Beyond fall prevention: Solving the hip fracture crisis

NOTE: This article no longer is eligible for ACHCA CE test credit.

With around 300,000 hip fractures anticipated to occur this year in the United States alone—the majority of these occur as a result of falls in long-term care facilities—it is not surprising that some have called this “a healthcare crisis.” 

But why is it “not just a fracture”? Apart from their clinical severity, hip fractures have few equals when it comes to devastating consequences for patients and facilities.  Consider the following statistics:

• Approximately 20–25 percent of people suffering a hip fracture die within a year of their injury, generally due to one comorbidity or another.¹
• About half of the survivors become permanently dependent on others, and are left with varying degrees of functional impairment. 
• Fear of falling is pervasive among older people—as many as a third limit their daily activities, which paradoxically increases the risk of subsequent falls and fractures through reduced mobility and weakness.
• A 2012 study found that hip fractures represent anywhere from about 40 percent to as many as 60 percent of fall-related injuries in nursing homes.²
• The average direct cost for just the perisurgical inpatient portion of hip fracture care averages $29,000 per episode, without even considering all the other associated recovery and rehabilitation costs.²

Hip fractures also take a serious financial toll on nursing homes and other LTC facilities. For example, significant staff resources must be devoted to responding to and following up after falls and hip fractures. Facilities may experience decreased income when residents are in a hospital or rehabilitation facility being treated for and recovering from a hip fracture. Upon the his or her return, increased care services may be required, such as additional assistance caused by increased functional impairment, and transport to and from meals and activities.  Fall-related injuries such as hip fractures also place nursing homes at significant medico-legal risk and, not surprisingly, account for a large proportion of healthcare litigation cases.

WIDESPREAD PROBLEM IN NURSING HOMES

The risk of falls and hip fractures is even greater for those living in LTC facilities than for those living outside such settings. In fact, injurious falls occur frequently and repeatedly among nursing home residents—the mean number of falls per bed per year is 1.5 and ranges up to 3.6, with patients with dementia averaging more than four falls per year.^2-4 The problem is not limited to ambulatory patents—about 35 percent of fall-related injuries occur in nonambulatory residents, such as those using wheelchairs.

With falls so prevalent among the very group of people most at risk for hip fracture, it is not surprising that fall prevention programs have attracted significant attention over the past few decades. In the LTC field, the American Medical Directors Association (AMDA) has been prominent not only in drawing attention to the problem but also in providing guidance through the publication of its “Falls and Fall Risk Clinical Practice Guidelines.” 

In the public sector, the Department of Veterans Affairs (VA) has led the way with the publication of its highly regarded and freely available “Falls Toolkit” published by its National Center for Patient Safety.⁵

Many—if not all—of the recommendations included in these authoritative documents have been progressively adopted by many LTC groups, and the medical supplies industry has been particularly active in offering a variety of assistive devices and staff training programs. 

Attention also has focused on other prophylactic approaches including exercise, diet, maintaining flexibility, gait analysis and correction and, of course, pharmaceutical regimens to promote better bone strength. 

FOCUS ON FRACTURE PREVENTION

Despite these efforts, however, falls and hip fractures continue to occur at an alarming rate. So much so that the focus has shifted from fall prevention to fracture prevention—if the fall can’t be prevented, at least the fracture may be.

The arrival of hip protectors was initially anticipated to play a significant role in decreasing the incidence of hip fractures. Protective shields held in place over the greater trochanter of the femur by a specialized undergarment with pockets, hip protectors seemed to be a relatively inexpensive answer to a devastating and expensive problem. 

Unfortunately, the ride has been bumpy. After an initial enthusiastic reception following a series of successful clinical trials,^6,7 the effectiveness of hip protectors was challenged by a prominent but controversially designed study funded by the National Institutes of Health, which suggested that the devices might actually increase hip fracture rates. Surprise at this counterintuitive outcome drew close attention that ultimately led to the discrediting of the study, in part due to its unorthodox design and in part to ethical issues surrounding how it was conducted. The net result, however, was to leave the field temporarily confused and uncertain as to how to proceed.

Undeterred, others continued to research the problem and explore better solutions, perhaps most notably the VA’s specialist VISN 8 Patient Safety Center of Inquiry. Focusing increasingly on preventing the fracture—not just the fall that precipitates the fracture—the center published its “Hip Protector Implementation Toolkit,” which extended the scope of its earlier “Falls Toolkit.”^5,8

Despite this encouragement, implementation of hip protector programs has been impeded by noncompliance issues. Healthcare providers who understood and accepted the potential value of hip protectors have been repeatedly challenged by patient perceptions or outright complaints of wearing discomfort, along with concerns about personal appearance and the disinclination to admit physical vulnerability that is a common hallmark of advancing age. 

In response, the medical supplies industry quickly took up the challenge of how best to improve wearing comfort without compromising efficacy. Initial hard-shell designs gave way to soft pads but gave up some efficacy in the process. Then came hybrid pads that combined hard and soft components, along with different shapes, each with its respective champions. Impact protection via shock absorption versus shunting became the subject of debate among some bioengineers, while healthcare providers continued to struggle with noncompliance. 

A NEW GENERATION OF HIP PROTECTION

As is often the case, it takes a technological breakthrough, often in another field, to shift the foundation of well-established behaviors. Recent advances in the molecular engineering of shock absorption materials, spurred by a growing demand for flexible, lightweight, low-profile yet armor-like protection capabilities from the extreme sports, military and law enforcement arenas have spawned a new generation of personal protection clothing that is only now extending to the healthcare field.

Soft, flexible, and pliable in their natural state, such materials become instantly rigid at the moment of impact, only to immediately relax once the energy of the impact is absorbed. As a result, they come closer than ever to the optimal wearable protective device—unnoticeable in everyday use, yet providing maximal impact protection whenever and wherever needed. 

The recent incorporation of this technology into hip protectors and other protective devices promises to significantly decrease the challenge of patient noncompliance, resulting in a win-win for long-term care providers not only in terms of improved clinical care but also in the potential for cost savings and enhancement of risk management practices. 

With growing rumors of Medicare moving to disallow reimbursement for fall-related injuries occurring in LTC facilities, the bottom-line competitive incentives to such improvements are clearer than ever. 

D. Stephen Robins, MD, is CEO of Medical Protection Technologies, distributor of the Fall-Safe Hip Protector. Dr. Robins has championed numerous patient safety issues over his 35-year medical career in clinical practice, clinical research and standards of practice development. He can be reached at dsr@medprotech.com.

REFERENCES

1. Leibson C, Tosteson A, Gabriel S, et al. Mortality, disability, and nursing home use for persons with and without hip fracture: A population-based study. Journal of the American Geriatric Society 2002;50:1644-50.
2. Quigley P, Campbell R, Bulat T, et al. Incidence and cost of serious fall-related injuries in nursing homes. Clinical Nursing Research 2012;21:10-23.
3. Rubenstein L, Josephson K, Robbins A. Falls in the nursing home. Annals of Internal Medicine 1994;121:442-51.
4. Van Doorn C, Gruber-Baldini A, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. Journal of the American Geriatric Society 2003;51:1213-8.
5. VHA NCPS Falls Toolkit. Washington, D.C.: National Center for Patient Safety, 2004.
6. Kannus P, Parkkari J, Niemi S, et al. Prevention of hip fracture in elderly people with use of a hip protector. New England Journal of Medicine 2000;343;1506-13.
7. Rubenstein L. Editorial: Hip protectors—A breakthrough in fracture prevention. New England Journal of Medicine 2000;343(21):1562-3.

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