Multidisciplinary model can cut refracture risk for hospitalized adults with hip fracture
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Key takeaways:
- Hospitals practicing an orthogeriatric model of care were much more likely to prescribe osteoporosis medication for hip fractures.
- Orthogeriatric assessment within 3 days of admission cut refracture risk by 18%.
A multidisciplinary care model can reduce the risk for subsequent fractures among adults hospitalized for a hip fracture, according to findings published in Journal of Bone and Mineral Research.
In an analysis of data from 172 hospitals in England and Wales, researchers assessed organizational factors that were associated with the likelihood of prescribing osteoporosis medication and the risk for refracture 1 year after discharge for hospitalized adults with a hip fracture. Researchers found 12 organizational factors associated with osteoporosis prescription odds and eight factors tied to refracture risk.
“This novel, national study highlights the importance of orthogeriatric care, physio- and occupational therapy provision in secondary fracture prevention in frail hip fracture populations, which may be generalizable to other countries,” Celia L. Gregson, PhD, MSc, MRCP, professor of clinical epidemiology and consultant geriatrician at the University of Bristol in the U.K., and colleagues wrote.
Researchers collected data from 178,757 adults aged 60 years and older admitted to a hospital in England or Wales with a hip fracture from April 2016 to March 2019. Adults were followed for up to 1 year after admission. Patient-level data, including the prescription of osteoporosis medication and refracture occurring from 30 days until 1 year after the initial fracture, were obtained from the Hospital Episodes Statistics Admitted Patient Care database in England and the Patient Episode Database for Wales. A systematic approach was used to identify 71 organizational factors related to the delivery of hip fracture care. Researchers linked the factors to patient-level data and the year of admission.
Factors tied to osteoporosis medication
Of adults with data available, 7% continued using preadmission osteoporosis medication, 50% initiated osteoporosis medication during hospitalization, 22% were deemed not to need medication, 18% did not receive a prescription and were discharged to await a DXA scan or outpatient appointment, and 3% had no assessment taken.
Twelve organizational factors were associated with odds of receiving an osteoporosis medication prescription. Adults admitted to a hospital with an orthogeriatric model of care were more likely to receive an osteoporosis medication prescription than those admitted to a hospital with a traditional orthopedic care approach (OR = 4.65; 95% CI, 2.25-9.59). Of hospitals included in the study, 97% employed an orthogeriatric model approach.
Hospitals were also more likely to prescribe osteoporosis medication if all patients were assessed with an abbreviated mental test before their operation (OR = 1.07; 95% CI, 1.03-1.12), if an orthogeriatric National Hip Fracture Database lead role was reflected in the hospital’s job plan (OR = 1.06; 95% CI, 1.02-1.1), if the hospital had protocol in place to prioritize hip fractures to the start of the trauma list (OR = 1.07; 95% CI, 1.04-1.11), if all patients were assessed by a physiotherapist (OR = 1.03; 95% CI, 1-1.06), if more than 75% of adults were not delirious after surgery (OR = 1.06; 95% CI, 1.01-1.1), if all patients received a bone health assessment at admission (OR = 1.09; 95% CI, 1.06-1.13), if the hospital conducted clinical governance meetings monthly (OR = 1.06; 95% CI, 1.02-1.11) and if a consultant anesthetist attended monthly clinical governance meetings (OR = 1.11; 95% CI, 1.07-1.16).
“These observations all suggest that well-organized hospitals, with established protocols and better patient care, are also better able to discharge patients on anti-osteoporosis medication,” the researchers wrote.
The odds for receiving an osteoporosis medication prescription were lower if more than 52% of patients were admitted to the orthopedic ward within 4 hours of ED admission (OR = 0.92; 95% CI, 0.88-0.96), if the hip fracture service underwent quality improvement work in the past year (OR = 0.87; 95% CI, 0.83-0.91) and if clinical governance meetings were attended by the trauma and orthopedics manager (OR = 0.9; 95% CI, 0.87-0.93), pharmacist (OR = 0.9; 95% CI, 0.85-0.95) or physiotherapist (OR = 0.96; 95% CI, 0.92-1).
Factors tied to refracture risk
Refracture occurred in 7% of participants. The median time to first refracture was 126 days, and 28% of adults died during follow-up.
Eight organizational factors were associated with refracture risk. Adults who were admitted to hospitals that provided orthogeriatrician assessment to all patients within 3 days of admission had a lower risk for refracture than adults admitted to hospitals that did not provide an orthogeriatrician assessment to all patients (OR = 0.82; 95% CI, 0.69-0.98). Other factors tied to a lower risk for refracture included if an orthogeriatric National Hip Fracture Database lead role was reflected in the hospital’s job plan (OR = 0.94; 95% CI, 0.88-0.99), if adults received physiotherapy on the weekend (OR = 0.92; 95% CI, 0.86-0.97) and if an occupational therapist attended clinical governance meetings (OR = 0.93; 95% CI, 0.88-0.98).
Adults who went 15 to 86 days between discharge and the start of community therapy were more likely to have a refracture than adults with less than a 15-day gap between discharge and community therapy initiation (OR = 1.15; 95% CI, 1.03-1.29). Other factors tied to higher refracture risk included hospitals who followed up with some patients within 120 days of discharge (OR = 1.1; 95% CI, 1.03-1.17), if data was submitted for average physiotherapy time in the first week after surgery (OR = 1.1; 95% CI, 1.03-1.18) and if a consultant orthogeriatrician attends clinical governance meetings (OR = 1.07; 95% CI, 1.01-1.14).
The researchers cautioned that the large sample size may have generated associations that are not clinically meaningful or prone to type 1 error, despite being statistically significant. However, they concluded a comprehensive, multidisciplinary approach is important for preventing future refractures.
“Fracture risk reductions associated with this multidisciplinary care provision are apparent within a year of hip fracture,” the researchers wrote. “Notably longer timeframes may be needed to see such fracture risk reductions from some anti-osteoporosis treatments.”
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