Management of hip fractures in older people in India

It is estimated that by 2020, almost 20% of the Indian population will be older than 60 years, and the annual incidence of hip fractures will reach 600,000. Based on current mortality data, an estimated 40% of these individuals will die within a year.

The introduction of integrated pathways of care for the management of hip fractures in Sweden and the UK has demonstrated significant reductions in mortality, length of hospital stay and cost. These care pathways comprise fast track admission to an orthopaedic ward, combined geriatric and orthopaedic care, early surgery, prevention of pressure sores, and treatment for osteoporosis and falls assessment.

Currently little is known about the pathways of care and outcomes for hip fracture in India. We are proposing to undertake a study to facilitate the development of evidence based strategies to improve the management and outcomes of hip fractures in India. Collaboration is being sought from orthopaedic surgeons, geriatricians/specialist physicians, anaesthetists, nurses, rehabilitation specialists and hospital managers involved in the care of the older people, to contribute to this proposed study.

Aims

  • To determine whether the pre-operative, peri-operative and post-operative pathways of care for individuals over 60 years of age, hospitalised with hip fractures in India, are consistent with national and international guidelines and/or best evidence-based practice
  • To identify factors associated with evidence-practice gaps and to determine potential barriers and facilitators relevant to reducing evidence-practice gaps
  • To document patient outcomes at one, four and 12 months following hip fracture and to determine potentially modifiable factors associated with best outcomes
  • To document the economic and social burden of hip fracture for the health system, and for families and carers, and to identify potentially modifiable factors relevant to reducing

Methods

A pilot study is proposed initially to assess the feasibility of conducting a larger prospective cohort study. Key issues for investigation in the pilot study will be the logistics of recruitment of hospitals, collaborators and patients and attrition rates.

Data collection instruments and assessment tools will be tested to determine ease of administration, feasibility for total data capture, and to identify and resolve barriers to capturing data.

We propose to undertake the pilot in three hospitals in Delhi (one major teaching hospital, one private and one general hospital). The main study will involve hospitals in a number of states or provinces, ranging from those with high per capita incomes to those with low per capita incomes. Samples of urban and rural hospitals, as well as government and private care providers, will be included.

The primary outcomes will be mortality and disability (measured in terms of quality of life and independence in activities of daily living), as well as social and economic burden (including duration of hospital stay and costs for both the health care system and individuals and their families). It is intended that the findings from the larger study will facilitate the identification of interventions that can be incorporated into practice in a national ‘Care Pathway’.

A likely outcome will be the establishment of an Indian Hip Fracture Registry/Database.

Status

Multidisciplinary groups of care providers in two participating centres in Delhi (AIIMS and JPN Trauma Centre, GTB Hospital and Medical College) have been identified and the proposal discussed with them. Application has been submitted to the institutional ethics committee of the respective institutions. The study will consist of interviewing clinical leads involved in the pathway of hospital care, focus group discussions with the hospital care providers and patient and carer groups.

Patients will be recruited from these three hospitals over the period of three months and collect vital information on socio-demographic characteristics, clinical condition, care and treatment during their stay at hospital. The study will also collect information on provision of care from these selected hospitals.

Each participating centre will set up an institutional steering committee consisting of representatives of the multidisciplinary group of care providers. A regional steering committee will be formed in Delhi with members from each participating centre and representatives of The George Institute, India.

Further reading