Clinical Practice Guidelines: What, Why, Who? Steven A. Olson, MD Professor, Duke University Health System Durham, NC

Disclosures Member AAOS Geriatric Hip FX CPG committee BOD of OTA Chair AAOS Geriatric Hip Fx Performance Measures Committee

Quality Improvement Research Becoming more common in Medicine It has other names Patient Safety Performance Improvement High Reliability Systems Medicine is not the only area with a concern for safety – Air Traffic Control, Construction, Industrial Product Assembly, etc

Where did this Concept Come From? A study reviewing data from New York State Hospitals from 1984 found that adverse events occurred in 3.7 % of hospitalizations. 27.6% of these advents were due to negligence or errors. 13.6% of adverse events led to death. Overall similar trends and incidence of adverse events, errors, and death rates were found in 1992 data from hospitals in Colorado and Utah. Brennan, T.A., et al., Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med, 1991. 324(6): p. 370-6. Thomas, E.J., et al., Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care, 2000. 38(3): p. 261-71.

To Err Is Human – IOM These reports and other data lead to the Institute of Medicine publishing its landmark document “To Err Is Human: Building A Safer Health System”. This work addressed the issue of medical errors. The IOM defined medical errors as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

Goals of “To Err Is Human” Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.

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Geriatric Hip Fractures Population based rates hip fx >age 65 are declining The population >age 65 is growing Still a net increase in older population world wide This group of patients has risks for Secondary osteoporotic fracture Change in living situation and need for more care Decreased activity and quality of life Increased mortality

Recognized Need To Optimize Care

3 Musculoskeletal diagnoses in the top 3 most expensive conditions for CMS 1) - Osteoarthritis 2) - Back pain and Spine care 3) - Hip Fracture 261,000 discharges 2.2% of all CMS costs

Hip Fracture Registries Australia Sweden Norway Finland England Scotland Spain Discussions of the potential for an Orthopaedic Surgery driven registry are on-going

The beginnings of a more comprehensive Orthopaedic effort in Hip Fx Care Best Practices Clinical Practice Guidelines (AAOS) - completed Appropriate use criteria (AAOS) - completed Process measures (AAOS) - in process Own the Bone – Secondary Fracture Prevention Program (AOA) Registries National registry – Partnership between AAOS and ACS to create a dedicated geriatric hip fracture module within NSQIP Hospital Program certification – Offered by International Geriatric Fracture Society

Significantly improves pre-op pain control Reduces narcotic use No data to support reduction in delirium post-op (yet)

Early fracture fixation is associated with: Reduction in Mortality Reduction in Hospital LOS Reduction in readmissions Reduction in patients needing a change in residence after hospitalization No change in 6 month functional results

Effect on platelets is irreversible once drug has acted - takes 7 to 10 days to get affected platelets out of system. Patients with coated stents must stay on clopidogrel

Outcome of Interest - Mortality General Spinal

Consistent with Own the Bone Will involve a variety of interventions Exercise, bisphosphonates, life style changes

Dedicated interdisciplinary care program Kates et al Geriatric Ortho Surg & Rehab 2010

The creation of an interdisciplinary care program is a “win-win” Patients receive better care Highly consistent care pathways Evidence driven The cost of care is better managed Can take turn the program from cost-center into a profit-center Kates et al Geriatric Ortho Surg & Rehab 2010

http://www.aaos.org/appropriateuse/

Next Step – Metrics AAOS has proposed a “Performance Measure” for geriatric hip fracture patients – The patient age 65 or older with an operative hip fracture is to be in the OR within 48 of admission to the ED. Data point based on CPG 50% of OTA members do not have formal hip fracture program in place. Other Geriatric Fracture Measures available

Summary Organized care programs are of value Timely surgical care Identify and encourage colleagues in other specialties to participate in care program Be a leader or active participant Follow your data and make changes as needed Show your hospital administrators the value you bring through the hip fracture program

Thank You!