Orthogeriatrics key in hip surgery

THE risk of older patients dying after a hip operation varies strikingly between hospitals, with new research suggesting the involvement of geriatric services could explain the difference.

The 30-day mortality rate after hip fracture surgery ranged from 2.7% to 11.6% in different NSW public hospitals between 2009 and 2011, a study published by the MJA reveals. (1)

However, in hospitals with an orthogeriatric service, the average mortality rate was just 6.2%, compared with 8.4% for hospitals without such a service. The research also found that mortality rates did not vary significantly between major trauma centres and other hospitals.

The study authors suggested the lower mortality rates in hospitals with orthogeriatric services might be due to a range of factors, including “medical optimisation before surgery, prevention and early detection of medical complications, better coordination of care, better communication between staff responsible for care, and better management of comorbidities”.

Of the hospitals included in the research, 62% had an orthogeriatric service, although the authors stressed these varied in form between hospitals. For example, a separate audit by the Australian and New Zealand Hip Fracture Registry (ANZHFR) found that only 14% of Australian and New Zealand hospitals had a shared-care arrangement between orthopaedic surgeons and geriatricians for all older hip fracture patients. A more common scenario was for a geriatrician, general physician or GP to review older hip fracture patients, either regularly or intermittently.

The MJA authors cautioned that one limitation of their study was the potential for backwards causation due to better overall standards of care in hospitals with an orthogeriatric service.

The study also found that patient length of stay was longer in hospitals with orthogeriatric services compared with those without (30.1 days v 28.7 days), although the authors said it was not clear whether the longer stay was appropriate and whether premature discharge could lead to higher rates of readmission.

The findings reflect a growing push to improve standards of care for hip fracture patients, following the example of the UK where hip fracture-related mortality fell from 9.4% to 8% between 2008 and 2011 following the introduction of hip fracture care audits and pay-for-performance tariffs at hospitals. (2)

Associate Professor Jacqueline Close, director of the Falls Injury Prevention Group at Neuroscience Research Australia and a coauthor of the MJA study, said mortality rates for hip fracture patients in Australia were comparable with the UK, but the “huge variation” between hospitals showed the need to standardise best practice.

“Aside from the mortality difference, there is also enormous variation in the time it takes to get an operation for hip fracture, which we know affects outcomes”, she told MJA InSight.

The ANZHFR released its new guidelines on hip fracture management this month, which echo many of the UK standards. They call for surgery to be performed on the day of, or the day after, presentation to hospital with a hip fracture. (3)

However, a study in the latest issue of the Australian and New Zealand Journal of Surgery, which Professor Close also coauthored, found that in some NSW public hospitals as few as 40% of hip fracture patients were operated on within this time frame. In other hospitals, more than 80% of patients received timely care. (4)

The availability of fracture liaison services could also substantially improve patient outcomes, Professor Close said. However, the ANZHFR audit revealed that only 20% of hospitals in Australia and New Zealand had this service.

“There is obviously quite a lot more to be done to improve hip fracture care”, Professor Close told MJA InSight.

Professor Close said the guidelines recognised that although it was important to ensure operations were performed as early as possible, this should not be before the patient was fit for the procedure.

“A real concern is rushing to operate on people without making sure they are medically stable”, she said.

Associate Professor Craig Whitehead, president of the Australian and New Zealand Society for Geriatric Medicine, said Australia had much to learn from the “amazing” reduction in hip fracture mortality in the UK.

One area where care could improve was in offering nerve blocks to patients for whom systemic analgesia did not provide sufficient pain relief, which was recommended in the new guidelines.

“Opioids can make a patient confused, but pain and stress can also drive delirium, so by using nerve blocks you can reduce their need for opioids and also decrease their risk of cognitive impairment”, Professor Whitehead told MJA InSight.

He said a major question arising from the latest study showing improved outcomes with orthogeriatric care was whether hospitals would employ extra geriatricians.

“A specialist physician is a relatively expensive resource”, he said. “However this study suggests they make a substantial difference.”

1. MJA 2014; Online 29 September
2. Royal College of Physicians: National Hip Fracture Database
3. Australian and New Zealand Hip Fracture Registry
4. ANZ J Surg 2014; 84: 633-638

(Photo: Marlinde / Shutterstock)