Osteoporosis care gap: audit reveals hip fracture warning signs missed
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Osteoporosis care gap: audit reveals hip fracture warning signs missed

Phyllis Barry has no idea how she came to be sitting in the corner of her garden one Saturday night, unable to move.

The last thing the 78-year-old could recall was bending down to pick up after her dog, who now barked furiously as she yelled for help.

Phyllis Barry, 78, at Prince of Wales Hospital. Ms Barry did not know she had osteoporosis when she fractured her hip earlier this month.

Phyllis Barry, 78, at Prince of Wales Hospital. Ms Barry did not know she had osteoporosis when she fractured her hip earlier this month.

Photo: Jessica Hromas

Her neighbours came to her rescue, jumping the fence and phoning an ambulance.

“I didn’t think I had done much damage until they lifted me up and then I realised I was in agony,” Ms Barry said.

She had badly fractured her hip and wrist. She was wheeled into an operating theatre at Prince of Wales Hospital the following afternoon and on Thursday – after 26 days of rehabilitation – she will be discharged with a diagnosis of osteoporosis and a treatment plan.

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“I had no idea I had it!" Ms Barry said.

Osteoporosis is a major cause of hip fractures in elderly Australians, yet just 8 per cent of patients were taking medication for the bone-weakening condition before they were admitted to hospital with a hip break, according to a major audit of 9408 patients records from 118 hospitals across Australia and New Zealand released on Thursday.

Phyllis Barry with her physiotherapist at Prince of Wales Hospital, Randwick, Sydney.

Phyllis Barry with her physiotherapist at Prince of Wales Hospital, Randwick, Sydney.

Photo: Jessica Hromas

Three-quarters of hip fracture patients leave hospital without osteoporosis treatment plans to prevent another painful and debilitating break, found the report compiled by the Australian and New Zealand Hip Fracture Registry at NeuRA.

Professor Jacqueline Close, Registry co-chair and principal research fellow at Neuroscience Research Australia (NeuRA), said the audit identified an "osteoporosis care gap" in Australia's health system, which missed the warnings signalling which older patients were at high risk of hip fracture.

"These fractures are an early warning alert to the system that these patients are coming,” Professor Close said.

About 50 per cent of hip fracture patients will have previously sustained a minimal trauma fracture, such as breaking their wrist or pelvis falling from standing height, Professor Close said.

Professor Jaqueline Close and hip fracture patient Rhonda Wilson at Prince of Wales Hospital, Randwick.

Professor Jaqueline Close and hip fracture patient Rhonda Wilson at Prince of Wales Hospital, Randwick.

Photo: Louise Kennerley

Roughly 22,000 hip fractures patients are treated in Australian hospitals each year, costing almost $1 billion, according to the report.

The average age of hip fracture patients was 84 years, and 69 per cent were female.

The 2017 audit found 5 per cent of hip fracture patients died in hospital and up to 25 per cent will die within a year as a direct result of their injury.

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“This is a high-risk group of individuals who are at risk of further falls and fractures and we know and have strong evidence out there that we can potentially reduce the risk of future fractures,” said Professor Close, also a geriatrician at Prince of Wales Hospital.

“We’ve had a number of medications available for decades now where, if we administer them, we know it is likely that we will reduce people’s future risk of fracture,” Professor Close said, referring to PBS-listed bisophosphonates, and injections Prolia and Aclasta.

The average time patients wait for surgery is 30 hours, or 54 hours if they are transferred to another hospital, according to the audit.

Roughly 23 per cent of patients waited more than 48 hours.

“Most of us would not be happy if our mother or father was lying in a hospital bed for 48 hours with a hip fracture in pain, with pressure injuries, and at risk of malnutrition because they’re fasting for surgery that keeps getting cancelled,” Professor Close said.

Professor Ian Harris said cutting surgery wait times for hip fracture patients was "the humane thing to do".

Professor Ian Harris said cutting surgery wait times for hip fracture patients was "the humane thing to do".

Photo: UNSW

“The bottom line is unless you have a medical reason for delaying, we should be getting these people straight into surgery."

Professor Ian Harris, Registry co-chair and orthopaedic surgeon at Liverpool Hospital,  said he pushed for shorter wait times for hip fracture patients because it was simply "the humane thing to do".

“Half of the reasons for delays we can fix,” Professor Harris said.

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A lack of access to theatres was the most common reason for the delay (35 per cent).

Professors Harris said major hospitals needed dedicated operating lists for hip fractures so these cases weren’t repeatedly “bumped” for other patients.

The report also found 46 per cent of hip fracture patients were still waiting for their pain to be assessed and documented 30 minutes after arriving at emergency departments.

Roughly 40 per cent already had some underlying cognitive problem before they were admitted to hospital, yet fewer than one in three hip fracture patients had a cognitive assessment documented before their surgery.

Encouragingly, hospitals were increasingly offering patients nerve block treatment to numb the pain (84 per cent in Australia) and relying less on morphine-like drugs that exacerbated cognitive problems such as delirium.

Australia was trailing well behind Britain when it came to osteoporosis, where the majority of hip fracture patients go home with treatment for osteoporosis, Professor Close said.

“The UK is also much better at identifying people with low trauma fractures and getting them into fracture liaison centres for investigation and treatment," she said.

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But Australia was making inroads, such as the NSW government’s rollout of an osteoporosis refracture prevention model of care across the state to improve outcomes for people with minimal trauma fractures.

Professor Harris said the audit’s transparent benchmarking individual hospital results would drive improvements. Underperforming hospitals will want to lift their performance and can learn from the best.

“It engenders some competition between hospitals, which is a strong motivator,” he said.