Patients with hip fracture admitted to critical care: Epidemiology,interventions and outcome

Introduction

Although there is much current debate about the use of critical care to enhance peri-operative care of patients with hip fracture there are limited supporting data. We investigated the epidemiology, critical care interventions and outcomes of patients with hip fracture admitted to a large UK critical care unit.

Patients and methods

We reviewed all patients with hip fracture (excluding those with multiple trauma, and those with femoral shaft or peri-prosthetic fracture) who were admitted to our critical care unit during a four year period. We recorded patient characteristics, reason for admission to critical care, interventions and organ support performed, and patient outcome.

Results

We identified 99 patients with a mean age of 81 years; this represented 1% of patients admitted to critical care, and 2.4% of patients with hip fracture admitted to hospital during the study period. Fifty-two patients required no organ support; 19 received only respiratory support, 13 only cardiovascular support, 12 received both respiratory and cardiovascular support, and 3 received respiratory, cardiovascular and renal support. Outcome worsened as the level of organ support increased (p = 0.01). Fifteen patients died in critical care, acute hospital mortality was 33% and 1-year mortality was 54%. No patient for whom admission was planned before surgery died in critical care and the 30-day mortality for this group was 13%. Outcome was related to the time between surgery and critical care admission: patients admitted before surgery or longer than 2 days after surgery had worse outcomes (p = 0.001). The reason for admission to critical care also influenced outcome: patients with sepsis had poor outcome with one-third dying in critical care and a further one-third not surviving to hospital discharge.

Conclusions

The major determinants of outcome in this population were reason for admission, and timing of admission to critical care. One year survival was better than that for unselected patients aged >80 years admitted to critical care. Admission to critical care and use of enhanced peri-operative care for selected hip fracture patients is entirely appropriate and beneficial.     

Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program

BACKGROUND: Patients undergoing hip fracture surgery often experience acute post-operative cognitive dysfunction (APOCD). The pathogenesis of APOCD is probably multifactorial, and no single intervention has been successful in its prevention. No studies have investigated the incidence of APOCD after hip fracture surgery in an optimized, multimodal, peri-operative rehabilitation regimen. METHODS: One hundred unselected hip fracture patients treated in a well-defined, optimized, multimodal, peri-operative rehabilitation regimen were included. Patients were tested upon admission and on the second, fourth and seventh post-operative days with the Mini Mental State Examination (MMSE) score. RESULTS: Thirty-two per cent of patients developed a significant post-operative cognitive decline, which was associated with several pre-fracture patient characteristics, including age and cognitive function, but also the number of peri-operative transfusions. The development of APOCD was also associated with impaired post-operative rehabilitation and an increased length of stay. APOCD was associated with the development of a major medical complication in 35% of all patients. In 65% of patients developing APOCD without a concomitant medical complication, the only risk factors were cognitive level and regular anti-psychotic treatment. CONCLUSION: On the basis of current evidence, APOCD is prevalent amongst hip fracture patients despite multimodal intervention; future research should therefore focus on defining subgroups of hip fracture patients amenable to specific prophylactic or interventional measures against APOCD.     

Efficacy of multimodal optimization of mobilization and nutrition in patients undergoing hip replacement: a randomized clinical trial

BACKGROUND: The aim of this trial was to assess the effects of optimization of mobilization and nutrition on patients undergoing primary total hip replacement (THR). METHODS: Seventy-nine patients undergoing elective primary THR were recruited prospectively. After randomization, one group received optimized pre-operative information and enforced mobilization and nutrition, another group received conventional peri-operative care. Epidural anaesthesia and post-operative epidural analgesia with local anaesthetics and opioids were used in all cases. Outcome related to length of stay, complications, pain, mobilization, energy intake, and physical activities of daily living (PADL). RESULTS: Although mobilization and nutrition were highly significantly increased in the intervention group, the reduction in length of stay was moderate (7.0 vs. 8.0 days P = 0.019). We found no differences between groups in relation to complications or pain. In the intervention group, the median day of independence in PADL was the third post-operative day (2 : 6 day) and the fourth post-operative day (2 : 7 day) in the control group. The difference was not significant. CONCLUSION: Compared with conventional care, optimal and aggressive nutrition and mobilization resulted in a very moderate reduction in length of stay. There were no differences regarding pain, complications or time until independence in PADL.     

The effect of a multidisciplinary care bundle on the incidence of delirium after hip fracture surgery: a quality improvement study

Delirium is a common complication following hip fracture surgery. We introduced a peri-operative care bundle that standardised management in the emergency department, operating theatre and ward. This incorporated: use of fascia iliaca blocks; rationalisation of analgesia; avoidance of drugs known to trigger delirium; a regular education program for staff; and continuous auditing of compliance. The study was conducted between June 2017 and December 2018. We recruited 150 patients before (control group) and 150 patients after (care bundle group) the introduction of the care bundle. In patients having surgery for a hip fracture, there was a lower incidence of delirium on the third postoperative day in the care bundle group compared with the control group (33 patients (22%) vs. 49 patients (33%)), respectively; p = 0.04). Patients in the care bundle group had an adjusted OR of 2.2 (95%CI 1.1–4.4) (p = 0.03) for the avoidance of delirium on the third postoperative day. There was no difference between groups for the secondary outcome measures (measured at 30 days postoperatively) including: all-cause mortality; composite morbidity; institutionalisation; and walking status. During the study period, compliance with elements of the care bundle improved in the emergency department (49 patients (33%) compared with 85 patients (59%); p < 0.001) and anaesthetic department (40 patients (27%) compared with 104 patients (69%); p < 0.001), while orthogeriatrics maintained a high level of compliance (140 patients (93%) compared with 143 patients (95%); p = 0.45). There was a clinically and statistically significant reduction in the incidence of delirium following hip fracture surgery in patients treated with a multidisciplinary care bundle.     

Total hip replacement for hip fracture: Surgical techniques and concepts

When treating a hip fracture with a total hip replacement (THR) the surgical technique may differ in a number of aspects in comparison to elective arthroplasty. The hip fracture patient is more likely to have poor bone stock secondary to osteoporosis, be older, have a greater number of co-morbidities, and have had limited peri-operative work-up. These factors lead to a higher risk of complications, morbidity and perioperative mortality.Consideration should be made to performing the THR in a laminar flow theatre, by a surgeon experienced in total hip arthroplasty, using an anterolateral approach, cementing the implant in place, using a large head size and with repair of the joint capsule. Combined Ortho-geriatric care is recommended with similar post-operative rehabilitation to elective THR patients but with less expectation of short length of stay and consideration for fracture prevention measures.     

Bypassing the post-anaesthesia care unit after elective hip and knee arthroplasty: a prospective cohort safety study

Following knee and hip arthroplasty, transfer to a recovery area immediately following surgery and before going to ward might be unnecessary in low-risk patients. Avoiding the recovery area in this way could allow for more targeted use of resources for higher risk patients, which may improve operating theatre flow and productivity. A prospective single-centre cohort study on the safety of criteria for bypassing the post-anaesthesia care unit in elective hip and knee arthroplasty was designed. Criteria were: ASA physical status < 3; peri-operative bleeding < 500 ml; low postoperative discharge-score (modified Aldrete-score); and an uncomplicated surgical and neuraxial anaesthesia procedure. The primary outcome was the number of patients in need of secondary readmission to the post-anaesthesia care unit. Events within the first 24 postoperative hours were recorded, along with readmission and complication rates. A total of 696 patients were included, with 287 (41%) undergoing total hip arthroplasty, 274 (39%) undergoing total knee arthroplasty and 135 (19%) undergoing unicompartmental knee-arthroplasty. Of these, 207 (44%) bypassed the post-anaesthesia care unit. Patients all received multimodal analgesia without peripheral nerve blockade. Only one patient in the ward group required secondary readmission to the post-anaesthesia care unit. Within 24 h, 151 events were reported, with 41 (27%) in the ward group and 110 (73%) in the post-anaesthesia care unit group. Two events in each group occurred within 2 hours of surgery. No complications were attributed to bypassing the post-anaesthesia care unit. The use of simple pragmatic criteria for bypassing the post-anaesthesia care unit for patients undergoing knee and hip arthroplasty with spinal anaesthesia is possible and associated with significant reduction of post-anaesthesia care unit admission and without apparent safety issues. Confirmation is needed from other studies and external validity should be interpreted cautiously in centres with different peri-operative regimens, organisational and staffing structures.     

Perioperative multimodal optimisation in patients undergoing surgery for fractured neck of femur

IntroductionEnhanced Recovery after Surgery protocols are associated with reduced length of stay and morbidity in patients undergoing major surgery. The aim of this audit was to assess the impact of a multimodal optimisation protocol in patients admitted with fractured neck of femur.Patients and methodsA multimodal optimisation protocol was introduced for the care of patients with proximal femoral fractures. The short-term effects of the optimised perioperative care programme was assessed and compared with the conventional perioperative care before the intervention.ResultsA total of 232 patients were included in this audit, 117 optimised care and 115 conventional care. Patients were similar with regards to age, gender, domicile, mental status and the type of operation. The optimised group suffered from fewer post-operative complications (36 out of 117 vs 48 out of 115, P = 0.04, Chi square test). There was no significant difference between two groups with regards to the length of hospital stay and 30-day mortality.ConclusionMultimodal optimisation may be associated with a decline in post-operative morbidity in patients with proximal hip fracture. It does not have any significant impact on the length of hospital stay and 30-day mortality.     

综合护理干预预防老年髋部骨折患者术后谵妄

目的探讨综合护理干预对老年髋部骨折术后谵妄的预防效果。方法将186例髋部骨折手术老年患者分为对照组94例、观察组92例。对照组行常规护理;观察组实施针对性综合护理干预措施,包括心理干预、疼痛管理、氧疗、视听觉及谵妄前兆的观察、睡眠管理,渐进式功能锻炼。结果观察组谵妄发生率及住院时间显著低于/短于对照组,患者满意率显著高于对照组(P0.05,P0.01)。结论对老年髋部骨折手术患者实施针对性综合护理干预能有效降低术后谵妄发生率,缩短住院时间,从而提高患者满意度。     

Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial

BACKGROUND: Treatment of osteoporosis following a hip fracture has been notoriously poor. Many efforts have been made to improve treatment rates. The purpose of this study was to determine whether a perioperative inpatient intervention program, involving patient education and providing a list of questions for the primary care physician, increased the percentage of patients in whom osteoporosis was addressed following a hip fracture. METHODS: A prospective, randomized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted. During their hospitalization, the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures, the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment, and the importance of medical follow-up for osteoporosis management. These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician, and they were reminded about the questions during a follow-up telephone call six weeks later. The patients in the control group received a brochure describing methods for preventing falls. Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed. Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy. RESULTS: The average age in each group was eighty-two years, and 78% of the patients were female. Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial. Fifteen (42%) of the thirty-six patients who had been randomized to the study group, compared with only seven (19%) of the thirty-six patients in the control group, had their osteoporosis addressed by their primary physician. This difference between the groups was significant (p = 0.036). CONCLUSIONS: Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions. Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management.     

Increased energy intake in hip fracture patients affects nutritional biochemical markers

Background and Aims: We have previously shown that nutritional guidelines decreased the incidence of pressure ulcers in hip fracture patients. In the present study, we evaluate whether the nutritional biochemical markers S-IGF-1 (Insulin-like Growth Factor 1), S-Transthyretin and S-Albumin are affected by patients' energy intake, and whether the markers are useful as predictors of postoperative complications. Material and Methods: Quasi-experimental design, with one intervention and one control group, as well as pre- and post-study measurements. Eighty-eight hip fracture patients were in-cluded: 42 in the control group and 46 in the intervention group. The control group received regular nutritional support pre- and postoperatively, while the intervention group received nu-tritional support that followed new, improved clinical guidelines from admission to five days postoperatively. S-Albumin, S-Transthyretin, C-Reactive Protein (S-CRP) and S-IGF-1 were analysed at admission and five days postoperatively as well as complications like pressure ulcer and infection. Results: The intervention group had a significantly higher energy intake; for example, 1636 kcal versus 852 kcal postoperative day 1. S-IGF-1 levels decreased significantly in the control group, while no decrease in the intervention group. S-Albumin and S-Transthyretin decreased and S-CRP increased significantly in both groups, indicating that those markers were not af-fected short-term by a high-energy intake. There was no correlation between short-term post-operative complications and S-IGF-1, S-Transthyretin or S-Albumin at admission. Conclusion: The results of our study showed that S-IGF-1 can be used as a short-term nutri-tional biochemical marker, as it was affected by a five-day high-energy regimen. However, neither S-IGF-1, S-Transthyretin or S-Albumin were useful in predicting postoperative com-plications within five days postoperatively.     

Guideline for the management of hip fractures 2020

We convened a multidisciplinary Working Party on behalf of the Association of Anaesthetists to update the 2011 guidance on the peri-operative management of people with hip fracture. Importantly, these guidelines describe the core aims and principles of peri-operative management, recommending greater standardisation of anaesthetic practice as a component of multidisciplinary care. Although much of the 2011 guidance remains applicable to contemporary practice, new evidence and consensus inform the additional recommendations made in this document. Specific changes to the 2011 guidance relate to analgesia, medicolegal practice, risk assessment, bone cement implantation syndrome and regional review networks. Areas of controversy remain, and we discuss these in further detail, relating to the mode of anaesthesia, surgical delay, blood management and transfusion thresholds, echocardiography, anticoagulant and antiplatelet management and postoperative discharge destination. Finally, these guidelines provide links to supplemental online material that can be used at readers' institutions, key references and UK national guidance about the peri-operative care of people with hip and periprosthetic fractures during the COVID-19 pandemic.     

A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care?

IntroductionHip fracture surgery is among the most performed surgical procedures in elderly patients. Mortality rates are high, however, and patients often fail to live independently following a hip fracture. To improve outcome, multidisciplinary care pathways have been initiated, but longer-term results are lacking. Aim of this study was to compare functional outcome and living situation six months after hip fracture treatment with and without a care pathway.Patients and methodsA multicentre prospective controlled trial was conducted with three hospitals: in one hospital patients were treated with a care pathway, in the other hospitals patients received usual care. All patients aged ≥ 60 years with a hip fracture were asked to participate. Besides basic characteristics, health-related quality of life (EQ-5D) and performance scores of activities of daily living (Katz Index and Lawton IADL) were assessed. Differences in scores were analysed using linear regression. Propensity score adjustment was used to correct for differences between the care pathway and the usual care group. Missing data were imputed.ResultsNo differences in rate of return to prefracture ADL level were found between patients in the care pathway group and the usual care group. The percentage of participants in the same situation as before the fracture was the same in both treatment groups (81%). There were no significant differences in quality of life, activities of daily living or mortality (15% vs 10%, p = 0.17), but hospital stay in the care pathway group was significantly shorter (median 7 vs 10 days).DiscussionTreatment of elderly patients with a hip fracture is commonly organised in care pathways. Although short-term advantages are reported, positive effects on longer-term functional results could not be proven in our study. This study confirmed a shorter hospital stay in the care pathway group, which potentially may lead to a reduction in costs.ConclusionsFunctional outcome and living situation six months after a hip fracture is the same for patients treated with or without a care pathway.     

The association between aspirin and blood loss in hip fracture patients

This is a cohort study involving 98 patients who presented to a regional orthopaedic unit with a hip fracture. Blood loss was assessed by pre and post operative haemoglobin concentrations, and transfusion requirements were used as outcome measures. The influence of pre-operative aspirin use and fracture type was analysed with respect to these outcome measures. Forty two percent of patients were regular aspirin users, and were comparable to the non aspirin group, apart from having a significantly greater prevalence of atherosclerotic vascular disease. There was no significant difference between the aspirin and non aspirin groups in terms of preoperative haemoglobin concentrations, perioperative changes in haemoglobin levels and transfusion requirements. Fifty one percent of patients had extracapsular hip fractures, and these patients were comparable in terms of demographic characteristics, including aspirin use, to the group with intracapsular hip fractures. The extracapsular hip fracture group were found to have significantly increased peri-operative blood loss as measured by changes in the haemoglobin level, and in transfusion requirements when analysed against the intracapsular hip fracture group. We found that it is the fracture site, rather than aspirin use pre-operatively, that is predictive of blood loss and transfusion requirements in patients presenting with hip fractures.     

Perioperative tobacco use interventions in Japan: a survey of thoracic surgeons and anaesthesiologists

BACKGROUND: Tobacco use interventions in surgical patients who smoke could benefit both their short-term outcome and long-term health. Anaesthesiologists and surgeons can play key roles in delivering these interventions. This study determined the practices, attitudes, and beliefs of these physicians regarding tobacco use interventions in Japan. METHODS: Questionnaires were mailed to a national random sampling of Japanese anaesthesiologists and thoracic surgeons (1000 in each group). RESULTS: The survey response rate was 62%. More than 80% of respondents agreed or strongly agreed with the statements affirming the benefits of abstinence to surgical patients. However, only 26% of surgeons and 6% of anaesthesiologists reported almost always providing help to their patients to quit smoking. Compared with anaesthesiologists, surgeons were more likely to perform the elements of current recommendations for brief intervention, and to have attitudes favourable to tobacco use interventions. The most significant barrier to intervention identified by both groups was a lack of time to perform counselling. Compared with non-smokers, physicians who smoked were less likely to perform each of the recommended tobacco interventions CONCLUSIONS: Although current rates of intervention provided by anaesthesiologists and surgeons are low, there is considerable interest among these physicians in learning more about interventions. Given the relatively high prevalence of smoking in Japan and the potential for surgery to serve as a 'teachable moment' to promote abstinence from smoking, leadership by these specialists in the area of tobacco control could have a major impact on public health in Japan.     

Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study

Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients (‘high-risk surgical bundle’) who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30–0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49–0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30–0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.     

Outcome assessment in hip fracture: evaluation of the practicality of commonly-used outcomes in hip fracture studies

Introduction  

Elderly patients are at a major risk for a first hip fracture. The decrease in bone mineral density may account for 60–85% of the variability in fracture risk. Other contributing factors for hip fractures include cognitive impairment as well as impaired mobility and visual depth perception. Dizziness and poor or fair self-perceived health care characteristics are predictive of a second hip fracture. In general, patients over the age of 65 years admitted to a geriatric rehabilitation unit after proximal hip fracture have complex multiple interacting pathologies with 78% having significant co-morbidity. Because of the added co-morbidity, we believed that the choice of outcome assessment in hip fracture studies would reflect the practical qualities of an instrument. The purpose of our study was to evaluate the practicality of functional outcome instruments found in the current literature in the elderly following postoperative hip fracture.     

Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial

Summary

Hip fracture patients can benefit from nutritional supplementation during their recovery. Up to now, cost-effectiveness evaluation of nutritional intervention in these patients has not been performed. Costs of nutritional intervention are relatively low as compared with medical costs. Cost-effectiveness evaluation shows that nutritional intervention is likely to be cost-effective.

Introduction

Previous research on the effect of nutritional intervention on clinical outcome in hip fracture patients yielded contradictory results. Cost-effectiveness of nutritional intervention in these patients remains unknown. The aim of this study was to evaluate cost-effectiveness of nutritional intervention in elderly subjects after hip fracture from a societal perspective.

Methods

Open-label, multi-centre randomized controlled trial investigating cost-effectiveness of intensive nutritional intervention comprising regular dietetic counseling and oral nutritional supplementation for 3 months postoperatively. Patients allocated to the control group received care as usual. Costs, weight and quality of life were measured at baseline and at 3 and 6 months postoperatively. Incremental cost-effectiveness ratios (ICERs) were calculated for weight at 3 months and quality adjusted life years (QALYs) at 6 months postoperatively.

Results

Of 152 patients enrolled, 73 were randomized to the intervention group and 79 to the control group. Mean costs of the nutritional intervention was 613 Euro. Total costs and subcategories of costs were not significantly different between both groups. Based on bootstrapping of ICERs, the nutritional intervention was likely to be cost-effective for weight as outcome over the 3-month intervention period, regardless of nutritional status at baseline. With QALYs as outcome, the probability for the nutritional intervention being cost-effective was relatively low, except in subjects aged below 75 years.

Conclusion

Intensive nutritional intervention in elderly hip fracture patients is likely to be cost-effective for weight but not for QALYs. Future cost-effectiveness studies should incorporate outcome measures appropriate for elderly patients, such as functional limitations and other relevant outcome parameters for elderly.     

多学科协作诊疗在老年髋部骨折治疗中的临床应用

目的探讨多学科协作诊疗模式在老年髋部骨折中治疗应用的临床疗效。方法回顾分析2020年4月至2021年4月北京市房山区良乡医院骨科采用多学科协作诊疗模式治疗的159例老年髋部骨折患者(研究组),与2018年12月至2019年12月采用传统模式治疗的183例患者(对照组)进行比较。结果两组在性别、麻醉ASA分级、髋部骨折类型比较差异无统计学意义(P>0.05)。研究组年龄显著高于对照组(81.4±4.2)岁比(79.6±3.2)岁。研究组手术治疗比例显著高于对照组(89.9%比80.9%)。研究组术前等待时间(3.6±0.4)d、住院时间(10.8±0.3)d,显著短于对照组。研究组院内并发症发生率显著低于对照组(4.40%比6.01%)。研究组120 d病死率显著低于对照组(3.77%比4.37%)。研究组120天Parker功能评分显著优于对照组。结论与传统的诊疗模式相比,多学科协作诊疗模式可以提高老年髋部骨折患者手术比例,缩短术前等待时间和住院时间,降低并发症发生率和病死率,提高功能效果。     

The cost of a hip fracture: Estimates for 1,709 patients in Sweden

We calculated the costs related to hip fractures and estimated the potential cost savings from preventing hip fractures. Subjects for this retrospective study were 1,709 hip fracture patients admitted for a primary hip fracture during 1992 in Stockholm, Sweden. Direct costs were compiled for the services of hospital orthopedics, hospital geriatrics, nursing homes, home for the elderly, group living, other acute hospital care, and municipal home help. The direct costs per patient during 1 year after a fracture amounted to about USD 40,000. The county council was responsible for 59% of the direct costs during 1 year after a hip fracture, while the remaining 41 % were referred to the municipality. In the morbidity group, the potential cost savings per patient from preventing hip fractures was about USD 22,000.