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

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

3. 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

4. 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, (6): p
Thomas, E.J., et al., Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care, (3): p

5. 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.

6. 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.

7. v

8. 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

9. Recognized Need To Optimize Care

10. 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

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

12. 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

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

17. 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

18. 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

19. Outcome of Interest - Mortality
General
Spinal

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

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

24. 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

26. 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

27. 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

28. Thank You!