Consortium addresses hip fracture care standards
Proponents call for longer lengths of stay
Question: When is a shorter length of stay not an indicator of quality? Answer: When it diminishes the quality of care.
Length of stay is one of many issues being tackled by a consortium begun by 11 national organizations to seek solutions to the morbidity, mortality, and loss of independence faced by patients with hip fracture. A total of more than 40 organizations attended the Hip Fracture Conference sponsored by the group in May 2001.
"Hip fractures are one of the most common, costly, and devastating injuries suffered by Americans," notes Joseph Zuckerman, MD, professor and chair of the NYU-Hospital for Joint Disease Department of Orthopedic Surgery in New York City, chairman of the Council on Education of the American Academy of Orthopaedic Surgeons, and a member of the conference steering committee. "They are occurring at an epidemic rate, with over 350,000 incidents per year accounting for approximately 30% of all fracture-related hospitalizations," he explains.
The conference recommendations fell into four broad categories:
- communication/continuum of care;
- reimbursement issues;
- prevention/education for public and professionals;
- research initiatives.
Targeting length of stay
While the recommendations are numerous and far ranging, it is length of stay that Zuckerman says is at the crux of many of the challenges presented by hip fracture patients. In a draft of a summary of conference recommendations, the steering committee wrote: "Discharge from the acute care setting to subacute, skilled nursing facility, or home should be based on the attainment of specific functional milestones, not achieving the shortest length of stay."
"Length of stay is a quality indicator for financial reasons, but not necessarily with respect to outcome," Zuckerman argues. "With this population, it is probably just the opposite." Length of stay, he notes, became an issue in the mid-80s when diagnosis-related groups (DRGs) came into existence. "It became incumbent on the hospital to become as efficient as possible," Zuckerman observes. "When you were paid on a per-diem basis, there was no reason to get the patient out of the bed."
With the system structured as it is now, it allows hospitals to do things only one way, Zuckerman concedes. "But they are shooting themselves in the fiscal foot," he asserts. "All we are doing is cost-shifting." In order for real change to occur, it has to be authorized as a Centers for Medicare and Medicaid Services issue, says Zuckerman. "This a real public policy issue; you can’t do that on a busy weekend," he declares.
That’s one of the reasons for this consortium. "It has to be shown — and we are very aware of this — that [keeping patients longer] is not just a way to get doctors or hospitals more money. We have to show it will lead to greater quality of care. The quality indicator should probably be how the patient is doing six months after the fracture. If a patient gets out of the hospital in five days but then stays in a nursing home for six months, do you really save money?"
Communication is one of the keys to establishing a true continuum of care, says Zuckerman. "If I operate on a hip facture patient and they get transferred on day five to their home, I have to communicate that information to their doctor; it’s very important that information gets transferred," he explains. "If they go to the rehab center, then leave and go back to their original doctor, how does [that physician] grasp the issues that have arisen in the interim?"
It is the responsibility of the quality professional, says Zuckerman, to be sure that when a patient leaves the facility, a proper transfer of records occurs — from physician to physician and from nurse to nurse. "That should be a quality indicator," he asserts. "How do we confirm that a record of what occurred got to the next facility? The Mayo Clinic focuses on this tremendously. If you send a patient to the Mayo, they send you back unbelievable information on that patient."
Toward a critical pathway
Under the heading of "Research Initiatives," the committee asserts that the care provided to patients with hip fractures should follow "an evidence-based multidisciplinary critical pathway." What might that pathway look like? "One of the elements should be standardized evaluation when the patient is admitted," says Zuckerman. "There should be rapid recognition as to whether the patient should get to the OR quickly for the stabilization of any serious factors. Patients who go to the OR two days after admission have a higher mortality rate."
As for the surgery itself, Zuckerman says that is difficult to standardize. "But we should stress prompt surgery, technically well done, rapidly progressive postop care, thromboprophylaxis to prevent clots, [and] ambulation — if you restrict weight bearing, you may as well leave them in bed." It also should be recognized that there is significant malnutrition in this population, Zuckerman says. "If they are admitted with a hip fracture and malnutrition exists, this is considered a co-morbidity and a separate DRG — which increases the level of reimbursement. In other words, hospitals should want to identify this condition."
Antiresorptive medication is another key consideration. "If a patient has a heart attack, there is no way he leaves the hospital without having his cholesterol and blood pressure checked, and if need be, being put on meds," he says. "There should be an analogy when we admit patients with hip fracture. Clearly this is a risk factor for osteoporosis, but probably less than 20% of these patients leave the hospital being treated for osteoporosis. Some in the medical profession question whether we could actually prevent osteoporosis, but we could clearly have an impact," Zuckerman says. n
Need more information?
For more information, contact: Joseph Zuckerman, MD, NYU-Hospital for Joint Diseases, Department of Orthopedic Surgery, 301 E. 17th St., New York, NY 10003. Telephone: (212) 598-6674.
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