How do geriatricians improve outcomes after hip fracture?
Jenny Neuburger is a Senior Research Analyst at the Nuffield Trust (@NuffieldTrust) and a Visiting Research Fellow at the London School of Hygiene & Tropical Medicine. She and her co-authors have recently published research in Age and Ageing journal.
We have just published a paper showing that geriatrician involvement in hip fracture care can improve patient outcomes. Patients treated on wards with higher numbers of geriatrician hours tended to have lower mortality within the 30 days after presentation.
We measured geriatrician hours worked in orthopaedic departments using data collected via the National Hip Fracture Database annual survey each year from 2010 to 2013 for English hospitals. Over this period, geriatrician hours increased from 1.5 to 4.0 hours per patient, reflecting investments made in response the financial incentives introduced under the Best Practice Tariff scheme.
We found that an increase of 2.5 geriatrician hours per patient was associated with a relative reduction in 30-day mortality of 3.4% (95% confidence interval 0.9% to 5.9%, p-value = 0.01). This corresponds to an absolute mortality reduction of approximately 0.3% for this level of investment from a 2010-rate of 8.7% (3.4% x 8.7% = 0.3%).
What do orthogeriatricians do?
A hip fracture has a major impact on an older person - causing severe pain and often substantial blood loss. Waiting for assistance after falling may also mean they become dehydrated and frightened. For a frail older person, this often contributes to development of confusion and delirium. Surgery, anaesthesia, peri-operative care and rehabilitation are often complicated by other health problems and medication.
Orthogeriatrics is a subspecialty that has developed in the UK to improve outcomes of older people with fractures by providing specialist medical care alongside orthopaedic surgeons within multidisciplinary teams. Orthogeriatricians improve early care in a number of ways. At the individual level, they may improve a patient’s physical fitness and readiness for surgery by ordering blood transfusions, stopping or starting medications and working closely with anaesthetists and surgeons to ensure that surgery is as prompt and safe as possible.
At the team level, the appointment of an orthogeriatrician often triggers a cultural shift with a renewed focus on a person’s health other than their fracture. They promote awareness of health problems associated with ageing and frailty. In senior roles, they are in a strong position to develop protocols and promote team-working to improve the consistency and coordination of care.
Improved outcomes attributed to involvement of geriatricians will reflect the work the whole team. They can also provide an environment in which improvements to care on the ward are valued and celebrated. For example, at St Helier’s hospital in Epsom, the team introduced a daily lunch club, with patients invited to dine together at a communal table rather than on their own by their bed. The team evaluated this change and found some evidence that people over 80, who had lower intake generally, ate more when they dined sociably.
Implications of our study
Although we used a limited measure of orthogeriatrician involvement (in hours per patient), our study contributes further evidence of the benefits of orthogeriatric care in improving patient outcomes. If the association we found were causal, the 2.5-hour increase in hours would equate with the avoidance of nearly 200 deaths within 30 days across the 65,000 people presenting with hip fracture each year (absolute reduction 0.3% x 65,000 = 195)
Read the full Age & Ageing paper Increased orthogeriatrician involvement in hip fracture care and its impact on mortality in England Interested in falls and postural stability? Join us at the 18th International Conference on Falls and Postural Stability in Birmingham where this topic will be a key focus!