Hip Fracture – the ultimate challenge

Antony Johansen

Orthogeriatrician – University Hospital of Wales, Cardiff

Clinical Lead – National Hip Fracture Database

Hip fracture is the commonest serious injury, the commonest reason for older people to need emergency anaesthesia and surgery, and the commonest cause of accidental death

Only a minority regain their previous abilities, increased dependency and difficulty walking mean that a quarter will need long-term care

The cost of this one injury is about 1% of the whole NHS budget

NOS conference – Bath 1998 Johansen et al. Injury 1997

The Cardiff fracture epidemiology study

A population-based study of the 306,600 people living in the City of Cardiff, as defined by post-code

A population with an age, sex and ethnic composition very similar to that of England and Wales

Hip fracture incidence vs. length of daylight

Hours of daylight per day

Hip

frac

ture

s per

day

R = - 0.285, p<0.001

7 8 9 10 11 12 13 14 15 16 17

Johansen, Boulton and Neuburger, Age and Ageing 2016

NHFD data on 64,102 people presenting in 2014

15.6% more hip # in December cf. all other months (9.5% vs. 8.2%, p<0.001)

Same pattern among people living in care homes (9.1% vs. 8.3%, p <0.001)

Diurnal and seasonal patterns in presentations with hip fracture

Johansen, Boulton and Neuburger, Age and Ageing 2016

The cost of osteoporotic fractures in the UK - projections for 2000-2020

0.5

1.0

1.5

2.0

2.5

£ - B

illio

ns

NOS conference – Bath 2001 Burge, Worley, Johansen et al. J Med Econ 2001

Hospital admission for older people with fractures

0

50

100

150

200

250

300

Num

ber o

f adm

issi

ons

55-64 years 65-74 years 75-84 years 85+ years

NOS conference – Bath 1998 Johansen et al. Injury 1998; 29: 799-84

Length of stay

Discharge destination for people admitted

from home

NHFD Annual Report 2015

NHFD annual report 2014

Linking NHFD data with figures from HES, PEDW and FORD

Admissions Super-spell Total bed days

England 59,344 22.5 1,335,240Wales 3,804 35.1 133,520Northern Ireland 1,845 33.3 61,439

Overall 64,993 23.1 1,499,593

An orthogeriatrician’s challenge to the NOS

I’d be pleased if we could:

- identify half of older people who will break their hip

- offer a treatment that halves hip fracture risk

- get half of them to continue taking it correctly

NOS conference – Edinburgh 2007

FRAX and NOGG in the real world

Retrospective (pre-fracture) FRAX for 100 consecutive hip fracture patients

1/3

2/3

NOS conference – Liverpool 2010 Johansen BMJ 2012;344.e4191

Proposed pyramid of implementation – DoH 2009

Hip fractureHip fracture

Fragility fractureFragility fracture

Secondary prevention 50% of hip fractures occur in people with prior fragility fracture

… 16% of the population

High risk of fractureHigh risk of fracture

General populationGeneral population

Osteoporosis trials - 2007

Trends in the age of people in osteoporosis drug trials

Despite demographic shift in the population – in the last two decades the mean age of trial subjects has fallen by 5 years, from 74 to 69 years

Marsh and Johansen – NOS poster 107 – November 2016

5 year survival after hip fracture - implications for secondary prevention

NOS conference – Manchester 2009 Johansen et al. Age Ageing 2010

An orthogeriatrician’s challenge to the NOS

I’d be pleased if we could:

- identify half of older people who will break their hip

- offer a treatment that halves hip fracture risk

- get half of them to continue taking it correctly

But this would still only prevent 12.5% of hip fractures

NOS conference – Edinburgh 2007

Intracapsular hip fractures

Trochanteric hip fractures

www.nhfd.co.uk

THR if eligible as defined by NICE CG124

THR if eligible as defined by NICE CG124

Perry et al. BMJ 2016

30-day mortality trend for one hospital

Neuburger et al. Medical Care 2015;53:686–691

National launch of NHFD

30-day adjusted mortality for one hospital

NHFD annual report 2016

Neuburger et al. Medical Care 2015;53:686–691

Participation in NHFD

Fitted trends in adjusted 30-day morality - before and after launch of NHFD

Fitted trend across participating hospitals

www.nhfd.co.uk - accessed 6th November 2016

All hospitals – unadjusted 30 day mortality

Neuburger et al. Medical Care 2015;53:686–691

Participation in NHFD

Fitted trends in adjusted 30-day morality - before and after launch of NHFD

Fitted trend across participating hospitals

6.4%2016

“ treat the patient and let the fracture go …”

Astley Cooper, Lancet 1894

“the surgical procedure must never be considered to be the whole treatment but merely an incident in the general rehabilitation of the patient”

Devas, BMJ 1974

Consultant OG (hours)

Middle grade OG

NHFD annual report 2015

Neuburger et al. Age and Ageing (in press)

30 d

ay m

orta

lity

Orthogeriatrician sessions per week

Increased orthogeriatrician involvement in hip fracture care and its impact on mortality in England

OG involvement and mortality

Variation in provision of orthogeriatrician support

NHFD annual report 2015

£20,000 /QALY

11,793 6,294

Overall saving to health services of an HFP £5,499

NICE economic model

Key recommendation

Offer all patients a formal, acute orthogeriatric or orthopaedic ward based Hip Fracture Programme that includes all of the following:

• orthogeriatric assessment

• rapid optimisation of fitness for surgery

• early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term well-being

• continued coordinated orthogeriatric and multidisciplinary review

• communication with the primary care team

What is the commonest complication

after hip fracture?

Reducing delirium after hip fracture: a randomized trial Marcantonio et al. J Am Geriatrics Soc 2001; 49:516–522

Geriatrician assessment and daily visits

- ensure adequate CNS oxygen delivery

- optimise fluid/electrolyte balance

- treatment of severe pain

- elimination of unnecessary medications

- regulation of bowel/bladder function

- adequate nutritional intake

- early mobilization and rehabilitation

- prevent, detect, and treat complications

- appropriate environmental stimuli

- treatment of agitated delirium

Bellelli et al. Age Ageing 2014; 43:496-502

What is the commonest cause of death

after hip fracture?

NOS – Harrogate 2006 Duncan, Beck, Hood, Johansen. Age Ageing 2006

Nutritional support following hip fracture – an RCT

What do patients fear more than death

after hip fracture?

Post-operative mobilisation

NHFD annual report 2015

Percentage of patients mobilised out of bed

on the day following hip fracture surgery

Overall NHFD figure 73.3%

21 hospitals (11%) achieved this

in less than half of their patients

HABAM: Hierarchical Assessment of Balance and MobilityHA

BAM

mob

ility

scor

e

Weeks after hip fracture

Mobile with aid 8-50m

Needs positioning in bed

Hubbard et al. J Gen Intern Med 2011

Discharge destination for people admitted

from home

NHFD Annual Report 2015

NHFD – CSP joint audit of hip fracture rehab. – Pilot study 2015

An orthogeriatrician’s challenge to the NOS

I’d be pleased if we could:

- identify half of older people who will break their hip

- offer a treatment that halves hip fracture risk

- get half of them to continue taking it correctly

But this would still only prevent 12.5% of hip fractures

NOS conference – Edinburgh 2007

antony.johansen@wales.nhs.uk

www.nhfd.co.uk