Management of Older People with Hip Fractures in China and India: A Systems Approach to Bridge Evidence-Practice Gaps



UK NHFD 2012 %

Admission to orthopaedics ward*
n = 780

n = 59,365

4 h



24 h



>24 h



Admission to surgery time
n = 702 %

n = 57,880 %

48 h



1 week



>1 week


n = 780 %

n = 59,365 %

Assessment by ortho- geriatrician


Pressure ulcer


Osteoporosis management


Specialist falls assessment


*In Beijing Jishuitan Hospital audit, refers to time from fracture to admission to orthopaedics ward; in UK NHFD, refers to time from admission to A&E to admission to orthopaedics ward

13.4.2 Operative Treatment of Hip Fracture

Operative treatment is the treatment of choice for all hip fracture, excluding the terminally ill. Operative rates (among people who reach a health facility with surgical services) are 97 % in the UK [19], 92 % in China [32] and a low of 66 % in India [21]. The audit from India suggests that 20 % patients or their carers refused surgical intervention [21]. This is likely due to carer inability to meet out of pocket costs, low priority for elderly health care and gender inequity for inpatient care, especially for widows [22].

There appears to be a selection bias against hospital admission of high-risk HF patients in India and in China. Surgeons are keen to maximise bed utilisation and sick patients requiring prolonged hospital stay have lower priority. The care seeking behaviour study and the HF audit from the geographical region suggests a bias against surgical care for older adults [21, 22].

13.4.3 Mortality

There was no in-hospital mortality from HF in the Beijing audit [32] compared to a 8 % 30-day mortality in the UK [25]. The 1–year mortality after a HF is 3.8 % in China compared to over 28 % in the UK and 45 % in Australia [25, 42, 43]. The higher mortality, longer LOS in hospital, and frequent ortho-geriatrician assessment is expected in the UK (Table 13.1) due to a considerably higher mean age than amongst the Chinese hip fracture patients. Early and 1 year mortality for operated patients in India is 7 % and 10 % respectively [21, 31]. The data on mortality from HF in China and India are based on tertiary care hospital audits and does not capture the deaths in the community of the significant numbers of non-operated HF [21]. The dearth of case-mix HF data, including mortality in the community, thwarts proper appraisal of the burden of HF in the population and is a barrier to generating political attention for HF as a public health issue.

13.4.4 Pressure Ulcer

This is a measure for quality of care. The audit from India reports an incidence of 66 % and 21 % for non-operative and operated HF respectively. The incidence for pressure ulcers is 2 % in China (Table 13.1) and this may reflect good care or under-reporting or admission bias against sick patients as mentioned above (Sect. 13.4.2).

13.5 Bridging the Evidence -Practice Gaps, Systems Strengthening and Generating Political Priority for Hip Fractures

13.5.1 Bridging the Evidence -Practice Gaps (EPG)

It is essential to determine the EPG through gap analysis to inform relevant intervention strategies to reduce the gap. The following activities can provide data and guidance for implementation of ICP.

  • Situation analysis of current management practices, infrastructure, referral processes and gaps in care.

  • Using the theoretical framework of implementation science to investigate significant factors that will inform contextually appropriate modifications of best practices for effective knowledge translation and implementation.

  • Assessing feasibility for an ICP approach to the management of HF through adopting the principles that impact outcomes [38].

  • Qualitative studies to capture health care providers’ perspective to inform behaviour change interventions to implement ICP for the management of older adults with HF [37].

  • Hip fracture audit

13.5.2 A Case for Hip Fracture Audit

Regular compilation of data is crucial to document morbidity, health care utilisation, cost and mortality from HF. Audits like the NHFD and FFN-supported Hip Fracture Audit Database and district audits for essential surgery will generate data to monitor, evaluate and plan for HF care. Furthermore, as described in Chap. 1, participation in continuous hip fracture audit has, in itself, the potential drive up the standard of care.

13.5.3 Systems Approach to Implement Best Practices for HF in Emerging Economies

Early findings from studies by the author (SR) on knowledge diffusion and ICP for HF have underlined the need for a systems approach to improve management of older adults with HF in India and China [22, 32, 37]. Each of the 3Ps for ICP requires a concerted plan, integrated within local health systems to ensure sustainability. A vertical approach to better one or more of the best practices without improving the health system will not produce the desired impact. For example, a push for OG care without simultaneous improvements in pre-hospital service and surgical capacity will not reap benefits. Advancing solutions with demonstrated efficacy in low-resource settings, building on existing and emerging national priorities, and developing a strong network of domestic and international allies are key to generating political priority and policy influence [45]. Promoting ICP and OG care for HF will trigger multidisciplinary practice and care pathways for other morbidities and contribute to strengthening local health systems.

I think integrated care pathways for hip fracture managements are very well established in certain western countries and there is a need to establish it even in our hospital and I think rather than having too many stakeholders for the beginning, you can just have orthopaedic surgeons, anaesthetists and internist and these 3 or 4 people can make the quality and patients can be operated earlier because the earlier you operate, the outcomes will be better”. KII with Orthopaedic Clinical lead

13.5.4 Generating Political Priority for Fragility Hip Fractures

Effective translation of knowledge and implementation of best practice for HF needs more than just medical or technical intervention. Experience from successful global health programmes suggest that strategies to generate political priority are key in achieving and sustaining the systems for good practice. Generating political priority can be defined as the degree to which global or national leaders actively pay attention to an issue and provide resources commensurate with the problem. The success in establishing ICP and HF audit in the UK and achieving the BPT as an incentive for good care, is a stellar example of ‘Generating political priority for fragility hip fractures care’. All the factors needed for political priority existed in the UK and a group of activists worked in cohesion with a well-defined strategy [44, 45]. Regional networks of professionals promoting collaborative multidisciplinary care can provide the impetus for change and generate political priority for fragility fractures.

13.5.5 Geriatric Care in India

A targeted programme for geriatric care was launched in 2010 under the aegis of the National Program for Health Care of the Elderly (NPHCE) to improve access to quality care in the public health system [46]. This flagship program is an example of success in generating political priority for the care of the elderly in India. The programme provides services at every level of health care, and investment for capacity building in human resource and infrastructure. The programme includes preventive and promotive care; management of illness, Health Manpower Development for geriatric services; Medical rehabilitation & therapeutic intervention; Developing appropriate training courses for medical and paramedical health professional in geriatric care; Promotional and encouraging basic, clinical, epidemiological and applied research in ageing and the health care of the elderly [46].

The NPHCE Program Implementation Plan (PIP) in India and activities up to District Hospital level [47] involves an identified District hospital, which will be strengthened for management of the elderly. It will have 10-bedded Geriatric Ward and run a Geriatric OPD on a daily basis. There will be a dedicated Physiotherapy Unit in all the District Hospitals with bed strength of 100 and above. Additional budgets have been sanctioned for appointing two Consultants in Medicine, six Nurses, one Physiotherapist, two Hospital Attendants and two Sanitary Attendants in each district hospital. Additional budget has been allocated for training staff in geriatric care. In due course, Geriatric Clinics will be established in primary care centres, along with home-base care for rehabilitative services at the door steps of such elderly patients. Primary Health Centre Medical Officer will be in-charge for coordination, implementation & promoting health care of the elderly. The ANM/Male Health workers will be trained to provide home based care for health care of the elderly.

Health system targets for the care of the elderly

Expected Outcomes at the end of 12th five year plan (2012–17) [47]

  • Additional 6400 beds in District Hospitals for care of the elderly

  • Geriatric Clinics and Physiotherapy units in the District Hospitals and more than 2000 Geriatric clinics in CHCs/PHCs

  • Free aids and appliances to elderly population

  • Improvement in life expectancy and better quality of life of the elderly population

13.5.6 Orthogeriatric Care in India

The NPHCE initiative of expansion of geriatric service in the entire health system provides an opportunity for developing a practical model of orthogeriatric care with HF management and osteoporosis prevention as the proxy. The following policy and practice guidance may be of value in promoting orthogeriatric care in India.

  1. 1.

    Physicians in primary care should be trained to diagnose HF and promptly refer to appropriate care centres.


  2. 2.

    All HF patients should be co-managed by a geriatrician or a physician with geriatric training within the first twelve hours after a diagnosis is made. The geriatrician should complete a comprehensive assessment and initiate appropriate intervention to manage co-morbidities and pain.


  3. 3.

    All decisions related to surgery should be made collaboratively by orthopaedic surgeon, anaesthetist and geriatrician within the first 12 h.


  4. 4.

    The geriatrician should co-manage the patient throughout pre- and post-operative periods.


  5. 5.

    Introduce curriculum for OG care in graduate and post-graduate training programmes.


  6. 6.

    Periodic interdisciplinary continuing medical education programmes on OG care should be made mandatory for renewal of licensing for practitioners.

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Aug 29, 2017 | Posted by in ORTHOPEDIC | Comments Off on Management of Older People with Hip Fractures in China and India: A Systems Approach to Bridge Evidence-Practice Gaps

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