Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study

Abstract

Objectives: to evaluate orthogeriatric and nurse-led fracture liaison service (FLS) models of post-hip fracture care in terms of impact on mortality (30 days and 1 year) and second hip fracture (2 years).

Setting: Hospital Episode Statistics database linked to Office for National Statistics mortality records for 11 acute hospitals in a region of England.

Population: patients aged over 60 years admitted for a primary hip fracture from 2003 to 2013.

Methods: each hospital was analysed separately and acted as its own control in a before-after time-series design in which the appointment of an orthogeriatrician or set-up/expansion of an FLS was evaluated. Multivariable Cox regression (mortality) and competing risk survival models (second hip fracture) were used. Fixed effects meta-analysis was used to pool estimates of impact for interventions of the same type.

Results: of 33,152 primary hip fracture patients, 1,288 sustained a second hip fracture within 2 years (age and sex standardised proportion of 4.2%). 3,033 primary hip fracture patients died within 30 days and 9,662 died within 1 year (age and sex standardised proportion of 9.5% and 29.8%, respectively). The estimated impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) = 0.73 (95% CI: 0.65-0.82) and HR = 0.81 (CI: 0.75-0.87), respectively. Following an FLS, these associations were as follows: HR = 0.80 (95% CI: 0.71-0.91) and HR = 0.84 (0.77-0.93). There was no significant impact on time to second hip fracture.

Conclusions: the introduction and/or expansion of orthogeriatric and FLS models of post-hip fracture care has a beneficial effect on subsequent mortality. No evidence for a reduction in second hip fracture rate was found.

Keywords: epidemiology; fracture liaison service; hip fracture; older people; orthogeriatrician; osteoporosis.

Figure 1.

Annual and quarterly regional trends in mortality (30-day and 1-year) and second hip fracture (2-year) after primary hip fracture during the study period.

Figure 2.

Forest plot of hazard ratios for outcomes within each hospital, comparing the time period after relative to the time period before orthogeriatric or FLS service model interventions for (A) mortality within 30 days, (B) mortality within 1 year and (C) second hip fracture following primary hip fracture.