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NIHR Signal Specialist hip fracture services linked to fewer deaths in South Central region

Published on 31 January 2017

doi: 10.3310/signal-000369

Following a hip fracture, nurse-led fracture liaison services or specialist consultant (orthogeriatrician) input both reduce deaths. They did not reduce the small number of people having a second hip fracture within two years of the first. Both models of care were cost effective, although the orthogeriatric model was favoured.

Despite national guidance recommending both use of a fracture liaison service and orthogeriatric model of care, variation exists and some hospitals have neither.

This NIHR-funded study analysed linked patient records in a time series analysis conducted in the South Central region of England. It looked at the impact over time of each model. It included people over the age of 60 with a hip fracture resulting from a fall.

Though both models of care were effective in the initial management of older people with hip fractures and in reducing mortality, poor patient follow up was identified as an issue. This may have affected adherence to bone protection medication and exercise programmes aimed to prevent further fractures. These are important parts of a comprehensive model of care whether they are delivered by an orthogeriatrician or fracture liaison service.

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Why was this study needed?

About 87,000 hip fractures occur annually in the UK equating to a cost to health and social care of around £2.3 billion. Significant variation exists in how fracture prevention services are structured in England. In some hospitals, no such specialised service is provided.

Components of an orthogeriatric model include optimisation of fitness for surgery (e.g. preoperative assessment by an orthogeriatrician) and early identification of rehabilitation goals to facilitate return home. There is also a focus on long-term well-being and integration with related secondary care services including secondary fracture prevention.

Components of a nurse-led fracture liaison service include case finding those at risk of further fractures, osteoporosis assessment and treatment initiation for bone health. They may also include falls risk education and strategies to monitor and improve adherence to recommended therapies.

To date there is no preferred service delivery structure for this population. This study was part of a programme of research into these services and this one looked into the relative effectiveness and costs of different models of care.

What did this study do?

This was a multicomponent study. A particular strand investigated the clinical and cost effectiveness of service delivery changes to secondary fracture prevention services in 11 NHS hospitals in a region of England between 2003 and 2012.

One part compared the introduction or expansion of either an orthogeriatric or a nurse-led fracture liaison service model. Researchers looked at a cohort of hip fracture patients and undertook an interrupted time-series analysis and a regression model of survival.

The main outcomes of interest were hip refracture and death rates within two years of the first hip fracture from a fall in people over 60. The researchers used data from the Hospital Episode Statistics database, a large repository of routine hospital activity data for the NHS that identifies those treated for hip fracture. This was linked to national mortality data from 1999 to 2011.

Relying on routine data can have limitations in that the underlying confounders and causes of the trends identified can’t be easily adjusted for or foreseen. So interviews to add further insights were conducted. The interviews with health professionals working in these services revealed little patient follow up after hospital discharge and this may have contributed to the failure of the services to show any reduction in second hip fractures.

What did it find?

  • Introduction of an orthogeriatrician reduced the death rate following hip fracture at 30 days by an estimated 27% (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.65 to 0.82) and at one year by 19% (HR 0.81, 95% CI 0.75 to 0.87).
  • A fracture liaison service model reduced death rate at 30 days by an estimated 20% (HR 0.80, 95% CI 0.71 to 0.91) and at one year by 16% (HR 0.84, 95% CI 0.77 to 0.93).
  • There was no effect on second hip fracture rate by either service over two years. It remained at 4.2% over the course of the study period.
  • Both the orthogeriatrician and nurse-delivered fracture liaison service models of care were likely to be cost-effective as part of delivery of secondary hip fracture prevention compared to standard care (at a £30,000 NHS threshold for good value). Adding an orthogeriatrician was 70% likely to be the most cost-effective option at £30,000/QALY across both sexes.

What does current guidance say on this issue?

No single model of care for delivery of secondary fracture prevention services has been recommended in the UK.

NICE’s 2011 guideline on hip fracture management contains multidisciplinary management recommendations that include orthogeriatric assessment, rapid optimisation of fitness for surgery, early identification of rehabilitation goals, continued review, and liaison or integration with related services.

In 2009, the Department of Health recommended a nurse-led fracture liaison service supported by a lead clinician in osteoporosis as a model of best practice to organise secondary prevention services.

The British Orthopaedic Association 2007 guidance includes best practice standards for a nurse-led fracture liaison service and orthogeriatric model of care for secondary prevention of fragility fractures.

What are the implications?

The introduction and/or expansion of an orthogeriatriatric or fracture liaison service model of care following hip fracture in the elderly can reduce rates of death. The services focused on initial management, rather than monitoring of secondary preventive measures, which may be why there was no reduction in second hip fracture rates over two years. The beneficial effects of preventive medication can also take a few years.

Nevertheless, these models reflect national guidance and are both cost-effective, with the orthogeriatric model being most cost-effective. The annual cost of introducing a grade seven fracture liaison nurse was estimated as £90,078 whilst a consultant orthogeriatrician costs £189,002 (including salary, training, management and non-staff overheads).

The introduction or expansion of these models of care may require increased training for nurses and orthogeriatricians.

Citation and Funding

Judge A, Javaid MK, Leal J, et al. Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England. Health Serv Deliv Res. 2016;4(28).

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR musculoskeletal biomedical research unit at the University of Oxford.

Bibliography

BOA. The Care of Patients with Fragility Fractures. London. British Orthopaedic Association; 2007.

Department of Health. Falls and fractures: Effective interventions in health and social care. London. Department of Health; 2009.

NICE. Hip fracture management. CG124. London. National Institute for Health and Care Excellence; 2011.

NICE. Falls in older people: assessing risk and prevention. CG161. London. National Institute of Health and Care Excellence; 2013.

Why was this study needed?

About 87,000 hip fractures occur annually in the UK equating to a cost to health and social care of around £2.3 billion. Significant variation exists in how fracture prevention services are structured in England. In some hospitals, no such specialised service is provided.

Components of an orthogeriatric model include optimisation of fitness for surgery (e.g. preoperative assessment by an orthogeriatrician) and early identification of rehabilitation goals to facilitate return home. There is also a focus on long-term well-being and integration with related secondary care services including secondary fracture prevention.

Components of a nurse-led fracture liaison service include case finding those at risk of further fractures, osteoporosis assessment and treatment initiation for bone health. They may also include falls risk education and strategies to monitor and improve adherence to recommended therapies.

To date there is no preferred service delivery structure for this population. This study was part of a programme of research into these services and this one looked into the relative effectiveness and costs of different models of care.

What did this study do?

This was a multicomponent study. A particular strand investigated the clinical and cost effectiveness of service delivery changes to secondary fracture prevention services in 11 NHS hospitals in a region of England between 2003 and 2012.

One part compared the introduction or expansion of either an orthogeriatric or a nurse-led fracture liaison service model. Researchers looked at a cohort of hip fracture patients and undertook an interrupted time-series analysis and a regression model of survival.

The main outcomes of interest were hip refracture and death rates within two years of the first hip fracture from a fall in people over 60. The researchers used data from the Hospital Episode Statistics database, a large repository of routine hospital activity data for the NHS that identifies those treated for hip fracture. This was linked to national mortality data from 1999 to 2011.

Relying on routine data can have limitations in that the underlying confounders and causes of the trends identified can’t be easily adjusted for or foreseen. So interviews to add further insights were conducted. The interviews with health professionals working in these services revealed little patient follow up after hospital discharge and this may have contributed to the failure of the services to show any reduction in second hip fractures.

What did it find?

  • Introduction of an orthogeriatrician reduced the death rate following hip fracture at 30 days by an estimated 27% (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.65 to 0.82) and at one year by 19% (HR 0.81, 95% CI 0.75 to 0.87).
  • A fracture liaison service model reduced death rate at 30 days by an estimated 20% (HR 0.80, 95% CI 0.71 to 0.91) and at one year by 16% (HR 0.84, 95% CI 0.77 to 0.93).
  • There was no effect on second hip fracture rate by either service over two years. It remained at 4.2% over the course of the study period.
  • Both the orthogeriatrician and nurse-delivered fracture liaison service models of care were likely to be cost-effective as part of delivery of secondary hip fracture prevention compared to standard care (at a £30,000 NHS threshold for good value). Adding an orthogeriatrician was 70% likely to be the most cost-effective option at £30,000/QALY across both sexes.

What does current guidance say on this issue?

No single model of care for delivery of secondary fracture prevention services has been recommended in the UK.

NICE’s 2011 guideline on hip fracture management contains multidisciplinary management recommendations that include orthogeriatric assessment, rapid optimisation of fitness for surgery, early identification of rehabilitation goals, continued review, and liaison or integration with related services.

In 2009, the Department of Health recommended a nurse-led fracture liaison service supported by a lead clinician in osteoporosis as a model of best practice to organise secondary prevention services.

The British Orthopaedic Association 2007 guidance includes best practice standards for a nurse-led fracture liaison service and orthogeriatric model of care for secondary prevention of fragility fractures.

What are the implications?

The introduction and/or expansion of an orthogeriatriatric or fracture liaison service model of care following hip fracture in the elderly can reduce rates of death. The services focused on initial management, rather than monitoring of secondary preventive measures, which may be why there was no reduction in second hip fracture rates over two years. The beneficial effects of preventive medication can also take a few years.

Nevertheless, these models reflect national guidance and are both cost-effective, with the orthogeriatric model being most cost-effective. The annual cost of introducing a grade seven fracture liaison nurse was estimated as £90,078 whilst a consultant orthogeriatrician costs £189,002 (including salary, training, management and non-staff overheads).

The introduction or expansion of these models of care may require increased training for nurses and orthogeriatricians.

Citation and Funding

Judge A, Javaid MK, Leal J, et al. Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England. Health Serv Deliv Res. 2016;4(28).

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR musculoskeletal biomedical research unit at the University of Oxford.

Bibliography

BOA. The Care of Patients with Fragility Fractures. London. British Orthopaedic Association; 2007.

Department of Health. Falls and fractures: Effective interventions in health and social care. London. Department of Health; 2009.

NICE. Hip fracture management. CG124. London. National Institute for Health and Care Excellence; 2011.

NICE. Falls in older people: assessing risk and prevention. CG161. London. National Institute of Health and Care Excellence; 2013.

Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England

Published on 1 September 2016

Judge A, Javaid MK, Leal J, Hawley S, Drew S, Sheard S, Prieto-Alhambra D, Gooberman-Hill R, Lippett J, Farmer A, Arden N, Gray A, Goldacre M, Delmestri A, Cooper C

Health Services and Delivery Research Volume 4 Issue 28 , 2016

Background Professional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals. Objectives To establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes. Design A service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care. Setting Eleven acute hospitals in a region of England. Participants Qualitative study – 43 health professionals working in fracture prevention services in secondary care. Interventions Changes made to secondary fracture prevention services at each hospital between 2003 and 2012. Main outcome measures The primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture. Data sources Clinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13, n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013, n = 11,243). Results Service evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician. Conclusion In hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered. Future work Reliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients. Funding The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR Musculoskeletal Biomedical Research Unit, University of Oxford.

A Fracture Liaison Service includes the following components: case finding those at risk of further fractures, an osteoporosis assessment, treatment initiation in accordance with guidelines for bone health and falls risk education and strategies to monitor and improve adherence to recommended therapies. Guidance recommends structuring this service around a dedicated co-ordinator to provide a link between all of the multidisciplinary fracture prevention teams.

Expert commentary

One in five people who break their hip will die within a few months of the fracture. Having broken one hip, those still alive are at high risk of breaking the other. Working out the best way to look after these elderly patients, is not simple, but neglect, as too often happens at present, is not an option. While superficially appearing the most expensive choice, a consultant-led orthogeriatric service should be a high priority for healthcare providers. It is as a cost-effective way to save lives at a time when the incidence of hip fractures is still steadily rising.

Richard Aspden, Emeritus Professor of Orthopaedic Science, University of Aberdeen