-hospital mortality. The annual case fatality rate was calculated using the probabilities obtained by estimating a logistic regression model in previous work. The estimated crude mortality rate per 100 000 persons was compared with that of cancer, as reported by the Ministry of Health.

Results

During 2017, 7421 hip fractures occurred, resulting in an incidence of 40 per 100 000 persons. Of these, 1574 (21.21%) cases did not undergo surgery. In-hospital mortality was found to be associated with no surgery (odds ratio 8.32, 6.20 to 11.17), and being treated in a public hospital (odds ratio 1.62, 1.00 to 2.68). The estimated annual case fatality rate was 0.30 (0.27 to 0.33), and the crude mortality rate per 100 000 persons was 10.78 (9.66 to 11.71).

Conclusion

Hip fractures mainly affect the population over 60 years old and women. Chile has an excessively high rate of non-operated patients compared to international reports. There is a significant difference between care in a public hospital compared to private clinics in terms of volume, access to surgery, hospital stay, in-hospital mortality, and estimated case fatality rate.