Management of older adults with hip fractures in India: a mixed methods study of current practice

13 Pages·2017·0.63 MB·English

by  Santosh Rath

ArchOsteoporos(2017)12:55
DOI10.1007/s11657-017-0344-1
ORIGINALARTICLE
Management of older adults with hip fractures in India: a mixed
methods study of current practice, barriers and facilitators,
with recommendations to improve care pathways
SantoshRath1,2&LalitYadav3&AbhaTewari3&TraceyChantler4&MarkWoodward1,5&
PrakashKotwal6&AnilJain7&AparajitDey8&BhavukGarg6&RajeshMalhotra6&
AshishGoel9&KamranFarooque10&VijaySharma10&PremilaWebster11&
RobynNorton5
Received:26September2016/Accepted:3May2017/Publishedonline:2June2017
#TheAuthor(s)2017.Thisarticleisanopenaccesspublication
Abstract torstoimprovingcare,andconsequently,identifiescontextu-
Summary Evidence-based management can reduce deaths allyappropriate interventions for implementingbestpractice
and suffering of older adults with hip fractures. This study formanagementofolderadultswithhipfracturesinIndia.
investigatestheevidence-practicegapsinhipfracturecarein Purpose Hip fracture in older adults is a significant public
threemajorhospitals inDelhi,potentialbarriersandfacilita- health issue in India. The current study sought to document
Electronicsupplementarymaterial Theonlineversionofthisarticle
(doi:10.1007/s11657-017-0344-1)containssupplementarymaterial,
whichisavailabletoauthorizedusers.
* SantoshRath KamranFarooque
[email protected] [email protected]
VijaySharma
LalitYadav
[email protected]
[email protected]
PremilaWebster
AbhaTewari
[email protected]
[email protected]
RobynNorton
TraceyChantler
[email protected]
[email protected]
MarkWoodward 1 TheGeorgeInstituteforGlobalHealth,UniversityofOxford,
[email protected]
Oxford,UK
PrakashKotwal
[email protected] 2 IGHI,ImperialCollege,Kensington,LondonSW72AZ,UK
3 TheGeorgeInstituteforGlobalHealth,NewDelhi,India
AnilJain
[email protected] 4 LondonSchoolofHygiene&TropicalMedicine,London,UK
AparajitDey 5 TheGeorgeInstituteforGlobalHealth,UniversityofSydney,
[email protected] Sydney,Australia
BhavukGarg 6 DepartmentofOrthopaedics,AllIndiaInstituteofMedicalSciences
[email protected] (AIIMS),NewDelhi,India
RajeshMalhotra 7 DepartmentofOrthopaedics,UniversityCollegeofMedical
[email protected] Sciences,Delhi,India
AshishGoel 8 DepartmentofGeriatrics,AllIndiaInstituteofMedicalSciences,
[email protected] NewDelhi,India
55 Page2of13 ArchOsteoporos(2017)12:55
currentpractices,identifybarriersandfacilitatorstoadopting over60yearsrisesto12.4%of1.36billionpopulation[7–9].
bestpracticeguidelinesandrecommendimprovementsinthe Adoptionofprotocol-basedcareandclinician-ledqualityim-
managementofolderadultswithhipfracturesinDelhi,India. provementinitiativeswhereauditplaysanimportantrolehave
Methods This mixed methods observational study collected demonstratedasignificantreductioninthe30-dayand1-year
data from healthcare providers, patients, carers and medical mortality rates following hip fracture injury among adults
records from three major public tertiary care hospitals in aged 60 years [4, 5, 10–12]. As a consequence, these audits
Delhi,India.Allpatientsaged≥50yearswithanX-raycon- havetriggeredworldwideinterestinprotocol-basedmultidis-
firmedhipfracturethatwereadmittedtothesehospitalsovera ciplinary care for the management of older adults with hip
10-week periodwererecruited.Patients’ datawerecollected fracture. Similar audits have recently begun in Ireland,
at admission, discharge and 30 days post-injury. Eleven key AustraliaandNewZealand,HongKongandCanada[13–15].
informant interviews and four focus group discussions were The global burden of hip fractures is likely to increase
conductedwithhealthcareproviders.Descriptivedataforkey significantly from an estimated 1.7 million in 1990 to 6.3
quantitative variables were computed. The qualitative data million in 2050 [16, 17]. These increases are primarily the
wereanalysedandinterpretedusingabehaviourchangewheel consequence of improved life expectancy, especially in
framework. emerging economies, and it isprojected thatby 2050 nearly
Results Atotalof136patients,74(54%)menand62women, halfofallhipfractureswilloccurinAsia,particularlyinIndia
withhipfracturewereidentifiedinthethreeparticipatinghos- and China [16, 18, 19]. Due to limited healthcare resources,
pitalsduringtherecruitmentperiodandonly85(63%)were nearly2billionpeopleworldwidelackaccesstosurgicalcare
admitted for treatment with a mean age of 66.5 years (SD [20,21].High-incomecountries(HICs)havemeanof14op-
11.9).Ofthese,30%receivedsurgerywithin48hofhospital erating rooms and 45 trained surgeons per 100,000 popula-
admission, 95% received surgery within 39 days of hospital tion.Incontrast,low-andmiddle-incomecountries(LMICs)
admission and two (3%) had died by 30 days of injury. havelessthantwooperatingroomsandlessthanonetrained
According to the healthcare providers, inadequate resources surgeon per 100,000 population [22]. Following a hip frac-
andovercrowdingpreventadequatecaringofthehipfracture ture, use of health services extends beyond the initial hospi-
patients. They unanimously felt the need for protocol-based talization for at least 1 year, with follow-up care accounting
managementofhipfractureinIndia. for the majority of health costs [21–24]. Patients, therefore,
Conclusion Thedevelopmentandimplementationofnational mustbemanaged effectively and efficiently according tore-
guidelinesandstandardizedprotocolsofcareforolderpeople source availability [25]. India does not have a universal
with hip fractures in India has the potential to improve both healthcaresystemforallitscitizens.Mosthealthcareexpenses
careandpatient-relatedoutcomes. are paid out of pocket by patients and their families, rather
than through insurance. According to the National Family
Keywords Hipfracture .India .Carepathways .Fragility Health Survey-3, the private medical sector remains the pri-
fracture .Mixedmethods mary source of healthcare for 70% of households in urban
areasand63%ofhouseholdsinruralareas.Butforpoorand
vulnerable people, the public sector remains the healthcare
system to access as they cannot afford private medical care.
Introduction
Moreover, there is no public pre-hospital care for trauma in
India. Rashtriya Swasthaya Bima Yojana (RSBY), a health
Hipfracturesinolderadultshavesignificantimplicationsfor
insurance scheme, initially launched for below poverty line
morbidity,mortality,hospitalutilizationandthecostofcarein
(BPL) households, now covers other defined categories of
the community [1]. The annual healthcare bill is around 12
unorganized workers.But thiscommunity insurancescheme
billionUSDforthemanagementof250,000individualswith
covers only a proportion of the population and defined dis-
hipfracturesintheUSA[2,3]andaround3billionUSDfor
eases requiring hospitalization. Besides, the implementation
thecareof70,000olderpatientswithhipfracturesintheUK
of this scheme is varied in nature across different states in
[4,5].AreportonIndiain2004estimatedanannualincidence
India[26,27].Earlyadoptionofbestpracticeguidelinesand
of600,000osteoporotichipfractures[6],andthiswasexpect-
protocol-basedcareinlow-andmiddle-incomecountriesmay
ed to increase significantly by 2026, as the share of people
havethe potential toreducetheriskofmortality and costof
9 DepartmentofMedicine,UniversityCollegeofMedicalSciences, care and improve quality of life for older adults with hip
Delhi,India fracture.
10 JPNTraumaCentre,AllIndiaInstituteofMedicalSciences,New Our long-term aim is to facilitate the implementation of
Delhi,India best practice for the management of older adults with hip
11 SchoolofPublicHealth,NuffieldDepartmentofPopulation fractures in India, to moderate the impact of this injury in
Sciences,UniversityofOxford,Oxford,UK the coming decades. In India, a systematic approach is
ArchOsteoporos(2017)12:55 Page3of13 55
requiredtosetminimumstandardsandadoptionofprotocol- government and receives patients from north Delhi and sur-
basedcarepathwaysforthemanagementofolderpeoplewith roundingareas.
hipfractures[28].Inthefirstinstance,thisrequirescompari-
sonofcurrentpracticewithrecognizedbestpracticestandard
tohelpidentifypracticegaps[23].Italsorequirestheidenti- Datacollectionandmanagement
ficationofbarriersandfacilitatorstoadoptingbestpracticeto
enable the development of strategies [24] to implement All hospitalized patients aged ≥50 years with an X-ray con-
evidence-informedprotocolsforcare[25]. firmedhipfracture[30]wereapproachedtoparticipateinthe
Thestudyaimstodocumentcurrentpractices,barriersand studyoveraperiodof10weeks.Patientspresentingwithahip
facilitators to adopting best practice guidelines and conse- fracturebutwhowerenotadmittedwerenotrecorded,sothe
quently makes recommendations for improving the manage- numbersofhipfracturespresentingacrossthethreehospitals
mentofolderadultswithhipfracturesinDelhi,India. studiedcouldnotbedetermined.Adesignatedresidentinthe
departmentoforthopaedicsateachstudyhospitalwasrespon-
sibleforseekinginformedconsentfromadmittedpatients.
Methods Patients’datawerecollectedattwotimepointsduringthe
hospitalization period. Information on socio-demographic
Studydesignandsetting characteristics (age, sex, education, residence and occupa-
tion),causeandtypeoffracture,knownpre-existingmedical
This mixed methods observational study collected quantita- conditions, pre-fracture mobility and American Society of
tive and qualitative data concurrently [29] from healthcare Anaesthesiologists(ASA)gradewerecollectedonadmission
providers (HCPs), patients, carers and medical records from tohospital.TheASAgradesareawidelyusedgradingsystem
threemajorpublictertiarycarehospitalsinDelhi,India,from forpre-operativehealthofsurgicalpatients[31].Information
September2014toMarch2015. onin-hospitalcarepathway,orthopaedicsandgeriatricianco-
Thestudysiteswereselectedpurposively.Delhiisthesec- management,timefromadmissiontosurgery,surgicalproce-
ondmostpopulouscityinIndiawithapopulationofnearly17 dure,complicationsincludingpressureulcers,medicationfor
millionandprovideshealthcareservices,bothforitspopula- bone health, falls prevention advice, in-hospital mortality,
tion, from surrounding states and country-wide referrals. lengthofstay(LoS)anddischargedestinationwerecollected
Surgicalservicesatthedistrictareoftenlimitedtocaesarean atthe timeofdischargefromcaselogs(Appendices1Aand
sectionsandabdominalsurgery,withlimitedorthopaedicser- 1B). LoS is defined as the time from hospital admission to
vice capacity, mainly for managing simple road traffic inju- discharge. A 30-day post-injury follow-up was conducted
ries.Geriatricpatientswithhipfracturesandcomplexortho- throughatelephoneinterview(Appendix2).Ofthethreepar-
paedic injuries are therefore usually self-referred to tertiary ticipatinghospitals,onehadanelectronichospitalrecordsys-
care centres in Delhi from the surrounding states. The tem.Inthishospital,hipfracturepatientsusuallyreporttothe
National Institutes receive patient from all over the country. emergency department, and depending upon the availability
There are over 10 public tertiary trauma care hospitals in ofbeds,onlyaproportionofpatientsareadmittedandothers
Delhi,somefundedbytheGovernmentofIndiaandtheothers arereferredtonearbyhospitals.
bythelocalDelhigovernment.Theprivatetraumacarehos- For the qualitative data collection, the study participants
pitalsfaroutnumberthepublichospitalsandprovidesubstan- were HCPs, including clinical leads, residents and nursing
tial trauma care in the Delhi region. Estimates are that over stafffromthedepartmentsoforthopaedics,anaesthesia,geri-
70%ofsurgicalcareinIndiaareprovidedbyprivatecare. atrics,medicineandphysiotherapyinvolvedinpre-operative,
Priortotheselectionofhospitalsites,astakeholderevent operativeandpost-operativecare.Elevenkeyinformantinter-
was organized for representatives of major tertiary carehos- views (KIIs) and four focus group discussions (FGDs) with
pitalsinDelhi.Theaimsandobjectivesoftheproposedstudy HCPs were conducted using interview schedule and FGD
werediscussed duringthis event and the sites, whichsubse- guide. These comprised of open-ended questions to obtain
quentlyagreedtoparticipate,wereselectedforthestudy.The information on existing care pathways within their hospital
studysitesincludedthreeGovernmenttertiaryhealthcarecen- settingandpotentialbarriersandfacilitatorstoadoptingbest
tres.Twoofthese,theAllIndiaInstituteofMedicalSciences practices(Appendices3and4).
(AIIMS) and Jai Prakash Narayan Apex Trauma Centre Tworesearchstaff,trainedinqualitativeresearch,conduct-
(JPNATC), are national referral tertiary care centre funded edtheseKIIsandFGDs.EachFGDcomprisedof8–10par-
by the Ministry of Health and Family Welfare, Government ticipants. All the interviews and FGDs were conducted in
ofIndia.Thethird,GuruTegBahadurHospital,theassociated English or Hindi (local language), or both, as appropriate.
teaching hospital of the University College of Medical All the conversation/discussions were audio-recorded, tran-
Sciences (UCMS), University of Delhi, is funded by local scribed and translated into English. The duration of the
55 Page4of13 ArchOsteoporos(2017)12:55
interviews and focus groups was 30–45 and 45–60 min, Qualitative
respectively.
Thedataweremaintainedandaccessiblebyresearchstaff The data were analysed using a thematic approach [33] and
at the George Institute for Global Health, India. Each site the files were uploaded to NVivo 9.2, a qualitative software
maintainedamastersheetwithidentifyinginformationduring programmewhichsupportsinorganizing,indexingandcod-
the enrolment period to ensure that multiple entries into the ingofdata.
database were not made for the same patient. The KIIs and The identified themes were further interpreted using
FGDs were recorded, transcribed verbatim and translated in the behaviour change wheel framework (BCW) (Fig. 1).
English(wherenecessary),andthefileswereonlyaccessible This allowed us to understand barriers and facilitators to
totheresearchteam. adopting best practice guidelines through 10 theoretical
domains, and to map contextually appropriate interven-
tions. BCW is not a linear model and components with-
Dataanalysis in the behaviour system interact with each other to gen-
erate desired behaviour that in turn influences these
Quantitative components [34].
The quantitative data were de-identified and entered into an
Excel spreadsheet. The electronic data were kept password Ethicalconsiderations
protectedandstoredonsecureservers.
Frequency distributions were computed for key quantita- EthicalapprovalswereobtainedfromtheInstitutionalEthics
tive variables including demographic characteristics, type of Committee (IEC) of all participating study sites (vide letter;
fracture,treatmentmodalityandtypeofanaesthesia.Wecal- IEC/NP-40/13.03.2014, RP-32/2014) and (vide letter
culated the time between injury and admission to hospital 18.07.2014) and Health Ministry Screening Committee
fromdatacollectedas‘thedayofinjury’and‘dayofadmis- (HMSC) at Indian Council of Medical Research (vide letter
sion’[32].Thetimeintervalfromadmissiontosurgery,length No. 54/1/Indo- foreign/GER/2014-NCD-II, dated
of stay and death at 30 days following the injury were 10.10.2014). Written informed consent was obtained from
determined. studyparticipants.
Fig. 1 Behaviour change wheel (BCW)—adopting best practice beliefs about capabilities and consequences; Opt & Int optimism and
evidenceinthemanagementofolderadultswithhipfractureinIndia. intentions[motivation];Socsocialinfluences;Envenvironmentalcontext
Know. knowledge; Mem. memory, attention and decision processes and resources [opportunity]. Sources of Behaviour box and arrow in
[capability]; Idsocial/professionalroleandidentity;Bel.Cap.&Cons green;InterventionFunctionsOrange;PolicyCategoriesBlue
ArchOsteoporos(2017)12:55 Page5of13 55
Results someorallmayhavedied.Twopatientsdiedby30-dayfol-
low-up, one post-surgeryin-hospitaland the otherfollowing
Quantitative dischargefromthehospital(Table1).
Atotalof136patients,74(54%)menand62women,withhip
fracture were identified in the three participating hospitals Table 1 Demographics, fracture type, in-hospital care and 30-day
during the recruitment period. As per our inclusion criteria, mortality
all admitted patients were recruited to the study. Of the 136
Variable Value n(%)
patients,51werenotadmittedduetolackofbeds(Table3).
Ofthe85admittedpatients(63%ofthetotal),46(54%)were Age(n=85) 50–59 24(28)
menand39women,withameanageof66.5years(SD11.9), 60–69 21(25)
andallconsentedtoparticipateinthequantitativepartofthe 70–79 25(29)
study. A fall from a standing height was the cause of the 80+ 15(18)
fractureinalladmittedpatients,andfracturesweresustained Gender(n=85) Male 46(54)
on both sides of the body equally. Of those admitted to the Female 39(46)
orthopaedicward,nearlyhalf(48%)ofthepatientsweread- Education(n=77) Illiterate 23(30)
mittedwithin24hoftheinjuryandafifthwereadmittedafter Primary 25(32)
48h. Secondary 16(21)
The majority (65%) of fractures were inter-trochanteric, Graduateandabove 13(17)
29% were intra-capsular and 6% were sub-trochanteric frac- Occupation(n=79) Employed 19(24)
ture.Alltheolderadultswereindependentlymobileandonly Unemployed 13(16)
13%ofrequiredmobilityaidspre-fracture.Themostcommon Retired 23(29)
co-morbid conditions were hypertension (29% of patients) Householdwork 22(28)
and type 2 diabetes mellitus in 12%. The ASA grades were Others 2(3)
documentedin50patientswithdatamissingfor40%ofad- Pre-fracturemobility(n=82) Withoutaid 71(87)
mittedhipfractures.Twenty-four(48%)patientshadgradeI,
Withoneaid 11(13)
22(44%)hadgradeII,2(4%)hadgradeIIIand3(6%)had
Typeoffracture(n=85) Intra-capsular 25(29)
gradeIVlevelofASA.Onlysixpatients(7%)wereonbone
Inter-trochanteric 55(65)
protectionmedicationwhichincludedbisphosphonatesalong
Sub-trochanteric 5(6)
withcalciumandvitaminDsupplements,priortothefracture.
Anaesthesia(n=82) General 2(2)
A total of 82 patients were operated for their hip fracture
Regional 80(98)
and almost all (98%) operated patients received a regional,
Surgicalprocedure(n=77) Intramedullarynail 32(42)
spinal or epidural anaesthesia. Only 30% received surgery
Dynamichipscrew 23(30)
within 48 h of hospital admission, 27% were operated upon
Cannulatedcancellous 6(8)
between3and7days,22%between8and14daysand21% screws
were operated upon 2 weeks after hospital admission. Hemi-arthroplasty 15(19)
Intramedullary implants were used in 58% of inter- Totalhipreplacement 1(1)
trochanteric fracture fixation and dynamic hip screws were Timefrominjurytohospitaladmission Lessthan24h 41(48)
usedfortherest.Themajorityofpatientswithintra-capsular (n=85) 24–48h 29(34)
fracturesreceivedacementedhemi-arthroplastyandonlyone 3–7days 10(12)
receivedatotalhipreplacement. >7days 5(6)
At the study hospitals in Delhi, co-management of Timefromhospitaladmissionto Within48h 24(30)
hip fractures by orthopaedic surgeons and geriatricians, surgery(n=81) 3–7days 22(27)
osteoporosis assessment and medication, and falls as- 8–14days 18(22)
sessment at discharge are not routinely practiced. Only Morethan2weeks 17(21)
nine patients (10%) received falls assessment and were Lengthofstay(LoS)(N=81) 2–3days 2(3)
prescribed anti-resorptive therapy along with calcium 4–7days 14(17)
and vitamin D supplement at discharge. Data on pres- 8–14days 30(37)
sure ulcers were not documented. 3–4weeks 26(32)
The mean LoS in hospital was 16 days (SD 10.91). All
>4weeks 9(11)
patients were discharged to their respective homes, as inpa-
30-daypost-injurymortality(n=74) Dead 2(3)
tient rehabilitation facilities were unavailable in these hospi-
Alive 72(97)
tals.Elevenpatients(13%)werelosttofollow-upat30days,
55 Page6of13 ArchOsteoporos(2017)12:55
Qualitative if there is a suspicion of frequent falls or vertebral
fractures^.
Healthcareproviders’experienceofhipfracturepatients’
carepathways Intervieweesdrewattentiontothelackofa‘fallsclinic’at
allthreeparticipatinghospitals;however,accordingtoasenior
According to HCPs, patients mainly originated from the na- physiotherapist,assessmentforfallspreventionisprovidedif
tionalcapitalregionofDelhi,whichincludesadjoiningstates, patientsarereferredforsuchadviceorattimesduringfollow-
and weresometimes referredfromhospitals lacking surgical up. Patients are followed up 2 weeks post-surgery by an or-
facilities. Patients were taken to the hospital mainly by their thopaedic surgeon for suture removal and 3 months post-
relatives and at times by the patrolling police. Interviewees surgery for bone union and full weight bearing walking
alsoreportedthatthemajorityofthepatientsseekingcarein ability.
publichospitalsarefromlowsocio-economicstatusandhave
poorfamilysupport. BYes, we give falls prevention advise, we use some
charts and boards and train them on walker … so that
BPatients admitted to public hospitals were from quite theydon’tfall^(KII-5,seniorphysiotherapist).
differentdemographicandeconomicgroup(lowsocio-
economic)andthenumberofmalesaremorethannum-
beroffemales^—orthopaedicsurgeon(KII-8). Healthcareproviders’perspectivesonbarriers
andfacilitatorstoadoptingbestpracticeguidelines
Mostpatientswithacutefracturesincludinghipfracturespres-
entathospitaleitheronthesamedayofinjuryor2–3daysafter The BCW framework (Fig. 1) was used to categorize
theinjury.Hipfracturepatientsgenerallypresentattheemergen- the cited barriers and facilitators, using the constructs
cydepartment,wheretheyareexaminedbyaresident,admitted of capability (knowledge and skills; and memory, at-
totheorthopaedicunitifbedsareavailable,orreferredtoother tention and decision processes), opportunity (social
hospitals.Manyintervieweeshighlightthatafteradmission,older influences; environmental context and resources) and
peoplewithhipfracturewerefrequentlydiagnosedforthefirst motivation (beliefs about capability and conse-
timewithunderlyingco-morbiditiessuchasdiabetes,hyperten- quences; social and professional role; optimism and
sionandrenalandcardiacconditions. intentions).
BThere maybe two factors… the family may be of the
Capability Knowledge and skills—The majority of the
perception that it is a lost game and there is no point
HCPs believe that the management of hip fracture in
wastingmoneyandletthepersonbeathome.Another
older adults requires multidisciplinary care but lack
may be that our health system probably chooses the
consensus on early operative intervention and priority
younger patient who has a better chance of recovery
for surgery. Most orthopaedic surgeons were familiar
than in comparison to the older person^—geriatrics
with the existing international best practice guidelines
physician(KII-IX).
for the management of older adults with hip fractures
but some HCPs were not. Orthopaedic surgeons were
Almostallintervieweesreportedthatinadditiontoortho-
viewed to be technically skilled in surgical treatment
paedics,manyotherdepartments(e.g.medicineorgeriatrics,
but less able to coordinate multidisciplinary care of
anaesthesia,physiotherapy, endocrinology)wereinvolved in
older adults with hip fractures. Even though a geriatric
treatinghip fractures.After the diagnosis ofhip fracture, the
department existed in one of the three hospitals, hip
usual protocol of care is to assess the status of co-morbid
fracture patients with co-morbidities were rarely re-
conditions and try to optimize them for surgery, which in-
ferred to this department. In effect, provision of spe-
volves a pre-anaesthesia check by a qualified anaesthetist.
cialist orthogeriatric care was non-existent across all
The majority of interviewees said that calcium and vitamin
three hospitals.
D supplements are part of standard care for all hip fracture
patients.Anti-resorptivedrugsarerarelyprescribedandonly
A senior orthopaedic consultant (KII3) commented:
topatientsatriskforfutureosteoporoticfracturesofthespine.
BIt’s probably a failure on the part of the orthopaedic
surgeon and geriatrician to appreciate the value of the
A geriatric consultant (KII1) opined: BOne might con- multidisciplinarycareandthelackofknowledgeofin-
sider prescribing zoledronic acid (anti-resorptive drug) tegratedcarepathways.Oftenthesurgeoniskeenonhis
ArchOsteoporos(2017)12:55 Page7of13 55
operating procedures and the physician feels bothered There are no dedicated trauma OTs or priority trauma lists.
beingcalledinforapatientwithasurgicalproblemand Compound fracture management and polytrauma patients
notamedicalproblem.Thereissomesortoffailureto consume most OT time. Orthopaedic OTs are often shared
understandthenecessityforcollaborativework^. byothersurgicaldepartments,therebylimitingtheopportuni-
ty to prioritize treatment for hip fractures. Other constraints
werefunctioningimagingequipment,radiographers,implant
availability and, occasionally, lack of donors for blood
BThegeriatricianisneverinvolvedinthepicture,mostly transfusion.
it’sthegeneralphysicianwhotakescareofthepatient’s
comorbidconditions^—anaesthetist(KII6). Motivation Beliefs about capability and consequences—
MostHCPsconsideredtheirmanagementofolderadultswith
Memory,attentionanddecisionprocesses—Almostallthe
hipfracturetobesatisfactoryandsomethoughtthatmultidis-
HCPsfeltthatDelhihospitalsincludingtheirorthopaedicde-
ciplinaryapproachesandbestpracticeguidelineneededcloser
partmentwere overcrowdeddue toa lack ofdefinitivetreat-
consideration.AlmostalltheHCPsacknowledgedtheburden
mentforhipfracturesatdistricthospitals.TheseHCPsfurther
ofhipfracturesforIndiainthecomingyearsandwerewilling
addedthatexcessiveworkloadfromroadtrafficcrashesdeters
tolearnfromthebestpractices.Mostrealizetheimportanceof
priority for older adults with hip fractures. They also shared
adoptionofcontextuallyappropriatemodelsforthemanage-
thatlackofadequatenumberofbedsleadstomultiplehospital
ment of older adults with hip fractures in India to reduce
referralsandabiasagainstadmittingsickpatientswhorequire
mortality, morbidity and economic cost to both family and
prolongedlengthofstay.HCPsopinedmanagementprotocols
thehealthsystems.
and prioritiesfor careof older adultswithhip fractures may
differ between surgeons and the orthopaedic units in each
hospital. They further recommended that adherence to stan-
BIthinkintegratedcarepathwaysforhipfractureman-
dard treatment guidelines will reduce variations in decision-
agementsareverywellestablishedinwesterncountries
makingandqualityofcare.
andthereisaneedtoestablishiteveninourhospitals.
Insteadofhavingtoomanystakeholdersforthebegin-
BHospitalsatalllevelslikeadistricthospitalshouldbe
ning, you can just have orthopedic surgeons,
fullyfunctionalandnotliketheexistingway.Evenpa-
anaesthetists and internist and these 3 or 4 people can
tientsfromsmallerhospitalsequippedwithdesiredsur-
improvethequalityofcareandpatientscanbeoperated
gical facility are referring to our hospital (All agree).
earlierandtheoutcomeswillbebetter^—seniorortho-
TherearemorepatientsbutthedoctorsandOT(opera-
paedicsurgeon(KII2).
tiontheatre)timeisless^—HCPsviews(FGD-3).
Professional/social role and identity—Most the HCPs
shared that orthopaedic surgeons can convince patients and
OpportunitySocialinfluences—AccordingtotheHCPs,the their carers to accept surgery as the preferred treatment for
majority of the patients are from low socio-economic back- the hip fracture. There are a group of patients with faith in
groundanddependupontheirfamilymemberstoreachhos- traditionalbonehealersandaversiontosurgicalinterventions.
pital. In addition, interviewees highlighted that the patients AlltheinterviewedHCPsfelttheneedtoadoptbestpractices
andtheirfamilymemberslackgeneralhealthawarenessand butonlyafewwereconfidentoftheirroletoinfluencechange
largenumbersofpatientswithpre-existingco-morbidcondi- totheexistingmanagementofolderadultswithhipfractures.
tions are diagnosed for the first time while admitted for hip Optimism and intentions—The HCPs in their interviews
fractures.Thereisscantknowledgeinthepatientpopulation, were positive about the need to act in the right direction to
particularly from the adjoining states of Delhi about local improvemanagementofhipfracturesinIndia.Althoughthey
healthfacilities,informationonservicesandlackoftriageto considered this to be an uphill task, they were optimistic as
accessappropriatecare,leadingtomultiplehospitaltransfers. community awareness around geriatric health including hip
Most of the patients and relatives had no knowledge on the fractureinjuriesisimproving.MostoftheHCPsthoughtthere
consequencesofhipfractureinjuryinolderpeople. wasscopeforfurtherimprovement,butveryfewsuggesteda
Environmental context and resources—According to the systemsapproachtoadoptbestpractices inthemanagement
HCPs, inadequate staff, insufficient beds and overcrowding ofhipfractures.Therewasconsensusthatearlyrestorationof
affect caring to the needs of the patients. The operating the- mobility isa necessity and participation ofoccupationaland
atres (OTs) are inadequate to cater to the surgical workload. physiotherapyhasthepotentialtoacceleraterecovery.Oneof
55 Page8of13 ArchOsteoporos(2017)12:55
thekeyinformantsbelievedthatmostoftheorthopaedicsur- engagement platforms, including social media. Public infor-
geons prefer complicated surgeries like other joint replace- mationcampaignswererecommendedtoeducateonhipfrac-
ments over hip fracture fixation. Even in private hospitals, ture in older persons as a life-threatening condition and the
therearesomepeoplewhodoalotofjointreplacementoper- need for immediate hospitalization and early surgery. Some
ations,andforthem,hipfracturesurgeryisalowpriority. otherkeyinformantssuggestedtoincreasecommunityaware-
nessaboutearlydiagnosisandtreatmentofco-morbiditieslike
Healthcareproviders’recommendationstoimprovecare hypertension, diabetes, anaemia and osteoporosis
pathways (communicationsandmarketing)(Fig.1).
RecommendationsprovidedbytheHCPswereinterpretedto
mapsixkeyinterventionfunctionsalongwithfiveapplicable Discussion
policycategories(Table2).
Themappedinterventionfunctionsrecommendtheneedto Thestudyidentifiedsignificantevidence-practicegapsinthe
educate, train and persuade HCPs on multidisciplinary care care pathway for the management of older adults with hip
for hip fracturemanagementintheir hospitalsettings. HCPs fracturesinDelhi.Datafromonehospitalindicatesthatnearly
feltthatcommunicationbetweenHCPsandpatientsorfamily twothirdsofhipfractureswerenotadmitted.Onlyaquarterof
caregiversisimportantinthedeliveryofqualityhealthcareas olderadultswithhipfracturesover80yearsofageweread-
patientswantdoctorstonotonlyskillfullydiagnoseandtreat mitted.KeyinformantinterviewandFGDssuggestaselection
their medical condition but also communicate with them ef- bias against patients with multiple co-morbidities, pressure
fectively. Patients should also be advised on how to protect sores and those with high risk for surgery when beds are
themselvesfromfallsinolderageandmakingadaptivechang- scarce. Patients or carers refusing surgical intervention may
es like, arrangement of furniture or switching on a light for have a low priority for admission. Such implicit biases are
visibilitywhilstsleeping,andsupporttoaccessthebathroom likely to impact key outcomes like mortality of older adults
fromtheirbeds(education,trainingandpersuasion).Theef- withhipfracturesinthecommunity(Table3).
fectiveimplementationofthestandardizedprotocolmustin- Our study revealed delays in admission to hospital and
cludepromptreferral,multidisciplinaryteamwork,jointtrain- further delays in receiving surgery for a large proportion of
ing of staff, task sharing, accountability and outcome mea- older adults with hip fractures (70% did not receive surgery
surements.MostHCPsbelievedthatbestpracticeguidelines withintherecommendedperiodof48h).Latearrivaltohos-
can beimplemented byenablingadequateinfrastructureand pitalanddelaysinreceivingsurgeryareimportantevidence-
resources within a hospital setting. This includes increasing practice gaps compared to the achievements in the UK of
the number and availability of OT, implants and human re- 100% admission by 24 h and surgery by 48 h for 83% [5,
sourcesindisciplineslikeanaesthesiaandphysiotherapy(en- 10–12]. Faith in traditional bone setter could be one of the
vironmentalrestructuring,modellingandenablement). reasonsinseekingcareandmultiplereferrals[35].
Ata policylevel development,intervieweesunanimously Ourstudyalsofoundthatmanyoftheotherpractices,rec-
agreed that there was a need to develop guidelines for hip ommendedininternationalguidelines,werenotbeingincor-
fracture management and establish standardized care proto- porated into routine care. Findings from the KIIs and FGDs
cols in India (guidelines and regulation). Many expressed revealedthatmanagementofhipfracturesisnotapriorityand
the importanceofanambulance service totransport patients thesepatientshavetocompetewithothertraumaforoperating
fromremoteareas.Therewasconsensusthatdistricthospitals theatre availability. Lack of multidisciplinary management,
shouldbeequippedwithfacilitiestoprovidesurgicalcarefor overcrowdingandinadequateresourcesweresignificantbar-
hipfractures(serviceprovision).MostHCPsfeltthatthesur- riers in adopting best practices. The need for having a stan-
gicalmanagementofhipfracturesimposesafinancialburden dardizedprotocolofcarewasconsideredbyHCPstobecru-
and often leads to impoverishing expenditure for the house- cial for the management of older adults with hip fracture in
holds. There was unanimous support for community health India. There is also a need to change the perception of the
insuranceschemelikeRashtriyaSwasthayaBimaYojana,par- healthcare providers, particularly when they are considering
ticularly for those who are poor and vulnerable, to avoid the management of hip fractures as satisfactory within their
impoverishing or catastrophic expenditure from treatment hospitals.
forahipfractureinanolderperson(environmentalorsocial Thepatternofhipfracturesinthisstudyissomewhatdif-
planning). Some participants suggested that there should be ferent to other published series. Findings revealed a higher
publicawarenessonosteoporosis,fallsandhipfractureinjury number of men (54%) with hip fractures, compared to the
ingeriatricgroupsusingeffectivecommunicationandsocial preponderance of hip fractures in women elsewhere [8,
marketingmethods,anapproachtodevelopactivitiesaimedat 17–19, 36]. A recent hospital-based study from India also
changing community perception using a variety of reported that a higher number of men (52%) suffered a hip
ArchOsteoporos(2017)12:55 Page9of13 55
Table2 Healthcareproviders’recommendationstoimprovecarepathways
Definition Studyfindings(quotes)
Interventionfunctions
Educationandtraining Increasingknowledgeor BIthinkthemostimportantistogenerateawarenessandpreventivecare
understanding pathway,itisbelievedthatthebonebreakspostfallbutit’susuallyduring
thefallthatthebonebreaks,sopreventthefall^—R11(KII)
Impartingskills BAwarenessandsensitizationintermsoftheirrolesisimportantandthatwill
certainlyhelpandimprovesituationsifaknowledgeableandinterested
Physicianwouldbeapartoftheinitialteamthatisdealingwithahip
fractureoranykindofafracturepatient^—R1(KII)
BIthinkabestexercisewouldbeajointtrainingoraskillupgradation
programmefocusedonhipfractures^—R1(KII)
Persuasion Usingcommunicationto BSomebodyneedstotaketheinitiative,ifyouhavetherightwillingpeople,
inducepositiveor youcanchargepeopletoimprovepracticebecauseoldpeoplewill
negativefeelingsor continuetofallandtheywillcontinuetobreakhip^—R10(KII)
stimulateaction
Environmentalrestructuring Changingthephysicalor BOncesuchapatientisadmitted,anetworkingsystemmustbeimmediately
socialcontext activatedwiththedutyoftheconcernedperson(HCP)beingcomingtothe
patientandprovidingtheadequatecareinregardstothatparticular
specialty.Thissystemshouldbeautomatedandreferraltoother
departmentmustbesmooth^—R8(KII)
BInter-departmentalcoordinationshouldbeverygood,fore.g.Medicineand
Endocrinologydepartmentsshouldcoordinateverywellwiththe
departmentofOrthopaedicsorAnaesthesiasothatweallcandecideto
operateasearlyaspossible^—R3(KII)
BThereshouldbeintegratedprogram—mymajorsuggestionisweshould
reducethereferencetime,likereferencefromtheendocrine,reference
fromthemedicine,referencefromthesurgicalpeople,thatkindof
integrated…sothatisdefinitelyintegratedcare…allthepeopletheyare
togetherthenandthenitcandone^—R3(KII)
BProbablyadedicatedfracturecarearea,dedicatedoperationtheatrepractice,
dedicatedteam,dedicatedcommunicationfromtheothersegmentsshould
be...shouldbecoordinatedwell^—R4(KII)
Modelling Providinganexamplefor BIthinkintegratedcarepathwaysforhipfracturemanagementsareverywell
peopletoaspiretoor establishedincertainwesterncountriesandthereisaneedtoestablishit
imitate eveninourhospital^—R2(KII)
Enablement Increasingmeans/reducing BIfyouincreasethenumberofanaesthetists,naturallythetheatretimewill
barrierstoincreasecapa- increaseandoncethetheatretimewillincrease,thesepatientswillbe
bilityoropportunity operatedearlier.ifyouhavetwodifferenttheatres—oneforneurosurgery
andonefororthopaedicsthennaturallyorthopaedicsurgerywillbefaster
andtheallthesepatientswillbeoperatedfaster^—R2(KII)
BOnemoreveryimportantsuggestionisthatweshouldhavemostofthe
implantsherewhichmostofthetimeswearenothaving,sothatthepoor
peopletheycangetthoseimplantsandwecangoforsurgeryastheyare
available^—R4(KII)
BTheexistinginfrastructureneedtobeupgradedalongwithadditionofnew
resourcesaswenotonlyhavepatientswithfracturesbutalsopatientswith
spineinjury,traumaanddeformitycompetingforbeds,OTtimeand
manpower^—R13(FGD1)
Policycategories
Communication/marketing Usingprint,electronic, BWeneedtoeducatethemassesandalsothecommunityhealthcareworkers
telephonicorbroadcast alongwithPHCsandCHCs(Primary/communityhealthcarecenters).
media Publiclecturesarenoteffectivebutadvertisingareofdefinitehelp.Live
feedsortelevisiondisplaymightbemorevaluableandmightbepickedup
fasterthanhandoutsorreadingmaterials^—R1(KII)
Guidelines Creatingdocumentsthat BDevelopmentofaspecificstandardoperatingprocedureonwhatneedstobe
recommendormandate done,howthesepatientsneedtobeapproached,whatistheminimumset
practice.Thisincludesall ofinvestigationsthatneedstobecarriedoutandwhatistheminimumset
changestoservice ofdrugsthattheyneedtogobackhomewith^—R1(KII)
provision
Regulation Establishingrulesor BAfractureteamcouldbedevelopedirrespectiveofthelocationinthe
principlesofbehaviouror hospital,ifthepatientpresentswithahipfracture,theteamneedstoattend
practice tothat,inasimilarmannerlikethecardioresuscitationteam.If
non-traumaticfracturereportstothehospitalorifafractureoccurringout
ofanon-majortraumaoratrivialtraumareportstothehospital,thenthis
teamcouldbeactivated.Thisteamresponsemaynotbeimmediateas
requiredincardiopulmonarypatientsbutsaywithinasetof24hours,this
55 Page10of13 ArchOsteoporos(2017)12:55
Table2 (continued)
Definition Studyfindings(quotes)
teamcouldbeactivatedandinitiatesproceduresaccordingtostandard
operatingprocedurethatwoulddefinitelyhelp^—R1(KII)
Environmental/socialplanning Designingand/orcontrolling BInsuranceshouldbecompulsorywhereeveryIndianshouldbeinsuredand
thephysicalorsocial thegovernmentshouldprovidenecessarysubsidy.Specificpolicies
environment shouldbemadeasitisamatteroffinancialconstraintforpoorpeople^—
R3(FGD-2)
Serviceprovision Deliveringaservice BAmbulanceserviceshouldbeavailableatallplacesespeciallyinruralareas
andthisshouldbewellequippedwithinstruments,doctorsand
guidelines^—R2(FGD-2)
fracture[37].Ourfindingscouldbeduetotherelativelyhigh patientsincludedinthestudyreturnedhomeortotheirorig-
numberofmeninDelhiwherethesexratiois868femalesto inalplace ofresidence after discharge, incontrasttothe UK
1000males[38]. where nearly halfof the patientsdo not return to their usual
Thechoiceofregionalanaesthesiafornearlyallpatientsin placeofresidence[4,12].Inourstudy,the30-daymortality
thisstudyisalignedtobestpracticerecommendationfromthe waslowerthanthe8%reportedintheNHFD,whichispartof
BritishSocietyforAnesthesiologist[39,40]andiscompara- theUK’sFallsandFragilityFractureAuditProgramme[12],
bletoarecentreportfromBeijing[23].Thetypesofsurgical but this may be an inappropriate comparison as significant
procedureandimplantsutilized,thatweredocumentedinthis losstofollow-upinourstudycouldsuggestthatmorepatients
study, are similar to the practice in the UK, except for the may have died after the discharge. Information on pressure
preference of intramedullary implants for inter-trochanteric ulcerwasnotcollectedroutinelyinclinicalpractice;therefore,
fractures in this study population. The National Institute of thisadverseoutcomeduetodelaysinsurgeryandimmobili-
Care Excellence (NICE), which is a body of department of zationcannotbereported.
healthintheUK,carriesoutassessmentsofthemostappro- Ourstudyfindingsacknowledgethatmanagementofolder
priatetreatmentregimensfordifferentdiseaseconditionsand adults with hip fracture requires effective coordination across
recommendstheuseofdynamichipscrewsforthesefractures variousdisciplinesinthehospitalincludingrehabilitation.The
[39]. The preference for intramedullary implants might be co-management of hip fractures by orthopaedic and geriatric
influenced by the intensive marketing strategies of implant medicinehasshowntobeeffectiveinachievingearlysurgery,
companies and a choice to ignore the evidence base. The mobilization and discharge from hospital with decrease in
choiceofcementedhemi-arthroplastyforintra-capsularfrac-
ture is similar to that reported in the National Hip Fracture
Database(NHFD)audits[4,5,10–12].However,nearlyhalf
Table3 Admittedvsnotadmittedhipfracturepatientsfromahospital
the patients in Delhi were mobilized by the second post-
operativeday,adaylaterthanrecommended[4,39,40]. Patientspresentingtoahospital Admitted,n(%) Notadmitted,n(%)
ThemeanLoSinourstudywas16days,whichishigher withhipfracture(N=78)
thaninSweden[41]andChina[23],butlowerthanthe20days
Age(inyears) 50–59 7(26) 15(29)
LoS in the UK. The majority of people with fragility hip
60–69 6(22) 12(23)
fractureinIndiaareyoungerthanintheUK[10–12],andthis
70–79 9(33) 10(20)
mayexplainthefasterpost-surgeryrecovery.Theoptimalstay
80–89 4(15) 11(22)
inhospitalfollowingahipfractureisstillbeingdebatedwith
90andabove 1(4) 3(6)
onestudysuggestingthatLoSshorterthan10daysisassoci-
ttest −1.993(p=0.040)
atedwithanincreasedriskofdeath[41],whileincontrast,the
Gender Male 14(52) 28(55)
Rochesterco-managementModelforHipfractureshowedno
Female 13(48) 23(45)
increases in mortality with decreased hospitalization time to
χ2 0.066(p=0.797)
4 days [42]. Evidence from a study in Brazil suggests that
Typeoffracture IC 11(41) 19(37)
delayed hospital admission for a hip fracture was associated
IT 15(55) 29(57)
with reduced survival at discharge and 1 year after surgery,
ST 1(4) 3(6)
anddelayinsurgeryatthehospitalwasnotfoundtobesig-
χ2 0.224(p=0.893)
nificantwithsurvival[43].
Total 27(35) 51(65)
Lackofosteoporosismanagementandfallsassessmentisa
significantlacunainthecarepathwayforhipfractureinDelhi
IC intra-capsular fracture, IT inter-trochanteric fracture, ST sub-
hospitals, similar to the findings from Beijing [23]. All the trochantericfracture