Masterclass 4 - Fragility Fracture Services: Updates and the Way Forward

1. Overview 
Geriatric fragility fractures are a significant public health concern due to their impact on morbidity, mortality, and healthcare costs. As the global population continues to age, there is a growing need for effective strategies to prevent and manage these fractures in elderly.
Service gaps in the geriatric fragility fracture care provision were well studied and recognized. Over the decades, multi-disciplinary health care professionals in Hong Kong contributed tremendously towards a systemic and comprehensive service model. with implementation of Key Performance index (KPI), enhanced timely intervention through designated fragility fracture surgery provision, Ortho-Geriatric collaborative care journey, Fracture Liaison Service, restorative and seamless rehabilitation from hospital to community, primary and secondary prevention by optimizing bone health & fall prevention.
Literatures have proven the value of early surgery is associated with reduced mortality and perioperative complications. Patients operated on within 48 hours had a 20% lower 1-year mortality. Though such KPI improved significantly in Hong Kong over the last 20 years, it is still a challenging mission which requires multidisciplinary collaboration and the availability of sufficient surgical capacity with competent teams and facilities support. Moreover, the longer life expectancies in Hong Kong indicated a high association of complex comorbidities in elderly demand a higher quality of peri-operative care for risk mitigation.
Huge volume of fragility fracture service load provides treasurable opportunity for the establishment of Hip fracture registry and electronic platform. Relevant Smart initiatives and the big data pool will certainly become a powerful tool for service improvement. A domestic Artificial Intelligence Hip fracture diagnosis assistance already developed and in use in local hospitals.
The extended post-discharge journey to primary medical care and community rehabilitation, in particular the new service model of District Health Center (DHC), are sustainable strategies to optimize the achievable functional recovery.

Geriatric hip fracture is more than a fracture. It is actually a representation of underlying frailty of the elderly. Therefore it has a potential devastating outcomes, resulting in high mortality, substantial debility, functional loss and poor quality of life. Clearly it is not enough nor ethical to just treat a geriatric hip fracture patient by an orthopaedic surgeon with operation alone. A comprehensive geriatric assessment by a geriatrician is needed to identify background frailty and co-morbidities, to improve clinical outcomes, to formulate a long-term care plan, and to prevent repeated admissions.


The first orthogeriatric unit was established in the United Kingdon in 1953. In 2007, British Orthopae-dic Association and British Geriatric Society jointly published the famous “Blue Book”, a bible adopt-ed for hip fracture care internationally, inside which orthogeriatic model is considered as one of the six standards. Worldwide, orthogeratric co-management model is emerging as the preferred model, with the benefits of less operation delay, complications, mortality, length of stay, and higher osteopo-rosis idenfication. 


United Christian Hospital has a long history in improving geriatric hip care services. Orthogeriatric collaboration was started since 1993 by our devoted geriatrician, without additional resources provided initially. Our famous weekly multidisciplinary orthogeriatic combined grand round has attracted not only local but overseas visitors. From 2015, we opened the first orthogeriatric specialty ward in Hong Kong to allow better intergration of different disciplines in provided a seamless care for our geriatric hip fracture patients. Over the years, we witnessed progressive improvement osteoporosis identification and treatment, as well as patients’ functional outcomes. Our work has been recognized internationally by being the first center obtaining Best Practise Framework recognition in the Capture-the-Fracture Programme of the International Osteoporosis Foundation since 2018.

With the increasing in ageing population, the prevalence of fragility fractures (FF) is expected to rise. A robust approach to manage osteoporosis, the underlying cause of fragility fracture, and its consequences is essential. The International Osteoporosis Foundation’s (IOF) Capture the Fracture® campaign advocates for worldwide implementation of Fragility Liaison Service (FLS), aiming to disrupt the FF cycle. FLS is designed to streamline patient care from hospitalization to rehabilitation, therefore to reduce the future incidence and healthcare costs associated with FF. 
Since 2018, the Hospital Authority has implemented the FLS in three hospitals, including Queen Elizabeth Hospital, Pamela Youde Nethersole Eastern Hospital and United Christian Hospital, and has since expanded to 13 hospitals across all clusters. The goals of FLS are 1) improving FF care by implementing integrated clinical pathways and coordinating multi-disciplinary care, FLS ensures seamless, quality treatment; and 2) preventing secondary fracture by utilizing proactive tracing systems to identify, investigate, and initiate treatment to mitigate the risk of subsequent FFs. 
FLNs are the key component of the Fracture Liaison Service, providing comprehensive care tailored to the unique needs of FF patients. Their role extends beyond clinical care, including education and coordination, thereby ensuring the program’s effectiveness in preventing secondary fractures and improving patient outcomes. 

District Health Centre: 
Funded by the Government, District Health Centre (DHC) operates through district-based medical-social collaboration in community to provide services in health promotion, health assessment, chronic disease management, community rehabilitation, etc.


Community Rehabilitation Programme – hip fracture (CRP-hip fracture):
Tertiary prevention programme for hip fracture is targeted for patients discharged from hospitals who have completed acute, subacute or day rehabilitation programme. Patients with more dependence in ambulation (MFAC II-V) require higher intensity of training and support for their carer. Patients with higher ambulatory level (MFAC VI- VII) may benefit from empowerment/exercise programmes.


CRP-hip fracture involves multi-disciplinary team (including nurse, physiotherapist, occupational therapist, dietitian, pharmacist, and social worker) as referred by medical doctor in hospital of the district. After receiving the electronic referral, the staff in DHC will contact the patient. Supportive transportation service is available for wheelchair users. Patients have to pay a subsidized fee for consulting physiotherapist, occupational therapist or dietitian with a maximum of 8 sessions while free consultations for other disciplines are arranged. Besides, there are education and exercise classes available to promote safe and active engagement in community.


Progress: 
From 2020, there were 180 hip patients enrolled into CRP-hip fracture in K&TDHC with 129(71.7%) completed and 51(28.3%) defaulted. The mean age was 81.7(SD 8.3) and average attendance was 6.7(SD 2.3) sessions. Before CRP, 60.5% of patients had to support with frame/rollator and lower to 39.5% afterwards. Use of one-sided support of aid (quadripod/stick) was 27.8% before and increased to 40.0% afterwards. Only four patients (2.2%) could walk unaided before and later 22(12.2%) patients. Before CRP, 58.4% patients walked with assistance. After CRP, 67.3% patients could walk independently. Besides there was significant improvement observed in mobility [EMS mean(SD) increase 2.45(2.56) points, p-value 0.000], balance [TUG mean(SD) decrease 14.53(19.04) seconds, p-value 0.000], modified Barthel Index [mean(SD) increase 6.41(6.65) points, p-value 0.000]. 


Conclusion: 
CRP-hip fracture enabled the hip patients and their carers to cope with barriers to re-integrate into community after hospital discharge, which is especially important in the early stages. The patients acquired higher level of independence in mobility and better control of fall risk.

Background
The development and adoption of technology in healthcare is transforming the way we provide care. Leveraging on technological advancements to facilitate seamless and efficient care delivery that benefits both patients and healthcare providers, the Clinical Protocol Management Information System (ProMIS) was developed to manage Fragility Hip Fracture (FHF) clinical pathway to support Protocol-Driven healthcare service and SMART care in Hospital Authority.


Protocol Management Information System
ProMIS integrates FHF clinical pathway multi-disciplinary clinical workflows across different phases of patient care, including acute, rehabilitation, and community stages. This ensures seamless communication and collaboration among healthcare providers for cohesive approach to patient management.
ProMIS operates as a unified platform accessible via mobile Clinical Management System (CMS), facilitating the integration of electronic clinical documentation. The streamlined workflow enables healthcare professionals to access patient information, track progress, and manage care more efficiently hence, ensuring timely intervention and adherence to protocols.
Throughout the patient journey, ProMIS offers a holistic view of clinical care. This patient-centered approach allows for personalized care planning, goal setting, and coordinated interventions as well as better patient experiences.
By implementing ProMIS across all hospitals, it promotes standardized practices and fosters protocol-driven care, benefiting patients and healthcare providers alike.
ProMIS minimizes paper-based forms and promotes digital documentation. This shift toward paperless processes improves data accuracy and contributes to the provision of high-quality data for data-driven care.


Results
The ProMIS was implemented for FHF Clinical Pathway during year 2021-2023 in Hospital Authority. As at end of year 2023, a total of 5641 FHF clinical pathways were utilized in 8 hospitals.


Conclusion
The integration of the FHF clinical pathway to the ProMIS system indeed holds great promise for optimizing workflow efficiency for healthcare professionals. This SMART innovative approach represents a positive step toward advancing protocol driven care and enhancing quality of patient care. With the success of implementation of FHF clinical pathway, extending the use of ProMIS to other protocol driven clinical pathways could facilitate SMART care in the future.

The impact of aging population is great to society. In Hong Kong, the aged population (age >=65) will increase from 20.5% in 2021 to 36% in 2046. Osteoporosis, as one of the major chronic diseases, should be treated in a more systematic approach. Attention only to the related complication, ie the fragility fractures (hip fracture, vertebral compression, and other fractures) is not adequate. The management should be a multidisciplinary holistic approach, including Acute, Rehabilitation and Community phases, with timely input from different disciplines. The challenges are great, especially in the era of preventive medicine and under the concept of chronic disease model of Hospital Authority nowadays. 


Acute phase is aiming at treating the fragility fractures timely, to reduce morbidity and mortality, and to enhance the outcome. The challenges will be the standardization of clinical pathway, the availability of ortho-geriatric co-care, protected operation list and the use of advanced surgical implants for immediate full weight bearing. 


Rehabilitation phase is aiming at early and continuous rehabilitation during hospitalization, to facilitate the return to community. The challenges will be the availability of rehabilitation bed and in-patient allied health.


Community phase is aiming at continuous rehabilitation after discharge, to achieve the pre-injury quality of life as much as possible, secondary prevention including bone health management, fracture and fall prevention. The challenges will be the availability of out-patient allied health, DXA scan, bone health medication, management on sarcopenia, frailty, and fall prevention.


Some measures had been started in the Hospital Authority to cope with the challenges, including additional resources for trauma list, surgical implants, and bone health medications. Fracture Liaison Service, Orthopaedic Day Rehabilitation and Telehealth had also been implemented. Our way forwards may include: 1) Collaboration with District Health Center, targeting Osteoporosis as a chronic disease model, with continuous quality care in the community. 2) Enhancement of e-platform on fragility fracture, with the concept of big data. 3) Early identification and treatment of osteoporosis by artificial intelligence detection of occult spine collapse or by community screening etc. 


Treating osteoporosis and fragility fracture patient better, is more cost-effective than treating them badly. This group of patients is worth receiving more attention and resources and intervening earlier.