Context and Policy Issues
Over 300,000 Canadians reside in long-term care (LTC) facilities. Hip injuries in these residents are a health concern. Each year approximately 50% of them fall at least once, and 5% to 10% of these falls will result in fractures. The one-year mortality rate following a hip fracture is about 20%. The societal cost in the first year following a hip fracture is about $34,000 per LTC facility resident (in 1997 Canadian dollars).
One approach to prevention of hip fractures is the use of an external hip protector. Hip protectors consist of an underwear-type garment with pockets in which protective pads (hard-shelled or soft-shelled) are inserted on each side over the greater trochanter. In the event of a fall, the shell disperses the force away from the hip and into the surrounding tissue.
- What is the clinical effectiveness of hip protectors to prevent hip fractures for residents of LTC and assisted or supervised care facilities?
- What is the cost-effectiveness of hip protectors to prevent hip fractures for residents of LTC and assisted or supervised care facilities?
- What are the guidelines and criteria for patient selection for use of hip protectors?
Published literature was obtained by cross-searching MEDLINE, EMBASE, and CINAHL databases on the OVID search system between 2003 and March 2008. Parallel searches were performed on PubMed and the Cochrane Library (Issue 1, 2008) databases. Web sites of regulatory agencies and health technology assessment (HTA) and related agencies were also searched, as were specialized databases such as those of the University of York Centre for Reviews and Dissemination. The Google search engine was used to search for a variety of information on the Internet. These searches were supplemented by hand searching the bibliographies of selected papers.
Included clinical studies needed to meet the following criteria: study design — HTA, systematic review, randomized controlled trial (RCT) or observational study; population — patients in LTC or assisted or supervised care facilities (but not home care or community use); intervention — hip protectors (both hard- and soft-shelled) ; comparator — not specified a priori (could be usual care, drug therapy, etc.); outcomes — hip injuries or fractures. Criteria for the economic evaluations were similar except that the study design was a full economic evaluation and the outcome was a summary measure of the trade-off between additional cost and additional benefit. Guidelines relating to hip protector use were also reviewed. Evidence on compliance with hip protector use, as well as evidence on who might best benefit from hip protectors, was compiled.
The primary economic evaluation was a cost-utility analysis developed within a Microsoft Excel spreadsheet using a Markov model with a one-year cycle length and a lifetime horizon. The perspective was that of a provincial ministry of health. The economic model allowed the evaluation of hip protector use in LTC facilities versus no treatment, treatment with alendronate, and the combination of hip protectors plus alendronate for the prevention of hip fractures.
Summary of Findings
Five systematic reviews on the effectiveness of hip protectors were retrieved. They all found hip protectors had a protective effect on hip fractures for the elderly in residential care. The relative risk (RR) varied between the systematic reviews, largely because the individual studies included in the meta-analyses differed. One RCT published subsequent to the systematic reviews was included. It did not find a protective effect for hip protectors, but the trial did not employ the recommended use for hip protectors. One observational study, described in two separate articles, was also included. Using the same group of patients in a pre-test/post-test design, it found hip protectors reduced the incidence of hip fracture and resulted in an odds ratio of 0.31 for hip protector wearers versus non-wearers.
Six clinical practice guidelines covering hip fractures were retrieved. Four of the six recommended the use of hip protectors, with varying grades of evidence. The National Institute for Health and Clinical Excellence (NICE) guideline did not recommend their use. It made an overall recommendation, not made specifically for LTC- or community-living individuals, which may explain its discordance with the other guidelines reviewed.
Eight economic evaluations were retrieved for review. With one exception, all of the economic evaluations found results favourable for hip protectors. For the three economic evaluations done in Canadian settings, all found hip protectors likely to be cost-saving.
For the primary economic evaluation, the base-case results found that, for the prevention of hip fractures, the incremental cost per quality-adjusted life-year (QALY) for hip protectors versus no intervention was $14,000. For the hip protector versus alendronate comparison, alendronate dominated (less costly and more effective). For the hip protector plus alendronate combination versus alendronate alone, the ICER was $40,000. The results were sensitive to changes in the compliance rate with hip protectors, the number of new hip protectors required annually, the relative risk reduction, and age.
Compliance has been recognized as an important issue in hip protector research and implementation. Compliance can be described as the percentage of time the hip protector is worn correctly, and it appears to be about 25%. Factors that make patients reluctant to use hip protectors include discomfort, appearance and distortion of body image, cost, skin irritation, dressing and toileting difficulties, and inadequate patient instruction and orientation on use. In terms of overcoming barriers to compliance with hip protectors, caregiver motivation and involvement appear to be crucial. In terms of those most likely to benefit from hip protectors, decision makers may consider targeting LTC facility residents with these risk factors: hypertension, incontinence, a previous history of falls and fractures, cognitive impairment, stroke (especially hemiplegia), dementia, disorders of gait and balance, Parkinson’s disease, peripheral neuropathy, lower extremity weakness or sensory loss, lower body mass indexes, and substantial vision loss.
Conclusions and Implications for Decision or Policy Making
Hip protectors appear to be effective at reducing the risk of hip fractures in LTC facility residents, with a relative risk of 0.77. Our primary economic evaluation suggests that if the available options are hip protectors, alendronate, alendronate plus hip protectors, and no treatment, a combination of alendronate and hip protectors causes the greatest reduction in disease burden and would be considered cost-effective compared to alendronate if a decision-maker is willing to pay up to $50,000 for a quality-adjusted life-year in women between 75 and 89 with a previous fracture. Compared to no intervention, hip protectors are a cost-effective treatment option (based on a willingness to pay of $50,000/QALY) for women over 70 years of age living in LTC facilities.