Osteoporosis 2016 | Hip fracture, the ultimate challenge: Dr Antony Johansen #osteo2016
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Transcript of Osteoporosis 2016 | Hip fracture, the ultimate challenge: Dr Antony Johansen #osteo2016
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Hip Fracture – the ultimate challenge
Antony Johansen
Orthogeriatrician – University Hospital of Wales, Cardiff
Clinical Lead – National Hip Fracture Database
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Hip fracture is the commonest serious injury, the commonest reason for older people to need emergency anaesthesia and surgery, and the commonest cause of accidental death
Only a minority regain their previous abilities, increased dependency and difficulty walking mean that a quarter will need long-term care
The cost of this one injury is about 1% of the whole NHS budget
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NOS conference – Bath 1998 Johansen et al. Injury 1997
The Cardiff fracture epidemiology study
A population-based study of the 306,600 people living in the City of Cardiff, as defined by post-code
A population with an age, sex and ethnic composition very similar to that of England and Wales
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Hip fracture incidence vs. length of daylight
Hours of daylight per day
Hip
frac
ture
s per
day
R = - 0.285, p<0.001
7 8 9 10 11 12 13 14 15 16 17
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Johansen, Boulton and Neuburger, Age and Ageing 2016
NHFD data on 64,102 people presenting in 2014
15.6% more hip # in December cf. all other months (9.5% vs. 8.2%, p<0.001)
Same pattern among people living in care homes (9.1% vs. 8.3%, p <0.001)
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Diurnal and seasonal patterns in presentations with hip fracture
Johansen, Boulton and Neuburger, Age and Ageing 2016
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The cost of osteoporotic fractures in the UK - projections for 2000-2020
0.5
1.0
1.5
2.0
2.5
£ - B
illio
ns
NOS conference – Bath 2001 Burge, Worley, Johansen et al. J Med Econ 2001
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Hospital admission for older people with fractures
0
50
100
150
200
250
300
Num
ber o
f adm
issi
ons
55-64 years 65-74 years 75-84 years 85+ years
NOS conference – Bath 1998 Johansen et al. Injury 1998; 29: 799-84
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Length of stay
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Discharge destination for people admitted
from home
NHFD Annual Report 2015
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NHFD annual report 2014
Linking NHFD data with figures from HES, PEDW and FORD
Admissions Super-spell Total bed days
England 59,344 22.5 1,335,240Wales 3,804 35.1 133,520Northern Ireland 1,845 33.3 61,439
Overall 64,993 23.1 1,499,593
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An orthogeriatrician’s challenge to the NOS
I’d be pleased if we could:
- identify half of older people who will break their hip
- offer a treatment that halves hip fracture risk
- get half of them to continue taking it correctly
NOS conference – Edinburgh 2007
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FRAX and NOGG in the real world
Retrospective (pre-fracture) FRAX for 100 consecutive hip fracture patients
1/3
2/3
NOS conference – Liverpool 2010 Johansen BMJ 2012;344.e4191
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Proposed pyramid of implementation – DoH 2009
Hip fractureHip fracture
Fragility fractureFragility fracture
Secondary prevention 50% of hip fractures occur in people with prior fragility fracture
… 16% of the population
High risk of fractureHigh risk of fracture
General populationGeneral population
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Osteoporosis trials - 2007
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Trends in the age of people in osteoporosis drug trials
Despite demographic shift in the population – in the last two decades the mean age of trial subjects has fallen by 5 years, from 74 to 69 years
Marsh and Johansen – NOS poster 107 – November 2016
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5 year survival after hip fracture - implications for secondary prevention
NOS conference – Manchester 2009 Johansen et al. Age Ageing 2010
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An orthogeriatrician’s challenge to the NOS
I’d be pleased if we could:
- identify half of older people who will break their hip
- offer a treatment that halves hip fracture risk
- get half of them to continue taking it correctly
But this would still only prevent 12.5% of hip fractures
NOS conference – Edinburgh 2007
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Intracapsular hip fractures
Trochanteric hip fractures
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www.nhfd.co.uk
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THR if eligible as defined by NICE CG124
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THR if eligible as defined by NICE CG124
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Perry et al. BMJ 2016
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30-day mortality trend for one hospital
Neuburger et al. Medical Care 2015;53:686–691
National launch of NHFD
30-day adjusted mortality for one hospital
NHFD annual report 2016
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Neuburger et al. Medical Care 2015;53:686–691
Participation in NHFD
Fitted trends in adjusted 30-day morality - before and after launch of NHFD
Fitted trend across participating hospitals
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www.nhfd.co.uk - accessed 6th November 2016
All hospitals – unadjusted 30 day mortality
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Neuburger et al. Medical Care 2015;53:686–691
Participation in NHFD
Fitted trends in adjusted 30-day morality - before and after launch of NHFD
Fitted trend across participating hospitals
6.4%2016
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“ treat the patient and let the fracture go …”
Astley Cooper, Lancet 1894
“the surgical procedure must never be considered to be the whole treatment but merely an incident in the general rehabilitation of the patient”
Devas, BMJ 1974
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Consultant OG (hours)
Middle grade OG
NHFD annual report 2015
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Neuburger et al. Age and Ageing (in press)
30 d
ay m
orta
lity
Orthogeriatrician sessions per week
Increased orthogeriatrician involvement in hip fracture care and its impact on mortality in England
OG involvement and mortality
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Variation in provision of orthogeriatrician support
NHFD annual report 2015
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£20,000 /QALY
11,793 6,294
Overall saving to health services of an HFP £5,499
NICE economic model
Key recommendation
Offer all patients a formal, acute orthogeriatric or orthopaedic ward based Hip Fracture Programme that includes all of the following:
• orthogeriatric assessment
• rapid optimisation of fitness for surgery
• early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term well-being
• continued coordinated orthogeriatric and multidisciplinary review
• communication with the primary care team
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What is the commonest complication
after hip fracture?
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Reducing delirium after hip fracture: a randomized trial Marcantonio et al. J Am Geriatrics Soc 2001; 49:516–522
Geriatrician assessment and daily visits
- ensure adequate CNS oxygen delivery
- optimise fluid/electrolyte balance
- treatment of severe pain
- elimination of unnecessary medications
- regulation of bowel/bladder function
- adequate nutritional intake
- early mobilization and rehabilitation
- prevent, detect, and treat complications
- appropriate environmental stimuli
- treatment of agitated delirium
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Bellelli et al. Age Ageing 2014; 43:496-502
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What is the commonest cause of death
after hip fracture?
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NOS – Harrogate 2006 Duncan, Beck, Hood, Johansen. Age Ageing 2006
Nutritional support following hip fracture – an RCT
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What do patients fear more than death
after hip fracture?
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Post-operative mobilisation
NHFD annual report 2015
Percentage of patients mobilised out of bed
on the day following hip fracture surgery
Overall NHFD figure 73.3%
21 hospitals (11%) achieved this
in less than half of their patients
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HABAM: Hierarchical Assessment of Balance and MobilityHA
BAM
mob
ility
scor
e
Weeks after hip fracture
Mobile with aid 8-50m
Needs positioning in bed
Hubbard et al. J Gen Intern Med 2011
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Discharge destination for people admitted
from home
NHFD Annual Report 2015
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NHFD – CSP joint audit of hip fracture rehab. – Pilot study 2015
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An orthogeriatrician’s challenge to the NOS
I’d be pleased if we could:
- identify half of older people who will break their hip
- offer a treatment that halves hip fracture risk
- get half of them to continue taking it correctly
But this would still only prevent 12.5% of hip fractures
NOS conference – Edinburgh 2007