Fragility hip fractures are likely to become a major public health challenge in the coming decades, as emerging economies with vast populations age. Half of the estimated 6.26 million hip fractures worldwide in 2050 are projected to be in Asia, predominantly in China and India. [1] Country-based incidence for hip fracture are unavailable, but data from India suggests that nearly a third of older people with hip fractures currently die within the year, with most deaths occurring in the first six months. [2] Implementing best practice guidance in these countries will mitigate the enormous loss of life and cost from the large number of fragility hip fractures approaching in the coming decades.  

In India the process of identifying a reliable surgeon in an affordable facility and organising finance for surgery causes long delays. [3] Only half of hip fracture patients are admitted to a treating hospital within 24 hours and only a third receive surgery by 48 hours. More than 40% of patients with fragility hip fractures receive surgery after 7 days, a significant evidence-practice gap. [4] Delays in hospital are compounded by the high burden of road traffic accidents, limited surgical capacity, and time required for co-morbidities management and optimisation for anaesthesia. A lack of ortho-geriatric services results in multiple super-speciality physician referrals, further adding to delays. [4]

Best practice guidance for the management of older people with fragility hip fractures have so far been formulated and implemented in the highly resourced western context. Widespread adoption of guidance in NHS hospitals in England and Wales has achieved reduction in 30-day mortality, shorter length of hospital stay and significant cost savings. [5] This guidance is considered as gold standard and is now being introduced in Ireland, Australia and New Zealand. Recommendations assume a high standard of healthcare provision and access and include: an integrated care-pathway of fast track admission to an orthopaedics ward, ortho-geriatric co-management, surgery within 36 hours, early out of bed mobilisation and pressure ulcer prevention, treatment for osteoporosis and falls assessment.

To what extent is this rigorous best practice guidance transferrable to the Indian context? A recent study highlighted multiple barriers to the implementation of best practice guidelines, most prominently, a demand-supply gap in the availability of trauma care beds; competing priorities from road-traffic accidents and complexities of care seeking behaviour. [3] Only a third of hip fractures arriving at a tertiary care centre are admitted. There is no triage or referral protocol and carers are left to decide on further pathways for care, mostly in the private sector. Heavy out-of-pocket expenditures lead to complex and difficult decisions often involving multiple hospital transfers and visit to local bonesetters. Families are less likely to risk such financial burden to seek treatment for female members, leading to gender inequities in care. [3]

The implementation of globally accepted best practice guidance in the Indian setting is impeded by differences in health service delivery, referral practices, care seeking behaviour, the burden of out-of-pocket-expenditure, and other factors not encountered during the development of available guidance in a high-income country. Bringing evidence based practice developed in and for well-resourced health system, to a poorly resourced system, will experience major barriers and is unlikely to be adopted widely. If the evidence to practice gaps are perceived as insurmountable, the likelihood for engaging stakeholders to appreciate the need to adopt evidence-based practice will be understandably low. This qualitative study revealed the scepticism of clinicians for implementing the proposed evidence-based care-pathways. During a key informant interview, a surgeon remarked “if a person with a hip fracture arrives a week after the injury, which part of the NICE guidance is applicable?”

So how to transform the knowledge of best practice evidence to improve outcomes of fragility hip fracture management in India? The way forward, with the Indian healthcare system as it currently stands, is threefold. Firstly, the principles of best practice management should provide direction for the development of appropriate guidance that are feasible to implement locally. A health systems approach, informed by robust feasibility studies, will be needed to identify locally appropriate practices for  inclusion in the National Programme for Health Care of the Elderly. Secondly, improving trauma care at district hospitals is necessary to avoid delays from travel to tertiary care and congestion at these facilities. Finally, we need to increase awareness among clinicians about the importance of physician-surgeon co-management and care protocols; fast-tracking surgery and emphasis on the importance of prompt care to reduce mortality of older people with hip fractures should play a role. [6]

Santosh Rath is a Visiting Professor at Institute for Global Health Innovations, Imperial College London. He is an Orthopaedic Hand Surgeon and was engaged in Leprosy deformity reconstructive surgery and disability care in Eastern India for 25 years.

References:

1. Cooper C. et al., ‘Secular trends in the incidence of hip and other osteoporotic fractures.’ Osteoporos Int 2011. 22(5): p. 1277-88.

2. Dhanwal, D.K., One year Mortality of hip fractures in India. Osteoporos Int, 2013. vol.24, supplement 1.

3. Tewari A, R.S., Yadav L, Sahu KS, Sundari DS, et al. , Care Seeking Behaviour of Older Adults with Hip Fracture in India: A Qualitative Study. . Journal of  Patient  Care 2017. 3:128.

4. Rath S, Y.L., Tewari A, Chantler T, Woodward M, Kotwal P, Jain A, Dey A, Garg B, Malhotra R, Goel A, Farooque K, Sharma V, Webster P, Norton R. , Management of older adults with hip fractures in India: a mixed methods study of current practice, barriers and facilitators, with recommendations to improve care pathways. . Arch Osteoporos. 2017 Dec;12(1):55., 2017.

5. Neuburger, J., et al., The Impact of a National Clinician-led Audit Initiative on Care and Mortality after Hip Fracture in England: An External Evaluation using Time Trends in Non-audit Data. Med Care, 2015. 53(8): p. 686-91.

6. S.Rath , A.B.D., Management of Hip Fractures in China and  India: A systems approach to bridge evidence practice gaps. Practical Issues in Geriatrics, ed. S. Giordano. 2017, Switzerland: Springer International Publishing