Friday, 7 March 2014

Femur fractures. Could its incidence be reduced?

Femur fractures represent a major health issue burden for healthcare systems as it is estimated that one in 20 people will have a femur fracture throughout their lives. According to the 2005 issue of the Atlas de Variaciones en la Práctica Clínica and a subsequent document linked to the same organism (Bernal 2009), the incidence of femur fractures in Spain is 511 new cases per year per 100,000 inhabitants, with a gender distribution clearly tilted towards women (2.6 times). The incidence in Catalonia is the highest, 623, while in Galicia is the lowest, 317.
Although it’s believed that the incidence of femur fracture has little variability, note that the autonomous region that has the highest figure is almost twice of the lowest and on the other hand, if we carefully analyse the Bernal document, we can see that there are certain lifestyles that have a clear impact on the frequency of  femur fractures, such as the following finding: if older people are living in a residence, they are three times more likely to break their femur that if living in their own house.

The incidence correlates with hospitalisation in 99% of cases

In the third graph of the post: The Poverty Hypothesis versus the Capacity Hypothesis, it was clearly seen how the  hospitalisation for femur fracture was not at all correlated with the number of set beds (R2 = 0,06), which is to say that the incidence of these accidents is perfectly correlated with the rate for its hospitalisation. It may seem strange now the subject is emphasised, but this is because the fractured femur has three almost unrepeatable characteristics in the world of medical case-mix:

1. It manifests with pain and loss of leg function. One cannot walk
2. The clinical diagnosis is easy and accurate
3. All doctors without exception recommend surgery

If we mentally go through how the three previous elements are seen in other circumstance of possible surgical decision, such as varicose veins in the legs, recurrent tonsillitis and susceptible coronary bypass etc; we’ll realise that in no other circumstance are the criteria as clear as in femur fracture situations. And of all the possible variables, the most noteworthy is the lack of uniformity of medical judgment (see post The Surgical Signature). It is curious how two of the conditions that may compete with hip fracture that correlate with the incidence of hospitalisation, such as acute appendicitis or inguinal hernia, cannot fit so well. In the first of the two cases, variability in the extraction of white appendicitis appear, and in the second, there are cultures where a considerable proportion of men still prefer to wear a brace as opposed to having surgery.

Clinical resolutions

There are many figures that explain the social and economic burden of this casualty, but now, as it is suitable for this blog, I will focus more on the clinical aspects. In the graph below, I show some estimated figures on what happens to the patients after the fracture and although in the scientific literature there is enough diversity, I think the numbers I present are a good summary:

The mortality during the surgical admission stage is 5% and this is a number that many systems use as an indicator of hospital quality. Another issue for the clinical management of patients who have a femur fracture (don’t forget that in general it affects to old or very old people) is the waiting time for interventions: although it seems intuitively reasonable that patients should be operated on as soon as possible, a review of 30 projects and 50,000 cases (Bernal 2009) does not manage to demonstrate that the centres that operate rapidly have a lower mortality than those who delay the interventions; moreover it seems that what’s to be avoided are night interventions conducted by little specialized surgical staff on guard, as indeed this only increases complications and mortality rates.

Can the incidence of femur fractures be reduced?

Osteoporosis is the origin of the fractured bones as they are brittle, and the femur fracture is the most common of all. Therefore, it seems logical that the primary prevention of osteoporosis should be a priority for health systems, which ought to:
  • Detect, diagnose and treat osteoporosis risk groups
  • Encourage healthy eating and exercise
Not to mention that a second line of intervention should influence the prevention of falling for older people policy:
  • Avoiding hypnotics whenever possible.
  • Review the hazards in houses where people at risk live: ensure enough light, avoid dangerous carpets, and avoid barriers in the usual circuits.
  • Review the possible hazards on the street circuits of people at risk: slippery floors, dirt, pavements, barriers, etc.

There are two documents of the "Ministerio de Sanidad", in collaboration with the "Agència d’Informació, Avaluació i Qualitat en Salut de la Generalitat de Catalunya (AIAQS)" to corroborate that fracture prevention is possible and must be strengthened.

So there is enough proof to think that the significant action to delay the onset of osteoporosis is crucial to reduce femur fractures in older people, but despite this, it has not at all detected a level of awareness prevention among professionals and among the population comparable to what happens with cardiovascular disease or diabetes, to name two examples.

And meanwhile, what do they do in the Kaiser Permanente?

The American assurance Kaiser Permanente is considered because when they’re certain that a preventive community action will reduce hospitalizations and improve the quality of life of individuals, they pursue it openly. The following article is an exemple of this:

The Area of Kaiser Southern California, which serves 3.1 million insured people, launched in 2002 the "Healthy Bones" program structuring multidisciplinary community intervention teams led by orthopaedists, and these teams set the following objectives:
  • Increase by 50% the densitometry scans among the population at risk of osteoporosis
  • Increase by 50% the anti-osteoporosis treatment in the diagnosed population
  • Improve self-care (diet and exercise) of the population at risk

This program achieved a reduction of femoral fractures of 37.2% (between 2002 and 2006); although the authors claim that they have evidence to believe that it should be easy to achieve 50%.

In summary

The population at risk of osteoporosis suitable for specific preventive measures (diet, exercise and treatment when necessary) should be identified in addition to promoting the policies of falls prevention at community level. This work should be led from primary care with specialist support. Then, if the fracture does occur, the patient should be operated on by specialized teams, always paying attention to achieve the maximum possible clinical stabilisation. That is, the intervention should be well planned, i.e. not hurried and subsequently the rehabilitation and return to the community should be in accordance with the medical requirements of each person’s geriatric complexity.

Jordi Varela

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