Home, No Follow-Up: Are we ignoring the significance of unplanned clinic attendances, re-admission and mortality in the first 12 months post-operatively in over 65 year olds’ hip fractures treated with DHS fixation?

Abstract

Introduction

80,000 hip fractures are admitted to UK hospitals annually (Royal College of Physicians, 2016). Little is known about 12-month post-operative re-admission, unplanned clinic attendance and mortality. We aimed to determine if there is a role for routine follow-up for certain strata of our hip fracture population treated by Dynamic Hip Screw (DHS) Fixation based on unplanned attendance to clinics and whether it is possible to stratify risk of re-admission, re-operation and mortality within the first 12 months post-operatively.

Methods

A prospectively collated single centre database of patients >65 years old undergoing DHS fixation for traumatic hip fractures between August 2007 and February 2011 was retrospectively analysed. Pre-operative data regarding patient demographics, mobility, residence and co-morbidities were collected. Post-operative (1, 4, 12 months) place of residence, mobility status, unplanned attendance to an orthopaedic clinic with symptoms relating to the respective limb, re-admission to hospital and mortality was collated. Regression analysis was performed (SPSS, IBM Corporation, version 24). P < 0.05 was considered significant.

Results

648 consecutive patients were identified. Increasing age (p = 0.006) and presence of pressure sores during initial admission (p = 0.0019) increased the frequency of unplanned clinic attendance. No significant predictors of re-admission to hospital were found. Overall mortality was related to increasing age (p = 0.042), male gender (p = 0.004) and ASA grade (p = 0.009).

Conclusion

There is no current vogue to follow-up such patients in this post-operative period. We have identified variables that should be sought prior to discharge in this population. 22% of our population had at least one unplanned clinic attendance with a cost implication of approximately £50,132 (£151 per appointment) over the study period and potentially over £1.6 million pounds annually in the U.K.

Implications

Formal follow-up/rehabilitation programs could be offered for those at risk of unplanned clinic attendance. Post-operative orthogeriatric and/or general practitioner follow-up may reduce 12-month mortality in those at risk but validated scoring and risk stratification systems are required to fully justify this.

Introduction

An estimated 80,000 hip fractures are currently admitted annually to UK hospitals [1], a figure which is only expected to rise as the nation’s population continues to age and life expectancy increases [2]. Of these, 34.3% of admitted hip fractures are intertrochanteric and dynamic hip screw fixation (DHS) is the treatment of choice in 79.8% of cases [1]. Statistics demonstrate that 88% of patients who present with a hip fracture are reviewed by an older person specialist within 72 h of admission, however little is known about the quality of care provided to these patients in the community following discharge [1]. Alarmingly, the 2016 National Hip Fracture Database (NHFD) Report states that only 5.6% of UK hospitals involve local community rehabilitation teams in their monthly hip fracture meetings and just 3.4% of hip fracture multidisciplinary meetings have a social worker present [1].<

In 2007, the Best Practice Tariff scheme was introduced in an effort to promote early surgery and involvement of an orthogeriatrician in the care of hip fracture patients. Indeed, overall national 30 day mortality in this patient group has decreased from 10.9% (2007) to 8.5% (2011) since the introduction of the scheme [3]. Paradoxically, limited research has been conducted to identify patient factors that may be associated with an increased risk of post-operative admission and unplanned clinic attendance. Both of these factors confer a significant cost to the patient and the healthcare system. Neck of femur fractures cost the NHS 1 billion pounds annually [1], with the majority of spending attributed to length of inpatient stay (1.5 million bed days per annum in the UK alone) [[1], [4]]. UK cohort studies have demonstrated that up to 19.0% of patients who undergo surgery for an acute hip fracture are re- admitted to hospital within 3 months of the index operation [5]. Unplanned clinic review is also costly, with the average unit cost of a consultant-led trauma and orthopaedics outpatient appointment being 151 pounds [6]. In a time of austerity, prevention of re-admission and unplanned clinic attendance in this patient group is paramount.

Our study’s aim was to identify pre-operative and 12-month post-operative variables (including residence and mobility status) associated with an increased risk of unplanned orthopaedic clinic attendance and unplanned re-admission to hospital. Overall 12- month survival was also correlated to the above variables. Thus, can we identify patients at risk of unplanned clinic attendance and readmission prior to index discharge?