The memorandum of understanding, signed by the presidents of BOA and BGS in 2007
The weight of professional opinion represented by the combination of these two national associations was sufficient to induce the National Institute for Health and Care Excellence (NICE) to convene a guideline group on the management of hip fracture in older adults. The guideline was published in 2011 , endorsing completely the recommendations of the Blue Book, advocating orthogeriatric co-management. In 2012, the recommendations were issued as Quality Standards , making them official NHS policy.
However, these developments at national level represented only half of the story. Equally important were the raising of consciousness and changing of practice in healthcare workers at local level. These were achieved by means of the National Hip Fracture Database (NHFD).
1.2.2 The National Hip Fracture Database
The idea of systematically monitoring the care of hip fracture patients on an individual basis originated in Sweden with the Rikshöft, which started as long ago as 1988 and is still going strong today .
From there it was transported to Scotland and the Scottish Hip Fracture Audit (SHFA) ran continuously from 1993 to 2010, when its government funding was withdrawn in the belief that the problem of hip fracture management was now solved! In parallel with the SHFA, the Scottish Intercollegiate Guidelines Network (SIGN) produced guidelines on the Management of Hip Fracture in Older People, which were regularly updated (SIGN-15 in 1997, SIGN-56 in 2002, SIGN-111 in 2009). The SIGN guidelines benefitted from the data that the SHFA generated and the practice of hip fracture management benefitted from the publication of the guidelines, in a way that the SHFA was able to measure and document. This experience in Scotland was of the utmost importance, because it demonstrated the powerful synergy between guidelines/standards and audit in changing clinical behaviour for the better. However, it is to be noted that this only works if the audit is continuous, with individual patient-level data fed back to the participants as a benchmark of their performance against national peers. Clarity on this point was crucial in the design of the UK NHFD.
Another lesson that was applied in setting up the NHFD was that a minimal dataset, including only those variables that are necessary for benchmarking, is much more useful than an elaborate dataset because – in a busy fracture unit – the minimal dataset is the only one that will be captured with any degree of completeness. However, there are times when more detailed data are needed, so the NHFD was designed so that the basic dataset, common to all, could be supplemented by more detail for a limited time in a limited group of hospitals.
The NHFD dataset contains the patient variables that are needed to casemix-control the outcomes (including ASA score and pre-fracture domicile). The process measures include perioperative orthogeriatric care, pressure sore prevention, time to theatre and secondary prevention (falls as well as bone health). The outcome measures include return to home within 30 days and mortality at 30, 120 and 365 days – the latter is obtained reliably from the Office for National Statistics. From the outset, it was agreed that, since the care was a team effort, data would never be reported at the level of the individual surgeon, only at the level of the fracture unit as a whole. However, individual hospitals are named in the annual reports, which are in the public domain .
The NHFD went live in 2007 , using money raised from industry. Most of the funding was needed to employ coordinators, who were experienced orthopaedic nurses seconded from the NHS. These, together with lead clinicans from orthopaedics and geriatrics, were a crucial resource, in spreading the idea of continuous audit and how the data could be used to obtain better facilities, as well as helping the data-inputters understand the details of the web-based data entry forms. The number of hospitals making use of it steadily rose and, by 2009, the government had realised that the NHFD was improving care for patients and they took over its funding.
As well as producing annual reports covering all hospitals, the NHFD provides near-real-time web-based feedback to individual hospitals, with run-charts showing trends over time. They can show, for example, the 30-day mortality, or average time to surgery, for that hospital’s hip fracture patients, displayed as a time series against the national or the regional average. These provide ideal discussion material for Fracture Unit audit or strategy meetings, which are very useful in keeping a high level of interest and awareness in spite of the inevitable turnover of staff.
In 2010, the UK Department of Health went a step further, by instituting a Best Practice Tariff (BPT) for hip fractures. This meant that – on an individual patient basis – a case that was treated to a high standard was reimbursed at a higher level than one that was not. The criteria for quality were orthogeriatric co-management, time to theatre less than 36 h and secondary prevention (both falls and osteoporosis). This brought the remaining hospitals into the NHFD and now at least 95 % of cases are captured in the NHFD. The annual reports of the NHFD show that the proportion of patients receiving high quality care (according to the BPT criteria) rose from 24 % in 2010 to 67 % in 2015.
A study by Neuberger and colleagues , using data independent of the NHFD (NHS Hospital Episode Statistics), showed that year-on-year improvements in process and outcome accelerated after hospitals began participating in the NHFD. However, the study also showed that this was at least equally true before the BPT was introduced. The implication is that the financial incentive is not essential; participation in continuous audit of hip fracture care is in itself a powerful driver of positive change.
1.2.3 The Role of Nurses
One of the factors that allowed standards in the UK to rise so quickly was the role played by specially trained nurses. Although the UK is relatively well-endowed with geriatricians, it is not possible for them to spend time on a daily basis in the fracture wards, except in the largest fracture units treating many hundreds of cases per year. Experienced nurses, from a geriatric or orthopaedic (or both) background, when employed permanently as Elderly Trauma Nurse Coordinators – or some such title – on a fracture ward, quickly become expert at recognising complications or comorbidities and assisting the junior surgeons in managing them per protocol or by contacting the orthogeriatrician.
This is hard for doctors in many countries to accept, because they are culturally conditioned to view nurses as caring but inexpert doers of the doctors’ bidding. Yet it is obvious that a previously already-experienced nurse, who has then specialised in hip fracture care for 5 years and seen well over a thousand cases, has something to offer a young surgical trainee with less than 6 months’ experience on the fracture ward. The experience in the UK has been that this relationship is usually a comfortable one, with benefits all round. It needs to be reinforced by several ward-rounds per week where the consultant geriatrician teaches them both at the bedside. For young doctors, particularly those whose destiny is to be other than surgeons, this training is invaluable because, with an average age of 83 years, hip fracture patients provide rich medical experience.
It is to be hoped that international attitudes to nurses’ roles can change rapidly because there are many parts of the world where there is neither the time nor the money to train large numbers of geriatricians in time to meet the tsunami of hip fractures that is on the way.
1.3 International Dissemination
The UK experience described above has been echoed in many other countries, mainly in Europe, North America and ANZ. It is now pretty clear that a multidisciplinary approach to the acute management of elderly fragility fracture patients, incorporating the philosophy and principles of geriatric medicine, not only gives a better quality of care, but also does so in a cost-effective way . Although the details of how such a service can best be supplied will vary in the different healthcare systems around the world, the principle probably applies everywhere. The question arises – how, in practice, can that perspective be shared around the world, particularly in the emerging economies, where the trajectory of population ageing is such that extremely rapid increases in incidence will occur? Two international organisations are prominent in grappling with this challenge.
1.3.1 The Fragility Fracture Network (FFN)
In 2002, the International Society for Fracture Repair (ISFR) held a symposium in Bologna on the subject of osteoporotic fracture repair. The initial focus was on surgical technique but it was rapidly accepted that the clinical care of elderly osteoporotic fracture patients had to be a multidisciplinary affair, because of their frailty and comorbidities. From that meeting, the ISFR initiated an Osteoporotic Fracture Campaign (ISFR-OFC)  that has remained active, mainly through workshops synthesising the evidence for treatment of various fragility fractures but including scientific as well as more holistic issues such as multidisciplinary acute management and secondary prevention. However, as a research organisation, the ISFR was a little uncomfortable with the more political, campaigning challenges of fragility fractures.
In 2009, the Bone and Joint Decade launched an initiative, initially titled the Osteoporotic Fracture Line, which did aspire to have a more campaigning nature. However, by the time of the BJD networking conference and 10-year review in Lund in September 2010, it was clear that this organisation (by now renamed the Fragility Fracture Network) had not taken off – because it had not embraced multidisciplinarity and was composed almost entirely of orthopaedic surgeons. It was clear that the multidisciplinary aspect of the ISFR-OFC and the campaigning aspect of the BJD-OFL needed to be combined into one fit-for-purpose organisation.
A new organisation, the FFN, was registered in Switzerland in 2011 and a Constitution was designed, which attempted to enshrine and serve these goals. One hundred contacts from the two preceding organisations, from all over the world, were invited to an “Expert Meeting” in Berlin, where the multidisciplinary agenda of the FFN was laid out and the first General Assembly was held, formally adopting the constitution and electing the first Board. In a memorable and lengthy discussion at the first Board meeting, the mission statement of the FFN was thrashed out and has stood the test of time:
To promote globally the optimal multidisciplinary management of the patient with a fragility fracture, including secondary prevention
Annual Global Congresses were organised and grew slowly but steadily. The Fifth was held in Rome in 2016. The ethos of the FFN is to be a network of activists, who work in their own countries and their own professional organisations but are united by a desire to change health policy and develop services to the benefit of older people with fragility fractures. As a matter of principle, the multidisciplinary management of the acute fracture episode and the secondary prevention of further fragility fractures were given equal priority. At the time of writing, orthopaedic surgeons constitute less than half of the FFN membership, but are the biggest single group, which is very appropriate given that most fragility fractures present to them. The two biggest non-surgical groups are geriatricians and trauma nurses.
188.8.131.52 The FFN Hip Fracture Audit Project
As described above, the Swedish Hip Fracture Registry, the Scottish Hip Fracture Audit, the UK National Hip Fracture Database and similar initiatives in Ireland, ANZ and elsewhere played pivotal roles in driving improvements in hip fracture care. Therefore, the question naturally arose within the FFN as to whether such a tool for measuring performance against agreed standards in managing fragility fractures might be more widely applicable. A Special Interest Group was formed, first to define a Minimum Common Dataset of the essential items needed to measure performance in hip fracture care. This was published on the FFN website  and attracted much interest. In 2014, funded by the implant company Biomet, a Hip Fracture Audit Database was developed and a pilot study conducted in Croatia, German, Spain and Malta, which demonstrated that a simple international hip fracture audit was feasible .
184.108.40.206 The 2015 Strategic Review
This strategic review reaffirmed the mission statement in the preceding section and complemented it with a Vision Statement:
A world where anybody who sustains a fragility fracture achieves the optimal recovery of independent function and quality of life, with no further fractures
The discussions also concluded that the development path in the UK, described in Sect. 1.2, remained the most promising model for achieving positive change and that there was no reason to suppose it would not be successful in other parts of the world. This led to the formulation of a Strategic Focus for 2015–2020:
In the next five years, the FFN will facilitate national (or regional) multidisciplinary alliances that lead to:
Systematic performance measurement
for the care of older people with fragility fracture.
Wherever possible, the multidisciplinary alliances referred to in this statement should be based on collaboration between orthopaedics and geriatrics, because those two disciplines best cover what elderly fracture patients need. However, it is recognised that geriatrician involvement will not be possible in many countries and, in any case, the alliances need to encompass other disciplines as well, such as anaesthetics and nursing.
The ‘systematic performance measurement’ in the statement refers in particular to hip fracture audit because that is what has been shown to drive positive change. For this reason, the FFN Hip Fracture Audit Database project is a key component of the operationalisation of the strategic focus. However, it is recognised that other ways of monitoring multidisciplinary management of the acute fracture episode could in principle be developed. Furthermore, the important dimension of secondary prevention is better monitored in a different way because it must include all fragility fractures, not just hip fractures. This aspect is covered in Chap. 12.
One of the most enthusiastic industrial sponsors of the above-mentioned ISFR Osteoporotic Fracture Campaign was Synthes, a devices company (since absorbed by Johnson and Johnson into DePuy Synthes). Presumably inspired by the multidisciplinary aspect of the OFC, they initiated a Geriatric Fracture Program . This was complemented by an ambitious global programme of education organised by AOTrauma , part of the AO Foundation, which has close historical ties with Synthes and the programme is mainly directed at orthopaedic surgeons.
The values and aims of this educational programme mirror very closely the aims of the FFN. However, they do not aim to influence healthcare policy, as the FFN explicitly aims to do, so the two organisations complement each other. Their courses are of very high quality and their penetration into emerging economies is second to none.
AOTrauma also led a project to define the outcome parameters that should be used to evaluate and compare different orthogeriatric services. They assembled a wide multidisciplinary and international group of clinicans experienced in the management of elderly fracture patients and published their consensus recommendations of both the multidimensional, patient-centred parameters and the most appropriate time points in the patient’s course when they should be measured . The recommended measures included length of hospital stay, mortality, time to surgery, complications both medical and surgical, 30-day re-admission rate, mobility, quality of life, pain levels, adverse drug reactions, activities of daily living, place of residence and costs of care.
A further imaginative initiative was the development of a mobile phone or tablet app, designed to be used at the bedside by orthopaedic surgeons looking after elderly fracture patients. It covers four key orthogeriatric topics: osteoporosis, delirium, anticoagulation and pain and the content was designed by a multidisciplinary panel drawn from Switzerland, Germany and Austria. Evaluation by nearly 18,000 users worldwide showed a very high approval rate, with 80 % finding the answer they sought and 47 % reporting a change in their management as a result .
Orthogeriatric co-management of elderly fragility fracture patients has developed rapidly in the last few years. It has progressed from being mainly about post-operative rehabilitation to encompassing multidisciplinary care in the acute, perioperative phase. This has been shown to raise quality, save lives and save money. In various forms, it has spread widely in Europe, North America and ANZ, but has only penetrated a little in the emerging economies. However, those are exactly the countries where some form of co-management is needed, because they face the fastest-growing burden of disease, particularly hip fractures, as a result of their rapidly ageing populations. The task for healthcare activists across the world is clear – and very challenging.
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