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Study Finds Broken Care for Broken Hips

Lack of continuity among caregivers a major problem

MONDAY, June 4, 2001 (HealthDayNews) -- If you're one of the 350,000 Americans who break a hip this year, your care could be as fractured as your joint, says a study that finds many health providers aren't communicating with each other.

"The current standard is to get you out of the hospital in few days," resulting in a lack of continuity in care, says senior study author Dr. Albert Siu, professor of medicine at Mount Sinai School of Medicine in New York City.

"You're a moving target," says Siu. Most people involved in care of hip fracture patients "only see the patients for a narrow part of the episode and are only aware of the outcomes of that part of the episode."

Leaving the hospital is "just the beginning of series of transitions that occur. There are a lot of handoffs," says Siu. And about 20 percent patients who go into a nursing home or acute rehabilitation get readmitted to the hospital, he says.

Siu and his team analyzed data on 571 hip-fracture patients admitted to four New York City hospitals between August l997 and August l998. "We found 14 percent died within six months, and one-quarter within a year," says Siu.

Care involves anything from inserting pins to total hip replacement, with recovery taking six to eight weeks, says Siu.

Because hip fractures "set up for complications, such as blood clots, pressure ulcers and delirium, the research focus has been on risk-adjusted (for complications) mortality by hospitals and health plans," Siu says. "Much less work has been done on functionality," and "function is really the important outcome of this disease," he says.

However, the researchers found that hospital data on mortality and functionality did not necessarily predict one another.

For instance, he says one hospital had significantly higher risk-adjusted death rates for hip fracture patients, but not a significantly worse risk-adjusted functional outcome. In another hospital, functional outcomes were poor, but the death rate was not higher in comparisons with other facilities.

Siu doesn't see the system improving any time soon. "With the balanced budget act of l997, and home care and rehabilitative care increasingly coming under prospective payment, these issues of handoffs are likely to be even greater in the future."

"This study brings attention to a major public health problem," says Dr. Joseph D. Zuckerman chair of orthopaedic surgery at New York University Hospital for Joint Diseases and a spokesman for the American Academy of Orthopaedic Surgeons. "Although there are over 300,000 hip fractures this year in people over 65, that will more than double by 2040. That's 600,000-plus elderly a year who will sustain hip fractures," says Zuckerman.

It's absolutely essential that "we be able to understand how we can optimize our success and results in this challenging population," he says. "Any research which helps identify the factors that predict outcomes and functionality will have an impact."

Zuckerman says in any patient population "there are those things we can't control, but the prospective health system put in place by hospitals to control costs has had a negative impact on hip fracture patients."

Zuckerman says until medical records are computerized and correlated for each patient sometime in the future, tracking a patient will remain more like the old game of telephone, with the message getting garbled by the time it gets to the last person in line.

Zuckerman suggests patients be moved from the hospital to other facilities based not on the length of stay but on their levels of functionality. And he says communication needs to be improved every step of the way.

Siu says, "We're not saying, 'Let's go back to the bad old days of patients staying in the hospital for several weeks,' [but] it's time to take a fresh look and determine how we develop the communication infrastructure to guarantee optimal care for each patient."

Zuckerman says the American Academy of Orthopaedic Surgeons began to tackle the issue at a meeting just last month of providers from different organizations involved in the care of the elderly.

Siu's study appears in today's issue of the Journal of the American Medical Association.

What To Do

If you or your parent breaks a hip, start asking questions right away, says Siu. "Each patient is different, so you should ask the physicians what their expectation is for the course of treatment over the next few weeks."

Assuming that care will take place in different settings, Siu says ask about providing continuity between the different facilities. The best person may be a primary-care physician, the orthopedic physician, a case manager or perhaps a social worker.

Don't forget to let your primary-care physician know you're in the hospital. "Often we hear they've never been contacted until they see their patients many months down the line," he says.

"Ask not only how long will it take, but also what kind of help will my mother or father need to get through this," says Siu. And keep asking questions. "You know more as you go along. You'll know more at hospital discharge than when you went in, and two weeks down the line."

Get the facts and figures on hip fractures from the American Academy of Orthopaedic Surgeons.

View X-rays of broken hips and learn more about hip fractures from emedx.com.

Read more HealthDay stories on hip fractures .

SOURCES: Interviews with Albert Siu, M.D., professor of medicine, Mount Sinai School of Medicine, New York City; Joseph D. Zuckerman, M.D., chair of orthopaedic surgery, New York University Hospital for Joint Diseases, New York City; June 6, 2001, Journal of the American Medical Association
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