Commentary: Benchmarks for the Management of Hip Fractures

James P. Waddell, MD, FRCSC
Professor, Division of Orthopaedic Surgery
University of Toronto

This point-counterpoint discussion between Drs. Karl-Andre Lalonde and Hans Kreder regarding benchmarks for the management of hip fracture patients is timely. The dilemma faced by all of us providing clinical care in orthopaedic surgery is limited resource allocation in most public hospitals in Canada. Our two protagonists are both from Ontario and therefore their arguments may seek parochial to those of you reading from outside that province. However, I can assure you that the move by the Ontario government to define wait times for both elective and emergent orthopaedic surgery (hip fractures) is a trend that will soon be national.

 

Both Dr. Lalonde and Dr. Kreder make very legitimate points in their essays regarding the benefits of and problems with the establishment of benchmarks. Essential to the establishment and, more importantly, adoption of benchmarks is first, evidence that the benchmarks are appropriate and second, a data collection/monitoring system that not only confirms that the benchmarks are being utilized appropriately but that their utilization does not adversely impact care for other deserving patients.

The importance of accurate data collection is clearly demonstrated by the wait time information system (WTIS) implemented through the Ministry of Health and Long-term Care in Ontario (MOHLTC). When it was decided that Wait 2 for hip and knee replacement surgery should not exceed 182 days (from time of consultation to time of surgery) there was considerable fear that by implementing this type of benchmark other patients awaiting elective orthopaedic surgery would be displaced thus lengthening their wait time for surgery. With the implementation of obligatory wait time reporting for all surgical procedures in the province came specific directions that all incremental funding for additional hip and knee replacement surgery provide additional operating room time and additional implants, forbidding hospitals from directing resources away from other orthopaedic patients to the hip and knee program.

Analysis of wait time data over the past three years available on the MOHLTC web site (http://www.health.gov.on.ca/en/) clearly documents that the average wait time for non-hip and knee replacement patients for surgery is approximately the same as that for hip and knee replacement patients. There are exceptions - foot and ankle surgery in particular as well as shoulder surgery in some jurisdictions and spine surgery in other jurisdictions are unacceptably long.

The concept of establishing a benchmark for acute surgery is not new. The Ontario program has been modeled on programs established in England and Scotland some years ago and analysis of data from those jurisdictions clearly demonstrate a decrease in morbidity and short-term mortality related to early hip fracture surgery but, unfortunately, no reduction in long-term mortality.

Research done by Dr. Nizar Mahomed (University of Toronto) and others through the Total Joint Network demonstrated that a comprehensive model of care for hip fracture patients could shorten the acute hospital length of stay for these patients as well as improve significantly the percentage of patients returning home as opposed to going to long-term care. Implementation of this model including such initiatives as early surgery, a surgical procedure that permits immediate weight-bearing, a care plan for hip fracture acute care and a care plan for postoperative rehabilitation. As part of the implementation of this comprehensive care plan we have developed an algorithm for expediting early surgery in this often frail patient population and this is available on the BJHN web site (www.boneandjointhealthnetwork.ca).

Just as we were able to demonstrate to government and hospital administration that additional resources were necessary to meet the demand for hip and knee replacement surgery (and hopefully the programs for foot and ankle surgery, spine surgery and shoulder surgery already developed) we should be able to demonstrate to hospital administration that additional operating room resources for hip fracture patients are important and achievable. This can be done without sacrificing access for other patients and has been demonstrated in many hospitals where the model has been adopted. Dr. Lalonde is rightly concerned that giving additional resources to hip fracture patients might impede access to care for other acute orthopaedic problems and this should not be permitted. Rather it is the obligation of the hospital to provide appropriate resources for all patients requiring urgent surgical care - not just orthopaedic patients - and hospitals should be asked to review priority ratings in their operating room for the classification of surgical emergencies. Furthermore the allocation of dedicated fracture room time should be revisited to ensure that hip fracture patients are given the same consideration as other fracture patients in terms of priority. The practice of discharging ambulatory fracture patients from the emergency department and re-admitting them semi-electively into dedicated fracture room time has become widespread and may limit access for hip fracture patients - this obviously must be discouraged.

There are approximately 30,000 hip fractures a year in Canada. The purpose of establishing guidelines is to ensure that these patients receive appropriate care not just from orthopaedic surgeons but from everyone involved in their care, including hospital administrators who are responsible for ensuring adequate access to appropriate care for everyone who is admitted to the hospital for which they are responsible.

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