Quality and Productivity

Fragility fractures –
rehabilitation
Provided by: Department of Health

Summary
Early involvement with orthogeriatrician-led multidisciplinary rehabilitation services improves
effectiveness and efficiency. This reduced mean length of stay from 8.3 to 4.6 days with
projected savings of £75 million if rolled out across the NHS. See also: Fragility fractures –
prevention; and Fragility fractures – acute care.
Evidence summary
Yes The intervention has been successfully implemented
Yes The intervention has been successfully replicated
Yes The intervention is linked to standards or guidance
Yes The intervention is supported by one or more national organisations
Yes An evaluation of the effects of the intervention has been carried out
Yes There are publications relating to this intervention

The proposal
Rehabilitation This document presents the evidence for rehabilitation. See also:
Strategy • Fragility fractures – prevention; and
• Fragility fractures – acute care.

Rehabilitation, integrated with social care, is a fundamental part of

the care pathway for patients who have suffered a fragility
fracture, and can significantly reduce costs. Rehabilitation will be
an intrinsic part of the restructured co-ordinated service and will
include:
• the provision of orthogeriatrician-led rehabilitative care
starting earlier in the care pathway;
• a focus on multidisciplinary care; and
• use of specialist falls services.

Purpose of change Rehabilitation care following hip fracture surgery has been shown
to be ineffective and inefficient and these changes aim to improve
NHS care in this area.

Pathway group Acute care

Type of change A service redesign for the provision of care following fragility
fractures in the elderly population, to improve the rehabilitation of
patients following surgery.

Related standards The National Service Framework for Older People stated that a

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and guidance specialist falls service should be in place and these changes will
contribute to achieving this aim.

Other information A large part of the burden on the NHS of treating fragility fractures
occurs after surgery has taken place, when rehabilitative care is
given. Greater effectiveness and efficiency in this area, through
better use of resources, can therefore significantly reduce the
cost burden whilst improving patient experience.

Evidence of implementation
Organisations where Co-ordinated management of fragility fractures has taken place in
the rehabilitation numerous settings. The evidence here is from a geriatric fracture
strategy has been clinic (GFC) in the USA.
implemented

Effect on quality of Involving multidisciplinary rehabilitation at an earlier stage was a

care key change implemented in the GFC studied. This reduced mean
overall length of stay significantly - from 8.3 to 4.6 days -
representing improved effectiveness of treatment. The shorter
stay would also improve patient experience.

Effect on productivity The significant reduction in overall length of stay represents a

reduction in the key source of expenditure for hip fracture care. If
similar benefits were realised across England, savings of £75m
could be achieved (calculated at £250 per bed day).

Timescales for The data were collected form patients who suffered hip fractures
realisation of benefits 6 months after the GFC was established.

Additional costs The restructuring of the services will involve an initial cost outlay.
However, time spent in hospital and rehabilitation care represent
a huge proportion of the cost of hip fracture patients to the NHS.
The savings made by reducing these costs would outweigh the
initial outlay.

Evidence for the The reduction in mean length of stay is detailed in Friedmand SA
effect on quality and et al. Arch Intern Med. 2009 Oct 12;169(18):1712-7 .
productivity

Evidence of replication
The proposal has Yes In the NHS
been replicated No Other UK
Yes International

Details of replication There are isolated co-ordinated fracture services within the NHS
that have resulted in reductions in length of stay. Other countries
have also adopted this change, such as Australia, where

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reductions in hospital readmissions and mortality have been

achieved.

Results of replication Yes A consistent cash-releasing saving or productivity gain was

achieved
Yes A consistent gain in the quality of services was achieved

Supporting evidence • For the NHS Orthogeriatric unit, see Boyd RV et al. The
Nottingham orthogeriatric unit after 1000 admissions.
Injury. 1983;15(3):193-196
• For reductions in readmission rates in Australia, see
Fisher AA et al. Outcomes for older patients with hip
fractures: the impact of orthopedic and geriatric medicine
cocare. J Orthop Trauma. 2006;20(3):172-180 .

Further evidence
Evaluations The British Geriatrics Society (BGS) and British Orthopaedics
Association's (BOA) 'Blue Book' on fracture care for the elderly
recommends the use of a combined orthopaedic and geriatric
fracture service with early and focused rehabilitation to improve
patient outcomes and reduce costs.

Related publications BGS / BOA's ‘Blue Book’ is available from the National Hip
Fracture Database website (www.nhfd.co.uk).

Support from national The Department of Health supports the changes as part of its
organisations programme developing care for patients who have suffered from
fragility fractures.

Other evidence The Scottish Intercollegiate Guidelines Network (SIGN) (June

2009) recommends multidisciplinary and early (within 24 hr
postoperative if medically suitable) rehabilitation, as proposed
here, to improve quality of long-term outcomes and reduce length
of stay.

Implementation advice
Implementation Rehabilitation care will be restructured as part of the introduction
guidance of co-ordinated fracture services that manage the care of elderly
patients who have suffered hip fractures. Rehabilitation will be
initiated earlier in the post-operative pathway and will be
managed with orthogeriatric input to ensure better outcomes for
the largely elderly patients that suffer hip fractures.

Further This is one example of the implications that system redesign can
considerations have on outcomes for fragility fracture patients and efficiency.
There are further examples relating to other aspects of the care
pathway that add to the overall impact on quality of care and

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efficiency savings in fracture care.

For these other examples, see:

• Fragility fractures – prevention; and
• Fragility fractures – acute care.

Contacts and The Department of Health contact is Anne Macleod, Wellington

resources House, London, 0207 972 1280.

ID: 1062

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