Early surgical intervention is thought to reduce in-hospital morbidity and mortality as well as short-term mortality rates for elderly patients with hip fractures. However, hip fractures are also thought to be a symptom of progressive decline in elderly patients with multiple medical comorbidities. A measured approach to medical optimization, which may preclude rapid surgical intervention, is often required to improve the patient’s ability to resume a prefracture standard of living. Of late, new models of geriatric hip-fracture care have emerged, most of which entail early involvement of geriatricians and interdisciplinary care pathways, while continuing to focus on rapid surgical treatment.
Key points
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Geriatric hip fracture is a common condition that is increasing in prevalence as the population ages.
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Geriatric patients with hip fracture often have multiple medical comorbidities that complicate their treatment and functional outcomes.
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Expedited surgical management of hip fractures in elderly patients is associated with improved outcomes and reduced early complications.
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Medical optimization of elderly patients with hip fractures before surgical management improves postoperative outcomes and long-term functional outcomes.
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Multiple models exist for care of geriatric patients with hip fracture.
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Early results indicate that protocol-driven, multidisciplinary care of geriatric patients with hip fractures appears to offer improved patient outcomes.
Introduction
Hip fractures represent one of the most common causes of hospital admission for elderly patients, and result in profound morbidity and mortality. As the population ages, the burden of osteoporosis and of hip fractures is expected to increase substantially. Care of the elderly patient with hip fracture is resource intensive, involving substantial costs as well as health care provider and family time, both in the United States and elsewhere. The annual cost of hip-fracture care in the United States for all age groups in 2004 was estimated at $9 billion. Estimates are that total annual costs for hip-fracture care in the United States may escalate to $35 billion (in 2012 dollars, $16 billion in 1984 dollars) by the year 2040.
Care of hip fracture traditionally has focused on stabilization of the fracture at the earliest possible opportunity. Early stabilization allows for pain control and patient mobilization. Many studies have demonstrated that delays of greater than 24 to 48 hours from injury result in an increased 1-year mortality rate in elderly patients with hip fractures ; this consideration, however, must be tempered by the fact that optimization of medical comorbidities is often necessary before successful surgical treatment of the hip fracture in elderly patients. Because many elderly patients with hip fracture have multiple comorbidities and often also have polypharmacy (administration of 6–9 drugs simultaneously), they require close medical management. Perhaps it is not simply the delay to surgery that results in the increased 1-year mortality rate.
Comanagement of geriatric patients with hip fracture was originally developed in England many decades ago. In most centers, however, elderly patients with hip fractures have normally been admitted to the orthopedic surgery services, with medical, cardiology, or geriatric consultation only as deemed necessary by the orthopedic surgeons. Over the past 20 years, however, increasing attention has been paid to comanagement models of elderly patients with hip fracture, with intimate involvement of geriatricians in the preoperative and postoperative care of these patients. At some institutions, standardized care pathways have been developed, with encouraging results. This article discusses historical methods of care of elderly patients with hip fracture, the development of comanagement strategies for geriatric patients with hip fracture, and the evolution of hip-fracture care models as they exist today.
Introduction
Hip fractures represent one of the most common causes of hospital admission for elderly patients, and result in profound morbidity and mortality. As the population ages, the burden of osteoporosis and of hip fractures is expected to increase substantially. Care of the elderly patient with hip fracture is resource intensive, involving substantial costs as well as health care provider and family time, both in the United States and elsewhere. The annual cost of hip-fracture care in the United States for all age groups in 2004 was estimated at $9 billion. Estimates are that total annual costs for hip-fracture care in the United States may escalate to $35 billion (in 2012 dollars, $16 billion in 1984 dollars) by the year 2040.
Care of hip fracture traditionally has focused on stabilization of the fracture at the earliest possible opportunity. Early stabilization allows for pain control and patient mobilization. Many studies have demonstrated that delays of greater than 24 to 48 hours from injury result in an increased 1-year mortality rate in elderly patients with hip fractures ; this consideration, however, must be tempered by the fact that optimization of medical comorbidities is often necessary before successful surgical treatment of the hip fracture in elderly patients. Because many elderly patients with hip fracture have multiple comorbidities and often also have polypharmacy (administration of 6–9 drugs simultaneously), they require close medical management. Perhaps it is not simply the delay to surgery that results in the increased 1-year mortality rate.
Comanagement of geriatric patients with hip fracture was originally developed in England many decades ago. In most centers, however, elderly patients with hip fractures have normally been admitted to the orthopedic surgery services, with medical, cardiology, or geriatric consultation only as deemed necessary by the orthopedic surgeons. Over the past 20 years, however, increasing attention has been paid to comanagement models of elderly patients with hip fracture, with intimate involvement of geriatricians in the preoperative and postoperative care of these patients. At some institutions, standardized care pathways have been developed, with encouraging results. This article discusses historical methods of care of elderly patients with hip fracture, the development of comanagement strategies for geriatric patients with hip fracture, and the evolution of hip-fracture care models as they exist today.
Traditional management of elderly patients with hip fracture
Hip fractures are a common cause of morbidity and mortality in elderly patients. Patients who sustain fractures of the hip (femoral neck fractures or intertrochanteric fractures) after a fall from a standing height are considered to be osteoporotic by the World Health Organization. The bulk of these patients are elderly and predominantly female. Attendant with advanced age are comorbidities and polypharmacy, either of which may be the proximate cause of the fall that precipitates the hip fracture. Nevertheless, the hip fracture itself is the factor that directly leads to hospital admission. That being stated, the focus of traditional care methods has been to repair the hip fracture as expeditiously as possible, and gives little emphasis to medical management of these patients or to the diagnosis and treatment of osteoporosis.
Fracture stabilization has been demonstrated to improve outcomes for elderly patients with hip fracture. Although nonoperative management of such patients has been advocated in the past (especially for nonambulatory patients), and early results of hip-fracture fixation in elderly patients were very poor, routine use of this management method has fallen into disfavor. Early evidence that operative management of elderly patients with hip fracture was effective in reducing mortality rates was published by Sherk and colleagues in 1979, demonstrating that early mortality decreased from more than 50% to 28% with “prompt” surgical stabilization (within 72 hours in 46 of 53 patients). Nevertheless, these mortality rates remained shockingly high.
Multiple studies have examined the effect of delaying surgical repair on outcomes in elderly patients with hip fracture. Conflicting reports were prevalent before 1995. One report indicated that patients undergoing early (ie, less than 24 hours post injury) hip-fracture fixation were more likely to expire within 1 year than those undergoing fixation 2 to 5 days after injury. The recommendation was that serious medical conditions should be stabilized for 24 hours or more after injury before scheduling surgery. However, another report showed that patients with 2 or fewer (but not 3 or more) preexisting medical comorbidities had increased 1-year mortality rates with operative delays of more than 24 hours after admission. Another report indicated that operative delay of greater than 24 hours resulted in an increased 1-year mortality rate, without controlling for medical comorbidities. Yet another report showed a decreased 3-month mortality rate in patients with hip fracture who had an operative delay greater than 48 hours from admission. To confuse matters further, another study demonstrated that there was no relationship between delays to surgical repair of hip fractures and mortality at 2 years.
In an effort to arrive at a recommendation for hip-fracture surgeons, Zuckerman and colleagues conducted a prospective study to examine the effect of delay to surgical repair of hip fractures on in-hospital complications and on 1-year mortality rates in patients who were ambulatory and lived independently before fracture. A total of 367 patients were studied, and surgical hip-fracture repair was performed within 48 hours in 267 of the patients. Operative delay beyond 2 days doubled the risk of 1-year mortality. However, controlling for age, sex, and medical comorbidities revealed that the increase in 1-year mortality associated with surgical delay was not significantly different from the rate in patients treated early. When controlling for medical comorbidities and American Society of Anesthesiologists (ASA) class, no differences in in-hospital complications were noted between patients who underwent expeditious hip-fracture repair versus those who had a delay of greater than 48 hours. Nevertheless, the investigators recommended that surgical repair of hip fractures should occur within 2 days of hospital admission to minimize 1-year mortality rates.
A more stringent recommendation for early hip-fracture fixation was subsequently made by Hamlet and colleagues, who conducted a retrospective review of 168 patients with 171 hip fractures. Data were gathered on ASA class as well as mortality rates for these patients. One-year mortality was only 20% if hip fracture repair was accomplished within 24 hours of admission, and 50% if accomplished after a delay of more than 24 hours from admission. The relative risk of death within 1 year was 4.5-fold higher in the surgical delay group, irrespective of the ASA classification. The investigators concluded that mortality rates are lower for patients with hip fracture if fracture repair is accomplished within 24 hours.
The publication of multiple studies implying that surgical delays for elderly patients with hip fracture resulted in higher mortality rates had the (perhaps) unintended effect of prompting caregivers to rush such patients to the operating room, sometimes forgoing complete medical optimization. Questions were asked about whether patients are at higher risk of mortality if their medical comorbidities are not optimized before surgical repair, and whether the higher mortality rate for hip-fracture patients who undergo delayed repair is exclusively due to the surgical delay or is instead due to the extreme comorbidities that may have caused the surgical delay. Surgical delays may be the result of unnecessary medical testing. A retrospective study of 235 consecutive elderly patients with hip fracture seemed to reveal that cardiology testing beyond electrocardiography (adenosine stress thallium testing, 2-dimensional echocardiography, dobutamine stress echocardiography, or diagnostic cardiac catheterization) did little else besides increasing costs and increasing delays between hospital admission and surgical care of the hip fracture. What, then, is needed for preoperative evaluation of elderly patients with hip fracture? Is surgical delay truly the variable that affects mortality?
To answer this question, Grimes and colleagues reported on a retrospective, multicenter trial of 8383 patients with hip fractures treated between 1983 and 1993. Long-term mortality rate (of up to 18 years) was used as the primary outcome measure. Early mortality (within 30 days), formation of pressure ulcers, serious infection, myocardial infarction, and venous thromboembolism were considered secondary outcome measures. Surgery was delayed more than 24 hours after admission in 4578 patients, to optimize the patients’ medical conditions. There was no increase in long-term mortality in patients who underwent surgical repair within 48 hours of admission, compared with patients who waited more than 96 hours. No association between time to surgery and early mortality, serious infection, myocardial infarction, or venous thromboembolism was noted. An increased risk of pressure-ulcer formation was noted in patients who had a surgical delay of 96 hours or longer. The investigators concluded that waiting for up to 72 hours did not affect patient outcomes significantly. Risk of pressure ulcers was increased with long delays, but these may be prevented by minimizing conditions under which patients might develop them (eg, careful monitoring, frequent turns, special mattresses, and nutritional supplementation). Delaying surgery for optimization of the medical condition of a patient with hip fracture was suggested to be beneficial in some cases.
Traditional methods of management of hip fractures in geriatric patients involved admission of patients to the orthopedic surgical service, rapid surgical stabilization, and involvement of other medical services only as deemed necessary by the attending orthopedic surgeon. Multiple studies revealed correlations between shorter times to the operating room and increased 1-year survival rates for these patients ( Table 1 ). These data may have prompted a headlong rush to the operating room for surgical treatment of these patients without considering that delays in operative management may have been necessary for medical optimization of the patients for surgery. Those patients delayed for longer periods may have an increased 1-year mortality rate owing to their overall medical condition, as opposed to simply the amount of time from fracture to surgical treatment. In recognition of these considerations, centers began considering the development of care pathways for geriatric patients with hip fracture, with the aim of improving long-term outcomes.
| Authors, Ref. Year | Country | Inclusion Criteria | Exclusion Criteria | Study Design | Conclusion Summary | Level of Evidence |
|---|---|---|---|---|---|---|
| Sherk et al, 1979 | USA | “Senile” elderly hip-fracture patients | None specified | Retrospective | Favors early stabilization, “early” and “prompt” not defined | IV |
| Kenzora et al, 1984 | USA | Hip-fracture patients | None specified | Retrospective | Favors surgical delay until medical condition is stabilized, 2–5 d | IV |
| Sexson and Lehner, 1987 | USA | Hip-fracture patients | None | Retrospective | Favors stabilization within 24 h of hospitalization if healthy, but delay for optimization of unhealthy patients is acceptable | IV |
| White et al, 1987 | Canada | Hip-fracture patients | Pathologic or “severe trauma” or loss to follow-up | Retrospective | Favors early stabilization, but considers that increased mortality in delayed patients was related to high surgical risk | IV |
| Davis et al, 1988 | Great Britain | Intertrochanteric fracture patients | <50 y old, unfit for anesthesia | Retrospective | Timing unimportant for outcome | IV |
| Davidson and Bodey, 1986 | Great Britain | Hip-fracture patients | None | Retrospective | No association between surgical delay and mortality | IV |
| Zuckerman et al, 1995 | USA | Hip fracture, ≥65 y old, live at home | Dementia, nonambulatory | Prospective | Favors stabilization within 2 d of hospitalization | I (prognostic) |
| Hamlet et al, 1997 | USA | Hip fracture | Fractures treated at different institution, nonoperatively managed fractures, polytraumatized patients, pathologic fractures | Retrospective | Favors stabilization within 24 h of hospitalization | IV |
| Ricci et al, 2007 | USA | Hip fracture, ≥60 y old | None | Retrospective | No conclusions regarding mortality; cardiac testing beyond electrocardiogram results in unacceptable surgical delay | IV |
| Grimes et al, 2002 | USA | Hip fracture, ≥60 y old, data available from previous transfusion study | Cancer, trauma, declined blood transfusion | Retrospective | Time unimportant for outcome | IV |
Development of care pathways and comanaged care for elderly patients with hip fracture
Geriatric patients with fracture provide layers of complexity in management that are often absent in the young patient. The geriatric patient not only desires a return to function but also generally desires a return to independence (or prefracture way of life). Involvement of multiple physician teams, each with different expertise, has come to be expected for the geriatric patient with fracture. Despite this, comanaged care models for geriatric patients with hip fracture are relatively new developments in the United States. Care pathways, however, have been used and examined in other countries, and have led to their development in the United States.
Geriatric orthopedics requires a good working relationship between medical and surgical specialists to achieve the most favorable outcomes. The idea of “total care,” or application of geriatric medical and surgical skills from the time of admission to the hospital through patient discharge, was proposed as important in giving the geriatric patient with hip fracture the highest likelihood of returning to independence (prefracture state of living). Emphasis is placed on total care of the elderly for the purposes of returning them to an independent, active life. One of the tenets described in the care of geriatric fracture is expeditious fracture stabilization, which allows for a more rapid return to independence. However, appropriate medical management of preexisting comorbidities, both preoperatively and postoperatively, is essential.
Implementation of care pathways for elderly patients with hip fracture has been analyzed extensively since the end of the twentieth century. A white paper from Great Britain’s National Health Service in 1997 stressed the need for health care providers to work collaboratively on integrated care for geriatric patients with hip fracture. Care pathways have been used successfully in multiple disciplines outside of hip-fracture care to improve care delivery for elderly patients. Examples of successful implementation of care pathways, both in the United States and elsewhere, include those for total hip arthroplasty, acute coronary syndromes, acute pediatric illnesses, and vascular surgery.
An early report regarding the use of care pathways for the treatment of elderly patients with hip fracture (in Canada) was published by Ogilvie-Harris and colleagues in 1993. The prospective cohort study compared 51 patients treated in a standard fashion with 55 patients treated according to a care map. The care map included a daily summary of scheduled events along with time frames for their completion. The maps were developed collaboratively by physicians, nurses, therapists, social workers, and others (as necessary) involved with the patient’s care, and included standardized order sets. The investigators reported a statistically significant difference in outcome, with more patients returning to prefracture ambulatory and living status. There were fewer postoperative complications, and a higher number of patients returned home within 2 weeks of hospital admission. There was a slight trend toward reduced length of stay in the care-map cohort (13.6 vs 15.3 days) if patients who required greater than 28 days of hospitalization were excluded from both groups.
In Australia, a clinical pathway for the management of elderly patients with hip fracture was successful in decreasing lengths of stay in hospital and rates of wound infection, without changes in unplanned patient readmission, walking ability before discharge, or destination after discharge. In this study, Tallis and Balla reviewed a clinical management program that was implemented in 1993, and their study compared two cohorts of patients: one of 90 patients who were treated in the 6 months before program implementation, and another of 88 patients who were treated in the 6 months following program implementation. Patients were excluded from analysis if they were younger than 50 years, had metastatic disease, or had multiple fractures. The average length of stay for hip fracture patients treated with the clinical management program decreased to 11.0 days, from 19.3 days before program implementation ( P <.0001).
Another study on the use of clinical pathways in the care of elderly patients with hip fractures revealed similar findings to those of Tallis and Balla. In this prospective trial, 111 consecutive elderly patients with hip fracture were “pseudorandomized” to receive established standard-of-care treatment (56 patients) or clinical pathway–guided treatment (55 patients). Clinical-pathway patients had a shorter hospital length of stay (6.6 vs 8.0 days, P = .03), and there was no difference noted in complications and readmission rates between the two cohorts.
Health-related quality of life and patient satisfaction with care of hip fracture does not appear to suffer from use of a clinical pathway, despite the decreased time of hospitalization. A 12-month prospective cohort study of 57 elderly patients with hip fracture revealed decreased complications and a decreased average length of hospital stay (3.3 days) when a care pathway was implemented, with no decrease in health-related quality of life or patient-satisfaction measures.
A large observational cohort study was published in 2000 by March and colleagues. This multicenter study compared 455 elderly patients with hip fracture managed before implementation of a hip-fracture clinical pathway with 481 patients managed after implementation. The results showed a small reduction in average length of stay in hospital and an increased use of evidence-based best practices after implementation of the clinical pathway, without changes in 4-month mortality rates or residential status of the patients after discharge.
The New Zealand Guidelines group recently published an extensive set of recommendations regarding multidisciplinary care of the elderly patient with hip fracture. These guidelines recommend that patients be admitted to a formal hip-fracture program that is either orthogeriatric or based in the orthopedic ward. The program should include orthogeriatric assessment, rapid surgical optimization, and identification of multidisciplinary rehabilitation goals for the hip-fracture patients such that the likelihood of returning to prefracture status is maximized. Also, multidisciplinary review of the patients should occur throughout the hospitalization. Liaisons should be in place to assist with prevention of falls, management of osteoporosis, social services, and mental health services.
As low-energy hip fractures in the elderly population are pathognomonic for a diagnosis of osteoporosis, incorporation of medical management of deficient bone density seems to be a reasonable component of a hip-fracture treatment pathway. In 2002, a report of 385 consecutive patients with low-energy fractures (“osteoporotic fractures”) revealed that almost two-thirds of patients were prescribed osteoporosis management regimens, and that two-thirds of those patients were still compliant with treatment at 6 months. Of note, treatment was based on results of dual x-ray absorptiometry testing, which is not currently reimbursable for inpatients in the United States. Nevertheless, incorporating osteoporosis management recommendations into a care pathway for hip fractures may prove to be beneficial for long-term outcomes.
Together, the aforementioned studies represent early evidence in favor of establishing care pathways for the treatment of elderly patients with hip fracture ( Table 2 ). The studies demonstrated reduced lengths of stay, and some revealed reduced complications, with implementation of a written hip-fracture management protocol. Further interest in the development of clinical pathways for care of patients with hip fracture has stimulated an investigation of 4 distinct models of care for this frail patient population.
| Authors, Ref. Year | Country | Inclusion Criteria | Exclusion Criteria | Study Design | LOS | Mortality | Complications | Conclusion Summary | Level of Evidence |
|---|---|---|---|---|---|---|---|---|---|
| Ogilvie-Harris et al, 1993 | Canada | Elderly hip-fracture patients | None specified | Prospective | Significantly more patients in protocol group were discharged in <14 d ( P = .047) | 16% in control group, 9% in protocol group ( P = .01 a ) b | 33% in control group, 18% in protocol group ( P = .01 a ) | Better outcome and fewer postoperative complications in group of patients treated with management protocol | II (therapeutic) |
| Tallis and Balla, 1995 | Australia | Hip-fracture patients | <50 y of age, multiple fractures, pathologic fracture | Retrospective | 19.3 d preprotocol, 11.0 d postprotocol ( P <.0001) | 2% in control group, 3% in program group | No difference for systemic complications, wound infection higher in control group (6.7% vs 0%, P = .02) | Outcomes quality maintained while LOS dropped dramatically after implementation of a care protocol for hip-fracture patients | III (therapeutic) |
| Choong et al, 2000 | Australia | Hip-fracture patients managed surgically | No surgery or “nonstandard” surgery | Prospective | 8.0 d control, 6.6 d pathway ( P = .03) | None reported | 36% control, 24% pathway ( P = .40) | Multidisciplinary care pathways for hip-fracture patients reduce LOS without increasing complications | II (therapeutic) |
| Santamaria et al, 2003 | Australia | Hip-fracture patients managed surgically | Pathologic fracture, dementia, unwilling to participate | Prospective | 14.4 d control, 11.1 d pathway ( P = .15) | One in each group ( P = .48) | 54% control, 48% pathway ( P = .90) | Shorter LOS and reduced complications noted for hip-fracture patients after implementation of care pathway | Uncertain |
| March et al, 2000 | Australia | All hip-fracture admissions | None | Retrospective | 11–11.5 d control, 9.0 d pathway ( P <.01) | 16.8% in control group at 3 mo, 17.6% in pathway group ( P = .826) | “…pathway use was not associated with a lower rate of postoperative complications…” | Clinical pathway results in reduced LOS but has no effect on mortality or residential status | III (therapeutic) |
a P value indicated for entire cohort including morbidity and mortality groups.
Models of care for the geriatric patient with hip fracture
Four distinct models for the care of geriatric patients with hip fracture ( Table 3 ) have been described by Pioli and colleagues, and reviewed more recently by Kammerlander and colleagues. The first model, considered the simplest, is standard orthopedic management with consultation by geriatric medicine only as desired by the orthopedic team, and often only postoperatively (perhaps a traditional standard-of-care method that predated comanagement models in the United States). The second is orthopedic admission with daily geriatric consultation from admission through discharge. The third is geriatric admission with orthopedic consultation from admission through discharge. The fourth model involves fully integrated care of these patients whereby the orthopedic surgeon and geriatrician comanage the patient entirely from admission through discharge.
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