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Reducing the incidence of osteoporotic hip fractures

Carol Jones
SRN SCM HV HealthEdCert
Osteoporosis Prevention Officer
Osteoporosis Dorset
E:mail@osteodorset.org.uk

Promoting health and independence for older people and ensuring that they have fair access to health services is at the very heart of the NSF for Older People. Of the eight standards in the NSF that set out the strategic direction, three have a more specific clinical focus. These are standard five on stroke, standard six on falls and standard seven on mental health.

Standard six requires the NHS to take action to prevent falls and more importantly reduce the number of resultant fractures, especially hip fractures. The NSF quite rightly flags up the important role that GPs have in helping to identify and treat osteoporosis (fragile bones) and reduce the incidence of osteoporotic fractures: the profession is urged to take responsibility to identify those who need prevention or treatment.(1) Nurses in primary care are equally well placed to help their PCTs deliver the aims/objectives of standard six: that is, to reduce the incidence of pain, disability dependence and premature death caused by osteoporotic hip fractures in their patient/client populations. But without an understanding of the evidence that links falls, fragility and hip fractures, it is possible for PCTs to achieve NSF milestones (see Table 1) and still fail to deliver any of the aims/objectives of standard six.

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Falls are the leading cause of mortality due to injury in people aged over 75 years in the UK.(2) Osteoporotic hip fractures alone cost the NHS more than £1.7b each year and result in more than 14,000 deaths.(3) Standard six introduces a new performance measure for the NHS to work towards. From 2004 all primary care organisations (PCOs) will be required to measure the incidence of fractured neck of femur, and the services that they put into place will be measured by their ability to reduce this incidence. There are two key strategies outlined by the NSF that aim to reduce the incidence of hip fractures. First, reducing the incidence of falls, since over 95% of hip fractures result from a fall.(4) While this means that nearly all hip fractures result from a fall, the vast majority of falls do not result in a hip fracture. In fact, less than 5% of falls end in fracture of any type, and less than 1% in a hip fracture.(5) As 90% of hip fractures occur in people who have fragile bones, osteoporosis is the missing link.(6) With this in mind, the NSF urges PCOs to introduce programmes to identify those individuals at high risk of fracture, such as fallers who have osteoporosis or people who have already suffered a fragility fracture. As the risk of falling and developing osteoporosis increases with age, it would seem logical that the Department of Health encourage Strategic Health Authorities to set more specific performance indicators for their PCTs: that is,  age- and sex-standardised incidence of fracture of proximal femur, as opposed to just incidence of fractured neck of femur, which could include younger adults who had suffered a road traffic accident! Nurses at PCT level can lobby for this more specific performance indicator.

Many PCOs have targeted either falls among older people or osteoporosis as a local priority, but rarely both.(7) Nurses in primary care are no more a homogenous group than older people themselves - some work strategically, delivering the NSF for Older People, others are at the "coalface", delivering care to individuals and their families. The enthusiasm and energy that some nurses have are essential ingredients at facilitating change.

The "sounds good let's do it" commissioning process describes an approach that Osteoporosis Dorset (see Box opposite) has often used over the last decade. It takes into account evidence and information to hand, what will work locally, and what is needed to start small schemes. Work is usually commissioned as a short-term measure, often pilot- or project-based using "soft money" obtained from specific bids, such as the "Break The Fall Not The Hip Campaign" (Dorset Health Authority and Poole Social Services) and the "Pre-retirement Health Check Pilot" (Health Development Agency). It has built partnerships, interest, credibility and support across local areas and organisations, which has facilitated getting some of the projects into mainstream local health improvement programmes (HIMPs).

Caroline Morrison, consultant in public health, Greater Glasgow NHS Board, also thinks that: "Funders are attracted to an approach from a multidisciplinary group, rather than one that emanates from one care area only. Working in partnership to make small, evaluated service changes and in ways that harness local interest may be an essential first stage in developing further commissioning. There is no better area for such collaboration than that of falls, fractures and osteoporosis."(10)

A project that aimed to reduce or stabilise the numbers of osteoporotic hip fractures would, according to Dr Morrison, be attractive to funders for a number of reasons - osteoporotic hip fractures cause emergency admissions, disrupt elective surgery, block beds as long-term care placements are sorted out, and affect waiting times and numbers - targets on which NHS managers' performance is assessed.

Of the £1.7b annual cost of treating osteoporotic hip fractures, 45% is for acute care, 50% for social care and long-term hospitalisation, and 5% for drugs and follow-up.(3) The overall cost does not include costs to informal carers and others of stopping work or reducing hours of employment to care for a relative injured as a result of a hip fracture, let alone the psychological impact of this social disruption.

When Osteoporosis Dorset's Scientific Committee was established in 1992 it calculated with the Dorset Health Authority an annual incidence of 1,000 hip fractures for the whole of the county with its population of approximately 700,000. Our statistics are slightly higher than average, reflecting the fact that Bournemouth and Christchurch are traditionally perceived as areas to which people retire. It is easy to become overwhelmed by the national statistics or even the local implications of the projected hip fracture data. In 2001, Cryer and Patel applied current epidemiological data to those aged 50 and over in a typical PCT (population 100,000): 420 people were admitted to hospital due to a fall per year, 140 were admitted to hospital with a hip fracture per year, and the annual number with a hip fracture was projected to rise to 400 by 2030.(7) As one in five nurses are aged over 50 years and eligible for early retirement at 55 (including me), and one in four family doctors in some areas in the UK are also due to retire in the next 5-10 years,(11) these hip fracture statistics could include us!

I've used the noun "patient" throughout the article; it is not exactly politically correct or accurate because some community nursing staff have clients, and ­individuals are not necessarily long suffering, philosophical, submissive or uncomplaining! In the context of this article they are the consumers or potential consumers of our services. What's in a name? The term "elderly" can, according to the WHO,(12) refer to anyone aged 60 years and over, covering a span of 40 years or more. From a demographic point of view, population ageing is a result of both fertility and mortality: fewer children are born and more people reach old age. Living longer offers unprecedented opportunities for personally and socially fulfilling lives. Dr Jed Rowe, a consultant in Birmingham, talks about the three ages of older life, starting with the "Bronze Age", when older people jet around the world chasing the sunshine. However, should they fall down the aircraft steps and land directly onto their hip they could easily enter the "Iron Age" (50% of fallers who fracture their hips are never functional walker's again(13) and require sticks or Zimmer frames [iron]). They could sadly go directly from the "Iron Age" to the "Stone Age", as one in five will die within six months.(13) A recent study on hip fracture that results in nursing home admission, which recorded the views of community-dwelling older women, showed that "Bronze Agers" viewed this in quality-of-life terms as "equivalent to death". Even osteoporotic hip fracture with maintenance of independence is viewed by older people as resulting in substantial reduction in quality of life.(14)

So for those with a vested interest or involved in patient care, the second part of this article (in the next issue of NiP) will deal with the evidence for reducing the risk of falling, addressing the force of a fall and bone fragility.

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References

  1. Department of Health. National Service Framework for Older People. Standard Six: falls 6.23. Available from URL:?http://www.doh.gov.uk/nsf/olderpeople
  2. Health Education Authority. Older people - older people and ­accidents. Fact sheet 2. London: HEA; 1999.
  3. Torgerson DJ, Dolan P. The cost of treating ­osteoporotic ­fractures in the UK female population [Letter]. Osteoporosis Int 2000;11:551-2.
  4. Grisso JA, et al. Risk factors for falls as a cause of hip fracture in women. N Engl J Med 1991; 324:1326-31.
  5. Tinetti ME, et al. Risk factors for falls among elderly persons living in the community.N Engl J Med 1988;319:1701-7.
  6. Phillips J, et al. The direct medical costs of ­osteoporosis for American women aged 45 and older. Bone 1988; 9:217-9.
  7. Cryer C, Patel S. Falls, fragility and fractures. Proctor and Gamble;2001. p. 6.
  8. Lauritzen JB, et al. Effect of ­external hip protectors on hip fractures. Lancet 1993;341:11-3.
  9. Villar TMA, et al. Will elderly rest home residents wear hip ­protectors? Age Ageing 1998;27:195-8.
  10. Morrison C. Osteoporosis services: ­negotiating ­funding. Osteoporosis Rev 2003;11(2).
  11. Meadows S. Great to be grey: how can the NHS recruit and retain older staff? London: King's Fund; 2002.
  12. World Health Organization. Population ageing - a public health challenge. Factsheet no. 135. Geneva: WHO; 1998.
  13. Spirduso WW. Physical ­dimensions of ageing. Human kinetics. Illinois: Champaign; 1996.
  14. Salkeld G, et al. Quality of life related fear of falling and hip fracture in older women: a time trade off study. BMJ 2000; 320:341-6.

Resources
Falls, fragility and fractures
A health ­improvement and modernisation plan (HIMP) for falls and ­osteoporosis. It is an NSF milestone for PCTs to have a HIMP in place by April 2004. This publication can be obtained by email E:wooller.r@pg.com
Primary Care Strategy for Osteoporosis and Falls Available from the National Osteoporosis Society
T:01761 471771