Clinical pathway after hip fracture

PURPOSE: Hip fracture occurs frequently, resulting in considerable morbidity, mortality and utilization of healthcare resources. Technical advances in fracture fixation and surgical treatment have improved outcomes following hip fracture in the elderly. However, further improvement in outcomes of hip fracture patients may be possible with utilization of a clinical pathway designed to enhance outcomes in a standardized, cost-effective manner. This paper presents a clinical pathway for the treatment of hip fractures in the elderly with the above aims. METHOD: The clinical pathway presented is based on personal experience and literature pertaining to the treatment of the elderly hip fracture patient. It outlines a suggested algorithmic approach to the patient that begins with the initial evaluation, progresses on through pre-operative and operative management, and ends with post-operative rehabilitation and treatment. RESULTS: The clinical pathway for the hip fracture patient in this paper is a working treatment algorithm that has been successful in personal experience. CONCLUSION: This treatment algorithm has been utilized successfully in personal experience. Further input from healthcare professionals may prove to enhance outcomes in a cost-effective, standardized manner.     

Clinical pathway after hip fracture

Purpose: Hip fracture occurs frequently, resulting in considerable morbidity, mortality and utilization of healthcare resources. Technical advances in fracture fixation and surgical treatment have improved outcomes following hip fracture in the elderly. However, further improvement in outcomes of hip fracture patients may be possible with utilization of a clinical pathway designed to enhance outcomes in a standardized, cost-effective manner. This paper presents a clinical pathway for the treatment of hip fractures in the elderly with the above aims.

Method: The clinical pathway presented is based on personal experience and literature pertaining to the treatment of the elderly hip fracture patient. It outlines a suggested algorithmic approach to the patient that begins with the initial evaluation, progresses on through pre-operative and operative management, and ends with post-operative rehabilitation and treatment.

Results: The clinical pathway for the hip fracture patient in this paper is a working treatment algorithm that has been successful in personal experience.

Conclusion: This treatment algorithm has been utilized successfully in personal experience. Further input from healthcare professionals may prove to enhance outcomes in a cost-effective, standardized manner.     

Scoring systems to evaluate elderly patients with hip fractures

Purpose: To report about different scales and scoring systems used to evaluate elderly patient with hip fracture during the acute post-fracture phase and during post-operative rehabilitation.

Methods and results: Report of the different scales from a literature review.

Conclusions: Standard validated scales are one of the tools to perform such an evaluation process as objectively as possible and to evaluate surgical, medical and rehabilitative management in these elderly patients. These scales are only a complementary tool, and they cannot replace physical examination. However, these validated tools are probably more accurate than just clinical impression. The appropriate combination of clinical experience and these scales may well contribute to a better care of elderly patients with hip fractures.     

Audit,guidelines and standards: Clinical governance for hip fracture care in Scotland

Purpose: To report on experience of national-level audit, guidelines and standards for hip fracture care in Scotland.

Methods: Scottish Hip Fracture Audit (from 1993) documents case-mix, process and outcomes of hip fracture care in Scotland. Evidence-based national guidelines on hip fracture care are available (1997, updated 2002). Hip fracture serves as a tracer condition by the health quality assurance authority for its work on older people, which reported in 2004.

Results: Audit data are used locally to document care and support and monitor service developments. Synergy between the guidelines and the audit provides a means of improving care locally and monitoring care nationally. External review by the quality assurance body shows to what extent guideline-based standards relating to A&E care, pre-operative delay, multidisciplinary care and audit participation are met

Conclusion: Three national-level initiatives on hip fracture care have delivered: Reliable and large-scale comparative information on case-mix, care and outcomes; evidence-based recommendations on care; and nationally accountable standards inspected and reported by the national health quality assurance authority. These developments are linked and synergistic, and enjoy both clinical and managerial support. They provide an evolving framework for clinical governance, with casemix-adjusted outcome assessment for hip fracture care as a next step.     

Clinical outcomes in transition program for older adults with hip fracture

Measuring and managing outcomes across the continuum of care has been a major task for healthcare organizations over the past decade. Care of older adults with hip fracture and their transition to the community is particularly challenging. This article describes a program designed specifically to meet these challenges. The goals of the transition program were to promote improved clinical outcomes, reduce acute care resource utilization through early discharge and provision of cost-effective home care, and maintain or improve patient satisfaction. Results of the outcome analysis demonstrated successful goal attainment. The strength of the outcome evaluation is that it links both a qualitative and quantitative approach, providing a richer and more holistic view of the client experience.     

Fear of falling and changed functional ability following hip fracture among community-dwelling elderly people: an explanatory sequential mixed method study

Purpose: The aims of the study were to assess self-reported fear of falling (FOF) and functional ability among community-dwelling elderly people 3–6 months post hospital discharge after a hip fracture, to investigate the association between FOF and functional ability, and to explore the lived experience of FOF and disability when recovering from a hip fracture. Method: A sequential explanatory mixed method design was used in a “face-to-face” survey assessing FOF (Falls Efficacy Scale-International, FES-I), avoidance of activities (Modified survey of Activities and Fear of Falling, mSAFFE), functional ability (Functional Recovery Score, FRS), and mobility (New Mobility Score, NMS) followed by in-depth interviews of four participants. Interviews were analyzed using systematic text condensation. Results: Among the 33 participants 58% had a high degree of FOF and avoided more activities, needed more assistance in activities of daily living, and were less mobile than participants who had a low degree of FOF (p < 0.0001). According to the informants FOF reduced their functional ability and seriously altered their lives. Conclusions: FOF was common and significantly associated with activity avoidance, disability, and affected the lives of elderly recovering from a hip fracture. Some patients were physically incapacitated by FOF.

Implications for Rehabilitation

• Fear of falling can affect post discharge recovery following a hip fracture and is a factor limiting functional ability in elderly patients.

• Fear of falling should be addressed in clinical practice and future research as fear of falling-screening at hospital discharge might be beneficial in tailoring rehabilitation efforts to the individual patient.

• Older patients recovering from hip fracture need to perform activities of daily living independently and overcome fear of falling to sustain quality of life and contain costs to society.

     

Costs and consequences of hip fracture occurrence in old age: An economic perspective

Purpose: To summarize the reported short- and long-term costs associated with hip fracture occurrence in old age, based on a systematic literature review of published studies. A further aim is to provide a clinician-oriented discussion of the different types of economic evaluations, with an emphasis on studies that examined potential determinants of the costs of care after hip fracture.

Method: Literature review.

Main results: Even after the initial hospitalization, hip fractures continue to generate significant costs throughout the one-year period after discharge, but particularly during the first three months. Cost estimates based on data obtained prospectively from hip-fracture patients and matched controls showed that the costs associated with the treatment of hip-fracture patients are about three times greater than those resulting from the treatment of age and residence-matched controls without a fracture. Two-fifths of these excess costs are incurred during the first three months following hospital discharge. Increasing age at the time of injury and living in an institution before the fracture are among the most important determinants of an increased cost of care after hospital discharge. Programs that focus on continuity of care, adopt a multidisciplinary approach, and accelerate rehabilitation have shown to be able to reduce the cost of care after hip fracture.

Conclusions: This review emphasizes the importance of current and future interventions to decrease the incidence of hip fracture. While the current review cannot provide definite answers to the questions of cost containment, our review provides critically important evidence about the need to base health policy decisions on empirical observations. Comprehensive economic analyses of financial costs and health outcomes are needed to develop cost-effective strategies.     

Fracture‐related hip pain in elderly patients with proximal femoral fracture after discharge from stationary treatment

Background: Proximal femoral fracture is a common condition in the elderly but very little is known about fracture‐related hip pain in these patients after discharge from stationary treatment. Aims: To identify risk factors associated with persistent hip pain in elderly hip‐fracture patients. Methods: We analysed data from a large observational study, evaluating the health care situation of hip‐fracture patients between January 2002 and September 2003 in Germany. For this analysis, we focused on a sub‐sample of patients who were 65 years or older, had sustained an isolated proximal femoral fracture and had undergone surgical intervention. A telephone interview was conducted 6–12 months after discharge. Pain intensity, pain‐related disability and severity of chronic pain were measured using the Graded Chronic Pain Scale (GCPS). Multivariate linear regression methods were applied to test hospital patient data for their value in predicting post‐hospitalisation presence of fracture‐related pain. Results: In total, 1541 patients (mean age 78.4, 76.1% female) were enrolled in this analysis. The prevalence of fracture‐related hip pain was 13.4% (206/1541). Among these 206 patients, 57.3% had pain intensity scores ≥50, 65.0% had pain disability scores ≥50, and the severity of chronic pain (Grades 1–4) was assessed as follows: (1) 34.0%, (2) 19.4%, (3) 31.5%, (4) 15.1%. The clinical variables age, weight and operative procedure were found to be predictive of post‐hospitalisation fracture‐related pain. Conclusions: This analysis shows that a substantial percentage of elderly patients with proximal femoral fracture suffer intense fracture‐related hip pain after stationary treatment.     

Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool

Purpose.?To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay.

Method.?One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index.

Results.?The average VAS score on admission was 7.38 ± 1.20 and on discharge 3.67 ± 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days.

Conclusions.?Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting.     

Delivering high quality hip fracture rehabilitation: the perspective of occupational and physical therapy practitioners

Aim: The majority of post-acute hip fracture rehabilitation in the US is delivered in skilled nursing facilities (SNFs). Currently, there are limited guidelines that equip occupational and physical therapy practitioners with a summary of what constitutes evidence-based high quality rehabilitation. Thus, this study aimed to identify rehabilitation practitioners’ perspectives on the practices that constitute high quality hip fracture rehabilitation.

Methods: Focus groups were conducted with 99 occupational and physical therapy practitioners working in SNFs in southern California. Purposive sampling of facilities was conducted to capture variation in key characteristics known to impact care delivery for this patient population (e.g., financial resources, staffing, and patient case-mix). Questions aimed to elicit practitioners’ perspectives on high quality hip fracture rehabilitation practices. Each session was audio-recorded and transcribed. Data were systematically analyzed using a modified grounded theory approach.

Results: Seven themes emerged: objectives of care; first 72?h; positioning, pain, and precautions; use of standardized assessments; episode of care practices; facilitating insight into progress; and interdisciplinary collaboration.

Conclusions: Clinical guidelines are critical tools to facilitate clinical decision-making and achieve desired patient outcomes. The findings of this study highlight the practitioners’ perspective on what constitutes high quality hip fracture rehabilitation. This work provides critical information to advance the development of stakeholder-driven rehabilitation clinical guidelines. Future research is needed to verify the findings from other stakeholders (e.g., patients), ensure the alignment of our findings with current evidence, and develop measures for evaluating their delivery and relationship to desired outcomes.

• Implications for Rehabilitation

• This study highlights occupational and physiotherapy therapy practitioners’ perspectives on the cumulative best practices that reflect high quality care, which should be delivered during hip fracture rehabilitation.

• While this study was limited to two professions within the broader interdisciplinary team, consistently occupational and physiotherapy therapy practitioners situated their role and practices within the team, emphasizing that high quality care was driven by collaboration among all members of the team as well as the patient and caregivers.

• Future research needs to evaluate the (a) frequency at which these practices are delivered and the relationship to patient-centered outcomes, and (b) perspectives of rehabilitation practitioners working in other PAC settings, patients, caregivers, as well as the other members of the interdisciplinary PAC team.

     

Influence of age,sex, fracture type and pre-fracture living on rehabilitation pattern after hip fracture in the elderly

Purpose: To evaluate the influence of background factors on the rehabilitation pattern after a hip fracture in the elderly.

Method: Prospective registration based on the Swedish national register for hip fracture patients called RIKSHÖFT/SAHFE (Standardised Audit of Hip Fractures in Europe). The place of living was registered both before fracture and during the following four months period (120 days). Graphs were calculated and drawn based on day-to‐day changes. Also influences of age, sex, fracture type and type of operation were analyzed.

Results: The patient's pre-fracture functional capacity as evidence by the place they were able to manage to live before the fracture was the most discriminating factor for the rehabilitation; more than sex, fracture type or type of operation. Age was also a highly discriminating factor with a pronounced influence on the rehabilitation pattern.

Conclusions: These background parameters are very important factors when planning the rehabilitation of hip fracture patients. A strategy with individualized planning of the rehabilitation procedure will be highly necessary in the future, in view of the increasing amount of elderly with hip fractures prognosticated during the coming decades. The knowledge about influencing factors here presented will be useful when planning and performing the rehabilitation for this resource-consuming group of patients.     

Endoprosthetic replacement of unstable,comminuted intertrochanteric fracture of the femur in the elderly,osteoporotic patient: A review

Purpose: To summarize currently existing evidence regarding prosthetic replacement for the treatment of intertrochanteric (extracapsular) hip fractures and their complications.

Method: Report of a clinical investigation program conducted at one academic institution and literature review.

Results: Although the majority of intertrochanteric fractures can be successfully managed with operative reduction and fixation, some patients may benefit from prosthetic replacement. For older patients with severe osteoporosis or comminution there are some definite advantages of prosthetic replacement over reduction and fixation. If the prosthetic replacement has been properly performed, there is very little concern over immediate ambulation and weight-bearing. This decreases the incidence of postoperative complications, such as pulmonary infection, atelectasis, and pressure sores. In addition, acute prosthetic replacement eliminates the possibility of excessive collapse compromising walking function, mal-union, as well as the uncommon problems of non-union and avascular necrosis. Likewise, hip arthroplasty is an effective salvage procedure after the failed internal fixation of an intertrochanteric fracture in an older patient. Most patients report good pain relief, and surprisingly few serious orthopaedic complications are associated with this procedure.

There are, however, a number of methodological concerns regarding previous studies which have examined the use of prosthetic replacement for the treatment of comminuted intertrochanteric fractures or non-union in the elderly patient. Many have been small case series without a control group. There are few comparative studies and even fewer prospective, randomized controlled trials which have compared prosthetic replacement surgery with standard internal fixation techniques in the long run.

Conclusions: Older patients with severe osteoporosis or comminution may benefit from prosthetic replacement to treat intertrochanteric fractures and non-unions. Overall, rigorously conducted prospective randomized clinical trials with long-term follow-up are lacking. Despite these methodological reservations, several authors have reported successful prosthetic replacement for treating intertrochanteric fractures and their complications in elderly patients. Few serious orthopaedic complications are associated with these procedures, and most patients have good pain relief.     

Factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture

Purpose: To examine factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture. Method: Population-based prospective data on 887 consecutive hip fracture patients aged 65 years and older. The domains of the geriatric assessment were the independent and changes in mobility level and living arrangements 4 months postoperatively the outcome variables. Results: Of the survivors, 499 (73%) attended the assessment. The mobility level had declined in 39% of the attendees and 38% of them had moved to more supported living arrangements 4 months after the hip fracture. In the age-adjusted univariate logistic regression analyses, almost all the domains of the comprehensive geriatric assessment were significantly associated with both outcomes. In the forward stepwise multivariate analysis, disability in activities of daily living, poor performance in Timed Up and Go and comorbidity as measured by the American Society of Anesthesiologists scores remained significantly associated with the outcomes. Conclusions: While comorbidity and disability in activities of daily living and mobility are the major indicators of poor outcomes of mobility and living arrangements after hip fracture, all the domains in the comprehensive geriatric assessment deserve attention during hip fracture care and rehabilitation.

• Implications for Rehabilitation

• In almost half of the patients the mobility level and living arrangements had deteriorated 4 months after the hip fracture, suggesting an urgent need for more effective postoperative rehabilitation.

• Almost all the domains of the comprehensive geriatric assessment were associated with poor outcomes and require equal attention during the acute and postacute phases of hip fracture care and in the course of rehabilitation.

• A geriatric outpatient assessment a few months after the hip fracture provides a check-point for the outcomes and an opportunity to target interventions at different domains of the comprehensive assessment.

     

Discharge planning for patients receiving rehabilitation after hip fracture: A qualitative analysis of physiotherapists' perceptions

Purpose.?To explore the perceptions of clinicians about walking requirements and discharge criteria for patients being discharged home in the community from rehabilitation after hip fracture.

Methods.?Twelve experienced clinicians (all females) (mean experience in rehabilitation 13 years) were interviewed using an in-depth semi-structured format. The recorded interviews were transcribed and coded independently by two researchers. From these codes themes were developed.

Results.?For discharge planning, all clinicians considered personal/psychosocial factors such as patient goals and social support. Almost all clinicians considered that the performance factor of safe and independent ambulation was important to consider when planning the patient's discharge, but did not set specific distances or speeds. Clinicians expected that pain, a lack of confidence, and walking outdoors would affect the mobility at home but these factors were considered little in discharge planning.

Conclusions.?In planning discharge after rehabilitation for hip fracture, clinicians place more emphasis on the individual needs and goals of the patient than on specifying objective performance criteria that must be met. The expectation that lack of confidence could be a problem after returning home suggests that this factor could be considered more in discharge planning.     

Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients

Background and purpose: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period.

Method: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine.

Results: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6?±?2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3?±?7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low.

Conclusions: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.     

A study of a pathway to reduce pressure ulcers for patients with a hip fracture

Due to an ageing population the numbers of patients with hip fractures are increasing. They often suffer from concomitant diseases and are therefore prone to be affected by complications such as pressure ulcers. The prevention of pressure ulcers among patients with a hip fracture is crucial. The aim of this study was to improve the quality of care and patient safety in patients with a hip fracture. A new evidence based clinical pathway was introduced to prevent hospital acquired pressure ulcers. Furthermore, the purpose was to bring attention to pressure ulcer prevention and to facilitate changes in clinical practice to improve quality of care and patient safety. A total of 478 patients with a hip fracture were consecutively included between April 2003 and March 2004. The new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article. In the intervention group, hospital acquired pressure ulcers decreased by 50% (p < 0.007). It is possible to reduce the development of hospital acquired pressure ulcers among elderly patients with a hip fracture even though it is not possible to eliminate the effect of factors such as increased age and the patients’ medical status which are often the two main risk factors.     

A systematic review of clinical outcomes,clinical process,healthcare utilization and costs associated with telerehabilitation

Purpose. To identify clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation for individuals with physical disabilities.

Method. Relevant databases were searched for articles on telerehabilitation published until February 2007. Reference lists were examined and key journals were hand searched. Studies that included telerehabilitation for individuals with physical impairments and used experimental or observational study designs were included in the analysis, regardless of the specific clientele or location of services. Data was extracted using a form to record methodological aspects and results relating to clinical, process, healthcare utilization and cost outcomes. Study quality of randomized clinical trials was assessed using the PEDro rating scale.

Results. Some 28 articles were analysed. These dealt with rehabilitation of individuals in the community, neurological rehabilitation, cardiac rehabilitation, follow-up of individuals with spinal cord injuries, rehabilitation for speech-language impairments, and rehabilitation for varied clienteles. Clinical outcomes were generally improved following a telerehabilitation intervention and were at least similar to or better than an alternative intervention. Clinical process outcomes, such as attendance and compliance, were high with telerehabilitation although few comparisons are made to alternative interventions. Consultation time tended to be longer with telerehabilitation. Satisfaction with telerehabilitation was consistently high, although it was higher for patients than therapists. Few studies examined healthcare utilization measures and those that did reported mixed findings with respect to adverse events, use of emergency rooms and doctor visits. Only five of the studies examined costs. There is some preliminary evidence of potential cost savings for the healthcare facility.

Conclusions. While evidence is mounting concerning the efficacy and effectiveness of telerehabilitation, high-quality evidence regarding impact on resource allocation and costs is still needed to support clinical and policy decision-making.     

Coordinated multidisciplinary rehabilitation after hip fracture

Purpose: To review the topic of coordinated multidisciplinary rehabilitation after hip fracture from a research perspective and to provide information to guide the provision of rehabilitation services for patients with hip fracture.

Methods: Literature review including searches of Medline, Embase, Cochrane Collaboration and evidence based clinical guidelines, checking of references of publications and consultation with researchers.

Results: The research evidence is heterogeneous and remains inclusive. Programs that assist patients with hip fracture to regain function and return home as soon as feasible are likely to be effective as they appear to increase the percentage of patients who return home and remain there after hip fracture. Rehabilitation programs that achieve this are likely to be cost effective. These programs involve health professionals from multiple disciplines (nurses, allied health professionals and medical practitioners) who work collaboratively, may operate in several settings, and routinely provide specific treatments that are supported by strong evidence of effectiveness.

Conclusions: Patients with hip fracture should be offered a coordinated a multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their pre-fracture living arrangements.     

G-CSF: filgrastim,lenograstim and biosimilars

Introduction: The identification, purification and molecular cloning of granulocyte colony-stimulating factor G-CSF in the 1980s; the nonclinical studies in the mid-1980s; and the subsequent development of G-CSF as a therapeutic agent in the late 1980s and 1990s have had a major influence on the treatment of many diseases. In the clinical setting, filgrastim and lenograstim are of benefit to patients receiving chemotherapy or myeloablative treatment. They have been shown to reduce morbidity and mortality in many patient populations. Stem cell transplantation using G-CSF-mobilised peripheral-blood stem cells revolutionised stem cell transplantation, making it simpler, more efficient and more widely applicable in the clinic.

Areas covered: This review discusses the development and clinical uses of filgrastim, lenograstim and other biosimilar G-CSFs.

Expert opinion: In the next few years, the economics of G-CSF may even change with the introduction of biosimilars. Initial concerns about the use of biosimilar G-CSFs, appear to be unfounded. Adoption of cost-effective biosimilars should help reduce healthcare costs and improve patient access to biological treatments.