Article

HIP fractures among white women



CHAPTER 1 INTRODUCTION



Introduction This study examines the conditions associate with the hip fractures among the aging white women 65 and older who have had a fractured hip due to falls while in the hospital. The motivation for this study comes from two guiding research question: (1) are the falls linked to other conditions? and (2) do insurance companies pay for in-hospital treatment of these fractures from falling while these patients are in the care of the hospitals? Hip fracture is a medical and socioeconomic problem among the population aged 65 years and older across developed countries. Geriatric hip fractures are a serious, common and disabling condition. Ninety percent of hip fractures occur in individuals age 65 or older, and almost all hip fractures (98%) are treated surgically (Weinstein & Birkmeyer (2000). Hip fractures are associated with significant morbidity and mortality (Leibson, Tosteson, Gabriel, Ransom & Melton, 2002). Nearly one-third of elderly hip fracture patients die within a year of their hip fracture (Jiang, Majumdar & Dick, et al, 2005) and less than half of patients ever regain their pre-fracture level of function.

Background Increases in life expectancy have resulted in rapid growth of the older adult population. Individuals age 85 and older represent the fastest growing segment of the population in the United States and the population of adults over the age of 65 is expected to reach 20% by the year 2030 (United States Department of Health and Human Services, Public Health Service, 1991). Growth of older adult population presents challenges to the health care system and to providers of health care services. Older adults are the highest users of acute hospital services accounting for 41 percent of inpatient hospital days (US. Special Committee on Aging, 1988). Physiologic changes associated with aging contribute to declines in function following acute illness. Hip fractures are a leading cause of functional decline among older adults.

Problem Statement May patients with hip fractures are discharged from the hospitals before they are fully recovered and capable of independent functions (Lin, Hung, Liao, Sheen and Jong, 2006, p. 251). This early discharge creates many problems for both the patients and the nurses caring them. From the patient perspective early discharge from the hospital negatively impacts their recovery process and leaves them on the mercy of their acquaintances to provide further care. From the nurses perspective the problem arises from the fact that they are unable to understand and measure the patient outcomes from the early discharge and the recovery process. As this study is conducted from the nurses perspective it will help to apply the problem in their everyday experience for investigation. Polit, Beck and Hungler (2001) explain in their textbook that in a quantitative research study “a well-worded statement of purpose identifies the key variables and their possible interrelationships as well as the nature of the population of interest” (Polit, Beck and Hungler, 2001, p. 101). The problem statement identifies the population of interest (patients), the independent variable (discharged from the hospital) and dependent variable (independent function). Hip fractures represent a major health problem within the older population. The event of experiencing a hip fracture impacts all aspects of functional status. The older adult’s ability to meet basic needs, fulfill usual roles, and maintain health and well-being is threatened. Elderly women, the most rapidly growing section of the population, are at the highest risk for hip fracture. As a major source of morbidity and mortality, hip fracture elderly people require not only orthopedic care but also care for their co morbidities and time to recover from their fracture. If patients are discharged to nursing homes or rehabilitation hospitals early, continuous effective care may not be provided. Separating acute care and rehabilitation may not necessarily be cost-effective

Objectives The objectives of this study are:
• To determine the concordance between predischarge ADL (Activities of daily living) assessment and post discharge ADL independence in elderly women with hip fracture.
• To determine the proportion of individual who have fracture hips and perform less independently at home post discharge than they did during predischarge ADL assessment.
• To measure the outcomes of the early discharge of elderly women with hip fractures and its impact on their recovery process.

Purpose of the study The purpose of this study is to examine the outcome of the hip fracture with the 65 ears and older white women patients with hip fracture while they are still in hospital and their early discharge. This study further aims to examine the role of the nurse specialist and the effects he or she projects on the staff training pertaining to fall prevention practices (Davies, et al., 2004).

Significance of the Study Finding from this study will contribute to a better understanding of factor involving in hip fractures caused by falls among elder white women as well as factors motivating these patients in rehabilitation. The findings of this study will also contribute to the knowledge base for rehabilitation nursing practice. For example this research study is important for current nursing because it discusses the universal issue of the aging population as it relates to the common medical diagnosis of a hip fracture and their needs at home after leaving a hospital. This research study is important for current nursing because it discusses the universal issue of the aging population as it relates to the common medical diagnosis of a hip fracture and their needs at home after leaving a hospital. Watters and Moran reinforce this issue; “More than 350,000 hip fractures occur in the United States every year, and the number will double by 2050 as baby boomers advance in age. Hip fractures remain one of the most common injuries of the geriatric cohort, where 9 of 10 patients with a hip fracture are 65 years of age or older and have multiple medical problems” (Watters and Moran, 2006, p.157). According to Lin, Hung, Liao, Sheen and Jong (2006), hip fractures are an important cause of morbidity and mortality among the geriatric population. As a result it is critically important for the nurse to make certain that quality discharge planning takes place as these services can play a crucial role and improve the outcomes for the patient. Negative outcomes that could potentially be avoided can include recurring falls, readmission to hospital, as well as improved activities of daily living which can all impact the already limited nursing resources available due to the shortage. Ultimately the importance of such a study upon nursing is that discharge planning interventions by a nurse can improve the physical outcomes and quality of life in geriatric hip fractures.

Research questions of the study Polit, Beck and Hungler (2001) explain that research questions guide the types of data to be collected in the study. To support this observation, Lin et al. (2006) further investigated these questions in the form of a literature review of hip fractures and care needs among the elderly in relation to their physical function as well as with their statistical analysis. In this context, the research questions that the researcher aims to address the following:

1. Are the elderly patients with hip fractures following discharge from a hospital able to care for themselves and are the caregivers able to meet the needs of these clients?

2. Are the nursing interventions and health education upon discharge adequate for these individuals to cope at home?

Hypothesis Study The study hypothesis is that; “There is a strong correlation between poor physical function in the elderly and high levels of care execution difficulty” (Lin et al., 2006, p. 257). The statistical tests support the researchers hypothesis as Lin et al. (2006) explain that the study illustrates that a reduction in physical functioning in geriatric patients results is a reduced self-care ability, which consequently leads to a higher rate of care difficulty for the main caregivers. Study variables are qualities, properties, or characteristics of persons, things, or situations that change or vary. Some variables are manipulated while others are controlled. Some are identified but not measured while others are measured with refined measurement devices. Independent variables are stimuli or activities that are manipulated or varied by the researcher to create an effect on the dependent variables. Dependent variables are the responses, behaviors, or outcomes that the researcher wants to predict or explain (Burns and Grove, 2003). Study variables in this research article include basic demographic data of the patients and caregivers, physical function status, relationship between physical functions and care needs, and the level of care difficulty. The independent variables include background information on the patients and caregivers, physical function status of the patients, care needs and level of caring difficulty. The dependent variables include the level of physical functioning before discharge and one week after discharge. The researchers predicted that additional discharge instructions, education of primary caregivers in relation to disease-related knowledge and elderly care skills as well as a rehabilitation plan to assist in progressing to a higher level of independence was needed.

Conceptual theoretical framework Anderson’s behavioral model of health services use and health outcomes can be used as a basis for conceptualizing the pathways related to utilizing health services and the quality related to falls care. The model shows the role of the external environment including evidence-based practices and policies on outcomes, the relationship of population characteristics on the use of health services, and the relationship of the use of health services and quality of care on outcomes including consumer satisfaction. Andersen’s conceptual framework highlights that improving access to care involves contextual and individual characteristics that predispose, enable, and necessitate the use (or not) of health services. These same characteristics can influence health providers in the provision of medical care, the process of medical care. One important outcome of health behavior and health services use is evaluated health status, such as measuring the reduced number of falls. Another important outcome is consumer satisfaction, how individuals feel about the health care they receive. Donabedian’s framework is a commonly used one in quality assessment and identified three dimensions of quality: structure, process, and outcomes. Structural quality refers to those characteristics of the health care delivery system that influence access to health care services. It includes characteristics of the community, health care organizations, providers, and populations. Process quality includes both technical excellence, such as adherence to practice guidelines or professional standards, and interpersonal excellence, such as patient-centeredness. Outcomes can include both condition-specific measures, such as the number of hip fractures and generic measures, such as patient satisfaction (31-33).

Chapter summary This chapter has presented the background of the study which is the hip fracture among the elderly women over 65 years of age. Hip fractures of the most common problem among elderly people and also the most morbid one which can cause even death. However, the much alarming situation is the early discharge of the patient with hip fractures which impacts their recovery process. Hence, this study is significant for both the nurses and the hospital administration in understanding the outcomes of the early discharge for the hip fracture patients.

CHAPTER 2-LITERATURE REVIEW



Cause and risk factors for falls While considerable evidence exists of the circumstances and risk factors surrounding falls, significant challenges still remain in our understanding of their cause and prevention. In biomechanical terms, most falls can be defined as loss of a stable upright posture due to movements (and lack of appropriate corrective actions) which displaces the body's center of gravity beyond its base of support. Most falls have no apparent link to environmental hazards (Morfitt, 1983), but instead result from failed attempts at performing activities of daily living such as walking, turning, rising, and bending (Nevitt & Cummings, 1993b; Parker, Twemlow, & Pryor, 1996; Tinetti, Doucette, & Claus, 1995). While slips and trips are common self-reported causes for falls, similar in frequency are claims of “loss-of-balance,” “leg gave way,” “changed posture,” or “don't know the cause” (Blake et aI., 1988; Brocklehurst, Exton-Smith, Lempert Barber, Hunt, & Palmer, 1978; Cumming & Klineberg, 1994). A variety of factors predispose individuals to falls, including medication use, stroke, neurological disease such as Parkinson's syndrome, and impairments in muscle strength, joint movement, balance, gait, vision, hearing, and cognition (see reviews in (Rubenstein, Josephson, & Robbins, 1994; Tinetti, 1994).

Role of Fall Mechanics in Determining Hip Fracture Risk An important question for hip fracture prevention strategies concerns the factors that separate injurious and non-injurious fall s, Investigators have examined this through questionnaire regarding fall characteristics in individuals who fell and fractured, versus those who fell and did not fracture (Greenspan et aI., 1998; Greenspan, Myers, Maitland, Resnick, & Hayes, ] 994; Keegan, Kelsey, King, Quesenberry, & Sidney, 2004; Nevitt & Cummings, 1993b; Parkkari et a1., 1999; Schwartz, Kelsey, Sidney, & Grisso, ] 998; Wei, Hu, Wang, & Hwang, 2001). These include questions about the direction of the fall (e.g., forward, sideways, backwards, or straight down), body parts that received the impact of the fall, and whether an attempt was made to break the force of the fall (e.g., with the outstretched hand). Several studies have also included comparison of bone mineral density (BMD) measures in fractured and non-fractured patients. These studies indicate that hip fracture risk is increased over 30-fold by landing on or near the hip (Hayes, Myers, Morris, Gerhart, Yett, Lipsitz, 1993; Nevitt & Cummings, 1993b; Schwartz et aI., 1998). In contrast, a single standard deviation decrease in femoral bone density increases fracture risk by 2 to 3-fold. Falling sideways causes a 5 to 6-fold increase in hip fracture risk (Greenspan, Myers, Maitland, Kido, Krasnow, and Hayes, 1994; Nevitt & Cummings, 1993b; Schwartz et aI., 1998). When compared to injurious falls, non-injurious falls are more likely to involve impact between the ground and the hand or knee, which reduces hip fracture risk by approximately 3-fold (Nevitt & Cummings, 1993b; Schwartz et aI., 1998). Risk for injury during a fall is also increased by lower limb weakness, which increases hip fracture risk over 5-fold (Schwartz et aI., 1998; Tinetti, Doucette, Claus, & Marottoli, 1995), and upper limb weakness, which increases fracture risk 2-fold (Nevitt & Cummings, 1993b). Thus, in contrast to the traditional view of hip fractures as a consequence of osteoporosis, these data suggest that fracture risk is dominated by the direction of the fall, the configuration of the body at impact, the intactness of specific fall protective responses (such as braking the fall with the outstretched hand), and the neuromuscular status of the faller. To design effective hip fracture prevention strategies, we must consider two sets of risk factors: those that lead to an increased propensity for falling, and those that increase the risk for hip fracture in the event of a fall. As reviewed by Tinetti (1994), risk factors for falls include increased age, medication use, neurological disease such as Parkinson's syndrome, stroke, and impairments in muscle strength, joint movement, balance, gait, vision, hearing, and cognition. Many of these factors also increase one’s risk for hip fracture, including impaired vision, use of specific medications, lower limb weakness, and neurological disease (Felson, 1989; Grisso et a1., 1991; Ray, 1989). Elderly women have significantly higher risk of falls than men of the same age and one-third of women aged 60 and older fall at least once a year (Tinetti, Speechley & Ginter, 1998). The lifetime risk of hip fracture for a Caucasian women and Caucasian man aged 50 years has been estimated at 17% and 5% respectively (Di Monaco, 2004). Several studies found that the risk of a second hip fracture is increased both men and women following the initial fracture (Elliot-Gibson, Bogoch, Jamal & Beaton, 2004).

Overview: hip fracture Three hundred twenty-nine thousand hip fractures occur annually in the US, and most of them are low-trauma hip fractures that usually occur in elderly people due to osteoporosis and low-energy falls. Compared with vertebral and wrist fractures, hip fractures cause more deaths, shorten more lives, and cost more money. A hip fracture may lead to severe disability or even death, often by causing acute coronary syndrome or pulmonary embolism. After a hip fracture, a woman’s life expectancy decreases by 5.4 years (National Hospital Discharge Survey, 2004) as women who have sustained a hip fracture have a 10–20% higher mortality than would be expected for their age (Cummings, Melton, 2002).Furthermore, hip fractures impose a major economic burden on the healthcare system costing 20 billion dollars annually and 18,000 dollars per hospital admission (Roudsari, Ebel, CorsoMolinari, Koepsell, 2005). The US life expectancy has risen 5 years since 1970, and, in 2004, it reached an average of 77.8 years for both sexes combined and 80.4 years for females(Minino, Murphy & Kochankek, 2007). By2030, 71 million Americans will be over 65 years old accounting for about 20 % ofthe US population (The state of Aging and Health in America 2007 Executive Summary). Looking ahead, the lifetime risk of hip fracture will increase aspeople live longer. Indeed, the estimated incidence of hip fractures among older adults (age >65 years) in the US in 2006 was 293,000 (NHCS NCfHS Trends in Health and Aging, 2006) and in 2040 is projected to be 512,000 (this estimate includes people aged >50) (Cummings, Rubin, Black, 1990) it importance. A person with healthy bone will not sustain a hip fracture following a low energy fall, such as tripping over the curb or falling from standing. Hip fractures following falls are mostly low-trauma fractures caused by osteoporosis, bone metastasis (Cheal, Hipp & Hayes, 1993), infection, or inherited metabolic bone diseases (e.g., Paget’s disease and ontogenesis imperfect)(Chavassieux, Seeman & Delmas, 2007). Osteoporosis, the most common cause of low trauma hip fractures, is the focus of this study. Age-related risk factors Age is considered one of the most significant contributors to the risk of hip fracture. The Study of Osteoporotic Fractures (SOF), considered one of the most authoritative studies, showed the risk of hip fractures increases 1.4-fold every 5 years after age 65 (RR2=1.4, 95% CI: 1.2, 1.6)(Cummings, Nevitt, Browner, Stone, Fox, Ensrud, Cauley, Black, Vogt, 1995) Age increases the risk of both osteoporosis and falls in women. In the case of osteoporosis, declining estrogen levels play a major role. Bone mass in both women and men reaches a peak between ages 20 and 30, remains stable until age 45–55years, then starts to decline thereafter. Women experience accelerated bone loss more than men do (Figure 1.1) (Seeman, 2002). Some women may be more prone to hip fracture at a younger age because early estrogen deficiency or late puberty affects bone maturation and formation during bone modeling [Luiza Loro, Sayre, Roe, Goran, Kaufman, Gilsanz, 2000; Lloyd, Chinchilli, Johnson-Rollings, Kieselhorst, Eggli, Marcus, 2000]. Most women, however, experience the most significant loss of bone mass during menopause, when they lose the protective effect of estrogen.

Increased frequency of falls Aging also increases falls and influences the characteristics of fall-related trauma. Elderly women are at greater risk of falling because of 1) their weak neuromuscular function [Cummings, Nevitt, Browner, Stone, Fox, Ensrud, Cauley, Black, Vogt, 1995]; 2) their poor ophthalmologic conditions (Grisso, Kelsey, Strom, Chiu, Maislin, O’Brien, Kaplan, 1991); 3)the side effects that they experience from medication (anti-hypertensive, diuretic, etc)(Wang, Bohn, Glynn, Mogun, Avorn, 2001) ; and/or 4) the increased incidence of cardiovascular disease, such as syncope, stroke, arrhythmia, and hypotension (Johansen, 2006).Moreover, environmental hazards such as unsecured throw rugs/mats, potholes, ice, revolving doors, and getting out of the car, are risk factors for age-related falls, and therefore for hip fractures (Stevens & Olson, 2000). Older individuals are highly vulnerable to any loss of balance caused by even a minor obstruction. Younger subjects live with the same environmental factors but do not have anywhere near the same fall or fracture rates (Cummings & Nervit,1989). It should be noted, though, that old people appear to fall mainly due to impaired general health, rather than external hazards (Stevens & Olson, 2000). The manner in which subjects fall may contribute to hip fractures in older individuals as they tend to fall laterally on their hip, whereas younger individuals tend to fall forward on their hands (Cummings, 2000).Age is a relatively crude risk factor because it encompasses a number of individual risk factors that tend to increase with age, such as gonadal dysfunction, decreased physical conditioning, and reduced nutritional input (Ensrud, Duong, Couley, Heaney, Wolf, Harris & Cummings, 2000). However to date, the effect of age has not been fully explained by the combined individual risk factors. It stands as an independent risk factor above and beyond those aspects that are correlated with it. In older women, the risk of hip fracture may be less affected by osteoporosis than by other factors which increase the risk of falling, such as frailty.

Consequences of Hip Fracture Mortality is a frequent outcome of hip fracture. Di Monaco (2004) reported that post hip fracture mortality rates ranged from 10% to 30% and have not declined in the past 20 years. Mortality was noted to be higher in men, older individuals, those with a greater number of comorbidities, the cognitively impaired, and those who were more functionally dependent prior to the fracture. Boone (2004) reported similar findings in regards to predictors of mortality. Similary, Nevalainen (2004) studied the in-hospital and 4 month post fracture mortality rate of community dwelling older men and women. In a sample of 1,292 hip fracture patients (26.5% men and 73.5% women) the mortality rate at 4 months post hip fracture was 9.9%. Cranney (2005) conducted a comparative study to examine health status of elderly women post hip fracture (n=35; mean age 80), compared to age matched controls (n=40; mean age 72), using the SF-36 instrument. Data were collected at baseline, 3 months and 9 months post fracture for the hip fracture group and at baseline for the control group. Health status was lower for women with hip fractures compared to control. Limitations include controls that were younger than the hip fracture patients who many have influenced HRQOL (Health related quality of life ) results, and control subjects were only interviewed only at baseline.

Post-Discharge Care Several studies have reported that most hip fracture patients will not gain pre-fracture functional levels for activities of daily living (Jette et al., 1987) walking (Marottoli, 1993), and stair climbing (Meadows, 1991). Reports also suggest that older patients recovering from hip fracture in the community experience severely diminished levels of daily physical activity (Jones, 2000). Impaired mobility and balance are two aspects of morbidity in hip fracture patients (Fox, 1998) and both are strong predictors of recurrent falls in an older adult population. Hall and Colleagues (2000) stated that the effects of impaired balance and mobility along with reduced functional and social independence are reflected in an overall diminished quality of life for hip fracture patients. A recent investigation suggests that quality of life is very important to older Australian women who would rather die than experience the loss of independence and quality of life associated with hip fracture (Salkeld , 2000). With such poor outcomes, it becomes apparent that hip fracture patients require intensive rehabilitation and care in order to ensure a return to the quality of life that they may have experienced prior to the hip fracture. Inpatient hospital rehabilitation has been shown to be effective in improving physical function after hip fracture (Cameron, 1993). Establishing effective rehabilitation intervention for the patients following hip fracture is a major challenge confronting health care providers who treat these patients.

Age, sex and race Hip fracture rates increase with age across all race and sex categories. Age specific hip fracture rates are highest for white women, with their rates of hip fracture increasing exponentially after the age of 70 (Karagas, Lu-Yao, Barrett, Beach & Baron, 1996; Fisher, Baron & Malenka, 1991). The second highest rates are for black women (Fisher, Baron & Malenka, 1991). Differences by race in the rates of hip fracture are believed to generally reflect the higher bone density among blacks compared to whites (Kyle, Cabanela & Russell, 1994). Despite these fracture rate differences by race, we are not aware of any studies that have compared device use based on bone density alone.

Comorbidities The number and type of comorbidities at the time of hospital admission for hip fracture is significantly and positively associated with mortality, both during hospitalization and within one year following hip fracture (Hudson et al, 1998). The presence of dementia or delirium at the time of hip fracture is associated with poorer outcomes and higher mortality (Kenzora, McCarthy, Lowell, Sledge, 1984).. We adjusted for the number and type of comorbidities using an adapted Charlson comorbidity index (Romano, Roos & Jollis, 1993). Although we assumed that surgeons consider comorbidity severity in their surgical planning, no studies indicate that device selection for intertrochanteric hip fracture treatment is based on comorbidities.

Subtrochanteric fracture Subtrochanteric fractures are considered unstable, and may therefore benefit from the IMN devices.

Surgeons The physician factors included are those that are known to influence the rate of new technology adoption in health care, or those that are associated with general levels of surgical proficiency. Our model included the following surgeon factors: intertrochanteric fracture case volume, surgeon age as a measure of experience, Board-certification status, degree (MD or DO), specialty and practice type (group, other). Intertrochanteric fracture case volume was calculated directly from the surgeons’ claims. The literature currently lacks information on how individual physician factors, such as age and level of experience, relate to surgical procedure choices.

Procedure volume Studies that examined physician factors relative to resource use and outcomes across multiple surgical specialties showed that higher physician surgical volumes resulted in lower mortality, fewer complications and shorter hospital stays. Although relatively small numbers of surgeons were classified as high volume across several studies, those who were performed a disproportionately large numbers of cases. The number of surgical cases of a particular condition necessary for a surgeon to qualify as high volume varied across studies and cut-points were often arbitrarily determined.

Surgeon experience In clinical trials of intertrochanteric fracture treatment, the level of surgeon experience in general and the amount of surgical experience with the IMN device was often not controlled for. As an estimate of surgical experience, this series of papers used a calculated surgeon age from the Medicare provider enrollment file, because it was more often populated with sensible values than we found within the medical school graduation year field.

Hospitals For elderly intertrochanteric fracture treatment under Medicare DRGs, additional financial pressure is placed on hospitals by surgeons’ use of IMN devices, due to the high cost of IMN implants relative to plate/screws devices. Device costs are rolled into Medicare DRG payments to hospitals, and are not reimbursed separately. We assume that hospitals aim to minimize costs and maximize revenue. Hospital cost containment incentives imposed by Medicare DRGs are in direct contrast to the surgeon income incentives created under Part B within the same payment system. Higher priced implants are thought to be less desirable to hospitals, unless such devices routinely decrease hospital costs in other stay-related variables, such as decreasing operating room times, lowering complication rates or shortening hospital stays.

Teaching status and residents The orthopaedic literature indicates that the presence of an orthopaedic residency training program is associated with longer hospital lengths of stay and higher readmission rates. Orthopaedic resident involvement in hip fracture cases is associated with higher complication rates among patients with complex fractures (Palm, Jacobsen, Krasheninnikoff, Foss, Kehlet, Gebuhr, 2007). From the technology diffusion literature, teaching hospitals tend to be early adopters of new technology, compared with non-teaching facilities. Patients treated in teaching hospitals may have lower mortality rates following hip fracture surgery when compared with patients treated at non-teaching facilities. Teaching surgeons have a responsibility to provide residents with exposure to a wide range of technology and procedures, some of which may be new. Device industry representatives focus a great deal of attention on teaching facilities to provide residents with experience in the use of their particular brand and type of devices, in hopes that such usage will continue after graduation.

Hospital intertrochanteric procedure volume Most studies that assessed the relationship between hospital surgical volume and clinical outcomes, such as mortality and complication rates, found that higher hospital and surgeon volumes of a particular procedure were associated with better outcomes and fewer complications (Shervin, Rubash, Katz, 2007).
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