Clinical Practice Guidelines: What, Why , Who?

1. Clinical Practice Guidelines:What, Why, Who? Steven A. Olson, MD Professor, Duke University Health System Durham, NC

2. Disclosures • Member AAOS Geriatric Hip FX CPG committee • BOD of OTA • Chair AAOS Geriatric Hip Fx Performance Measures Committee

3. Quality Improvement Research • Becoming more common in Medicine • It has other names • Patient Safety • Performance Improvement • High Reliability Systems • Medicine is not the only area with a concern for safety – Air Traffic Control, Construction, Industrial Product Assembly, etc

4. Where did this Concept Come From? A study reviewing data from New York State Hospitals from 1984 found that adverse events occurred in 3.7 % of hospitalizations. 27.6% of these advents were due to negligence or errors. 13.6% of adverse events led to death. Overall similar trends and incidence of adverse events, errors, and death rates were found in 1992 data from hospitals in Colorado and Utah. Brennan, T.A., et al., Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med, 1991. 324(6): p. 370-6. Thomas, E.J., et al., Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care, 2000. 38(3): p. 261-71.

5. To Err Is Human – IOM • These reports and other data lead to the Institute of Medicine publishing its landmark document “To Err Is Human: Building A Safer Health System”. This work addressed the issue of medical errors. The IOM defined medical errors as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

6. Goals of “To Err Is Human” • Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.

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8. Geriatric Hip Fractures • Population based rates hip fx >age 65 are declining • The population >age 65 is growing • Still a net increase in older population world wide • This group of patients has risks for • Secondary osteoporotic fracture • Change in living situation and need for more care • Decreased activity and quality of life • Increased mortality

9. Recognized Need To Optimize Care

10. 3 Musculoskeletal diagnoses in the top 3 most expensive conditions for CMS 1) - Osteoarthritis 2) - Back pain and Spine care 3) - Hip Fracture 261,000 discharges 2.2% of all CMS costs

11. Hip Fracture Registries • Australia • Sweden • Norway • Finland • England • Scotland • Spain Discussions of the potential for an Orthopaedic Surgery driven registry are on-going

12. The beginnings of a more comprehensive Orthopaedic effort in Hip Fx Care Best Practices • Clinical Practice Guidelines (AAOS) - completed • Appropriate use criteria (AAOS) - completed • Process measures (AAOS) - in process • Own the Bone – Secondary Fracture Prevention Program (AOA) Registries • National registry – Partnership between AAOS and ACS to create a dedicated geriatric hip fracture module within NSQIP • Hospital Program certification – Offered by International Geriatric Fracture Society

16. Significantly improves pre-op pain control • Reduces narcotic use • No data to support reduction in delirium post-op (yet)

17. Early fracture fixation is associated with: • Reduction in Mortality • Reduction in Hospital LOS • Reduction in readmissions • Reduction in patients needing a change in residence after hospitalization • No change in 6 month functional results

18. Effect on platelets is irreversible once drug has acted - takes 7 to 10 days to get affected platelets out of system. • Patients with coated stents must stay on clopidogrel

19. Outcome of Interest - Mortality General Spinal

22. Consistent with Own the Bone • Will involve a variety of interventions • Exercise, bisphosphonates, life style changes

23. Dedicated interdisciplinary care program Kates et al Geriatric Ortho Surg & Rehab 2010

24. The creation of an interdisciplinary care program is a “win-win” • Patients receive better care • Highly consistent care pathways • Evidence driven • The cost of care is better managed • Can take turn the program from cost-center into a profit-center Kates et al Geriatric Ortho Surg & Rehab 2010

25. http://www.aaos.org/appropriateuse/

26. Next Step – Metrics • AAOS has proposed a “Performance Measure” for geriatric hip fracture patients – The patient age 65 or older with an operative hip fracture is to be in the OR within 48 of admission to the ED. • Data point based on CPG • 50% of OTA members do not have formal hip fracture program in place. • Other Geriatric Fracture Measures available

27. Summary • Organized care programs are of value • Timely surgical care • Identify and encourage colleagues in other specialties to participate in care program • Be a leader or active participant • Follow your data and make changes as needed • Show your hospital administrators the value you bring through the hip fracture program

28. Thank You!