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Hip Protector Compliance: A 13-Month
Study on Factors and Cost in a Long-
Term Care Facility

Jeffrey B Burl, MD, CMD, James Centola, PT, Alice Bonner, APRN-BC, and Col een Burque, PTA Results: By the end of the third month, hip
Objective: To determine if a high compliance
protector compliance averaged greater than 90% rate for wearing external hip protectors could be daily wear. The average number of fal s per achieved and sustained in a long-term care month in the hip protector group was 3.9 versus 1.3 in non-participants. Estimated total indirect staff time was 7.75 hours. The total cost of the Study Design: A 13-month prospective study of
study (hip protectors and indirect staff time) was day time use of external hip protectors in an at- risk long- term care population. Conclusions: High hip protector compliance is
Setting: One hundred-bed not-for-profit long-
both feasible and sustainable in an at-risk long- term care facility. term care population. Achieving high compliance Participants: Thirty-eight ambulatory residents
requires an interdisciplinary approach with one having at least 1 of 4 risk factors (osteoporosis, department acting as a champion. recent fal , positive fal screen, previous fracture). The cost of protectors could be a barrier to Intervention: The rehabilitation department
widespread use. Facilities might be unable cover coordinated an implementation program. the cost until the product is paid for by third Members of the rehabilitation team met with party payers. (J Am Med Dir Assoc 2003; 4:
eligible participants, primary caregivers, families, 245—250)
and other support staff for educational instruction Keywords: hip protectors; compliance; fal s;
and a description of the program. The costs and cost analysis; long-term care facilities rehabilitation team assumed overal responsibility for measuring and ordering hip protectors and monitoring compliance Hip fractures exact a heavy financial and human toll
importantly, a sideways fall on the greater trochanter of the proximal femur.16-20 Multidimensional programs in the United States. More than 250,000 individuals designed to reduce hip fractures has been reported, sustain a hip fracture each year. Nearly 20% of those and most include reducing falls and fall risk factors, individuals die from complications of the fracture increasing bone density and muscle strength, and within 1 year, another 25% seek long-term placement, improving gait and balance.21 However, some recent and less than half fully recover. 1—8 Over $5 billion is meta-analyses have reported limited statistical power spent annually in direct and indirect hip fracture to detect the effectiveness of specific strategies or programs to prevent falls and fractures.22,23 Ninety percent of hip fractures occur in individuals Use of an external hip protection system that covers over the age of 70.12,13 Close to 2 million elderly, with the greater trochanter of the proximal femur has been a mean age of 84 years, reside in long-term care shown reduce the incidence of hip fractures.24-30 Yet, facilities. An estimated million reside in the low compliance remains a major obstacle in the community with similar functional and medical effective use of hip protector systems.24,28,30-32 This 1- impairments. This population of frail, at-risk elders year study was undertaken to determine if moderate to has the highest potential for future hip fractures.14,15 high levels of hip protector compliance could be Several factors that potentially increase the risk for hip achieved and sustained in a long-term care facility. fracture have been identified. They include osteoporosis, low body mass index, and, most Reprinted from Journal of the American Medical Directors Association September/October 2003 Equipment
A local Massachusetts manufacturer of soft hip protectors, the HipSaverTM Company, Inc., was Subjects were residents of The Masonic Home, a not- contracted to provide product. They were selected for- profit, 100-bed long-term care facility in Central based on extensive discussions of various models, Massachusetts. Eligible residents were ambulatory, including results from the PACE Programme with or without the use of an assistive device. High- (Programme for All-Inclusive Care of the Elderly) in risk residents were identified as having at least one of East Boston, which had successfully used this hip the following criteria: protector model over 2 years.33 The Hip Saver 1. Diagnosis of osteoporosis (T-score <2.5) Company in Canton, Massachusetts, was also selected because of close proximity to study site and the ability 2. History of one or more falls within the past 6 to provide comprehensive customer service. The hip protector company provided in-service 3. History of prior fracture education to the department of rehabilitation on 4. Positive falls screen on admission for residents measuring residents for proper size, ordering, and admitted within the previous 3 months laundering requirements. They provided a sizing chart, and all subjects were subsequently measured and fitted Fifty-six long-term care residents met the criteria for by the rehabilitation department for the proper-sized participation in the hip protector compliance study. protector (there were 4 possible sizes). A hip The enrolment period was continued from September measurement was performed around the widest 2001 through the end of December 2001 and ran circumference of the pelvic region. through September 2002. After discussions with the nursing, rehabilitation, and Study Design
Iaundry departments, it was determined that 4 sets of All eligible participants were invited to attend a 1-hour protectors would be dispensed to each resident to educational session conducted by the medical director, ensure that a protector would be available when the director of rehabilitation, and a physical therapist. needed. The rehabilitation staff was responsible for ordering the protectors and marking them with the This session explained the use of hip protectors, the potential risks and benefits, and the objectives of the resident's name before distribution. The nursing staff study. At that time, any interested individuals were was responsible for distribution and storage of nursing invited to participate and consent was obtained. units. The cost of each hip protector, at the beginning of the study, was $30. Residents who agreed to participate at the initial meeting were measured for hip protectors (see Tracking Compliance
"Equipment" section). For eligible residents with a diagnosis of dementia or other cognitive impairment, For the purposes of this study, any individual who families received a letter explaining the use of the hip wore hip protector at least once and was able to be protectors, the potential risks and benefits, and the monitored a minimum of 9 months was included. It objectives of the study. Families of those residents was felt that a longitudinal follow up was essential to were given the option of having the resident determine if consistent wearing of the hip protectors participate in the study, and consent was obtained could be maintained over time. Only daytime hip from the appropriate family member. The medical protector use was evaluated (i.e., use the time the director, the director of rehabilitation, and the physical resident was dressed in the morning until were in bed therapist were also available to answer individual for that night). Nursing staff received the protectors questions at any time. and distributed them to the appropriate residents. Those with activities of daily living deficits were One-hour in service education sessions by the given reminders by the CNAs and staff assistance in rehabilitation department were provided to all licensed donning the protectors when needed. nursing and Certified Nurse Aide (CNA) staff on the use of hip protectors, their potential benefits, the Percent compliance was measured monthly by number of protectors each resident would receive, and dividing the total days hip protectors were worn by the how and when they should be worn. Although these number of days in the month. Nursing tracked daily sessions were not mandatory, most of the nursing staff compliance on a log created and kept in the did attend. The rehabilitation department met medication administration record (MAR) on the separately with those individuals unable to attend the medication cart. At the time of medication pass, the sessions to explain the study. CNA reported to the nurse whether the resident had worn the hip protector for that day. The nurse noted Laundry and housekeeping were in-serviced this in the study log. Nursing was interviewed monthly separately by the director of rehabilitation on the hip by a representative from the rehabilitation department protector product, and the handling and laundering to obtain ongoing compliance data in the study instructions (no bleach). They were informed of the subjects. The rehabilitation department reviewed total number of protectors that would be circulating monthly tracking record and recorded monthly through the department. compliance for each resident. Compliance data was recorded for a total of 13 months. Reprinted from Journal of the American Medical Directors Association September/October 2003

Table 1. Demographic Characteristics
Fifty-six long-term care residents met the inclusion Fig.1 Percent hip protector compliance from
criteria for the study. Five residents agreed to September 2001 through September 2002 participate when initially approached by the medical director, but refused to be measured and were not the study, 2 fractures (clavicle, humerus) in 1 issued the hip protectors. These residents were not individual. Three of the 4 individuals who sustained a considered to be in the study. Six residents died, and non-hip fracture were in the study group. Two subjects an additional 7 had a significant change in condition to sustained fractures during the night (pelvis, rib) when nonambulatory status well before the 9-month they were not scheduled to wear the hip protectors. minimum could be completed. These 2 subgroups The other subject sustained a forearm fracture from a were not included in the data. Thirty-eight residents fall. She was wearing hip protectors at the time of the completed at least 9 months of the 13-month trial, with fall. By the third month of the study, average a mean follow up of 11.9 months, Data was collected compliance exceeded 90%, and this was sustained for on a total of 38 residents. the remainder of the study (Fig. 1). The average age of study participants was 89.5 years, with a mode of 93 years. Seventy-five percent of the CNAs were interviewed by the rehabilitation staff in participants were women, and 78% had a primary cases of non-compliance and were asked why hip diagnosis of dementia. Ninety-two percent of protectors we not being worn. Most often, CNAs participants were on state medical assistance reported that the individuals were not wearing the hip (Medicaid) and 86% had Medicare coverage for part A protectors because of acute illness (not expected to get expenses. More than half of the participants had 2 or out of bed that day) or possibly a result of laundry more risk factors, and approximately one third had issues (occasional difficulty getting protectors back only one risk factor (Table 1). The total number of from laundry on Mondays, according to CAN. medications per resident did not change significantly Another reason given was that the resident was going during the study. The total scheduled psychoactive out see a specialist (medical or surgical), where the medications averaged one medication per participant use of hip protectors was felt to be an added burden during the appointment. By the third month of the study, residents (those not requiring help with During the 13-month study period, a total of 206 falls activities of daily living) appeared to consider the occurred in the facility, averaging 15.8 falls per month protectors part of their daily dressing routine and for or approximately 1.5 falls per resident per year. One the most part, only required minimal cues from CNAs. hundred twenty-six of the falls (61%) involved 34 of Two participants wore hip protectors regularly for the the 38 study participants, or one-third of the total 100- first month of the study, but reported that they were bed nursing facility population (average occupancy, not comfortable. Despite size changes, these subjects 98.9). Mean number of falls per participant was 3.9, elected not to continue the hip protectors but were compared with 1.3 falls for those not in the study. counted in the compliance data. There were 2 hip fractures in the facility in the year before the start of the study. There were no hip Staff time spent in the initial phase of the study on fractures in the facility during the 13month educational sessions for the residents and staff was intervention. There were 5 non-hip fractures during 7.75 hours, for estimated indirect cost of approximately $500. Total cost for the hip protectors Table 2. Prestudy Average Medications
for the 49 participants who agreed to be measured was $5880, for a total direct and indirect cost $6300 for the study. None of the 6 deaths was related to a fall, and was not related to the use of hip protectors. The average time that hip protectors were worn by the 7 subjects who had a change in condition was 1.8 months (range, 1-4 mo). Average compliance for this group was 55% (range 35—75%). The average time that hip protectors were worn the 6 subjects who died was 3 months (range, 0—7 mo). The average compliance was 93% (range, 67—100%). Reprinted from Journal of the American Medical Directors Association September/October 2003 DISCUSSION
noted a compliance rate for complete and incomplete wear in 88 subjects of 70% and 17% respectively.26 The incidence of hip fractures is expected to vanSchoor, using a self-reporting mechanism, found significantly outpace the growth of the senior compliance of 4 months and 37% at the end of 12 population in the coming years. Between 1970 and 1997, the Finnish population over age 50 increased by 53%, whereas hip fracture incidence increased by The reasons for low compliance in these studies are more than 169%.34 The total number of hip fractures described in detail; however, study design could be worldwide is predicted to more than quadruple from one factor. Individuals are often asked to wear hip 1.6 million to more than 6.2 million by 2050 if nothing protectors without staff having had detailed education is done to prevent this potential health crisis.34 regarding their use. The lack of staff understanding and support could have been a factor in some studies. Although the incidence of falls in long-term care is 1.5 Hip protectors are most likely to of benefit with falls per bed per year,24,35,36 only 1—2% of all falls maximum daily wear. Based on Parkkari's framework, result in a hip fracture.37,38 Studies have shown that a structured educational program for both staff and the major causal factor for hip fracture is an impact to patients was instituted in this study. The intent was to the greater trochanter, in which the impact energy of a have staff support and encourage the use of the hip fall exceeds the average fracture threshold of the protectors. In addition, the concept of daily wear count proximal femur.16-20 In addition, studies have was used in determining compliance. Each day the demonstrated that osteoporosis, low body mass index, CNA provided feedback on hip protector wear, which and height of a fall are independent risk factors for hip was documented in the MAR. This was felt to be a fracture. 16—20 more accurate assessment of total hip protector wear and fracture prevention. In our study, residents with Successfully reducing hip fracture rates requires an significant change in condition or decline in functional inter disciplinary process in which all risk factors are status had lower compliance than the other subjects addressed. To date, efforts to reduce falls, improve (55%). One explanation for the low compliance in this gait and balance, and increase body mass index have group is that when patients become acutely ill, staff met with only partial success. Treatment of determines other care is to be of higher priority. Also, osteoporosis with antiresorptive medications might when patients spend more time in bed, for example only increase femoral neck density by 2% per year, 39 when acutely ill, CNAs might elect not to use hip which might not be sufficient for fracture reduction in pads. This specific topic might require dedicated in- long-term care residents whose average life service education. expectancy is approximately 24 months.15 One preventive strategy that could potentially reduce the Based on the results of this study, it appears that impact energy of a fall to the greater trochanter is the relatively high compliance is feasible and potentially use of external hip protectors, an external padding sustainable in a long-term care facility. Compliance system that both absorbs and shunts energy away from after the third month did not drop below 90%. This the proximal femur. Studies have demonstrated the could have been attributable in large part to the effectiveness of hip protectors, with one estimate that rehabilitation department's role as a champion as well hip fractures could be reduced by 60% in those as the formal educational component of study. There wearing the device, and up to 80% if all residents were 2 individuals included in the compliance who wore the protectors.28 could not wear the hip protectors as a result of poor fit. Despite repeated attempts to optimise fit, the Two recent studies have questioned the efficacy of hip individuals complained of discomfort. If we exclude protectors. In a randomised, controlled trial with 18 these 2 subjects the data, average daily compliance months of follow up, Meyer showed a relative reduction in hip fracture of more than 40%, but at borderline significance.30 van Schoor randomised a Failure to achieve higher compliance in the first 3 mixed group of community-dwelling elderly and months could have been the result, at least in part, of nursing facility residents in a 16-month study.40 No issues with laundering of the protectors. Because of statistical difference between the control and study limited laundering, on the weekends, especially for the groups was realized. However, the authors noted a incontinent residents who needed frequent changes, 23% non-significant reduction in hip fractures in clean hip protectors might not have always been individuals who wore the hip pads, as well as a lower available on Monday mornings. This was solved by fracture rate per fall in the study group.41 providing those residents with 2 additional sets of protectors. One positive finding was that CNAs who The definition of compliance is not standardized, received the educational session would often call the making comparisons between studies problematic. rehabilitation department to obtain hip protectors Several studies report compliance only at the time of a before getting residents out of bed, if none were fall, as opposed to reporting total number of days of available in the patient's room. The CNAs reported fracture protection per patient. Lauritzen et al. base occasionally borrowing unused/unopened hip their compliance reporting on fall registers, ie, the protectors from other residents in an emergency, rather number of times the resident was wearing the hip than getting a resident out of bed without them. For protectors at the time of the fall with a compliance rate continent residents, 3 sets of hip protectors might be of 24%.24 Two other studies using similar compliance sufficient. However, incontinent residents might need measures had rates of 46% and 54%, respectively. 25,30 more than 4, depending on the frequency of laundry Harada, using a case-controlled observation method, Reprinted from Journal of the American Medical Directors Association September/October 2003 services. Previous studies have not always reported the with the statistical methods used in the results. We number of pads dispensed per resident. In some also want to acknowledge both the encouragement and studies, only 2 or 3 protectors per resident were used. support of the board of directors of The Masonic It is possible that the higher compliance rate in this Health Care Systems, without which we would not study was, in part, related to the relatively high have a successful hip protector program. number of pads dispensed to each resident. 1. Melton LJ III, Chrischilles EA, Cooper C, et al. Kannus estimated that 42 individuals would need to be How many women have osteoporosis? J Bone Miner treated for 1 year to prevent one hip fracture28. Given Res 1992;7:1005—1010. the compliance and number of users in the current study, approximately 1—2 hip fractures per year could 2. Cummings SR, Rubin SM, Black D. The future of be prevented. This could represent a potential cost hip fractures in the United States: numbers, cost, and savings to Medicare of approximately $20—40,000 potential effects of post-menopausal estrogen. Clin (Fallon Community Health Plan, unpublished Orthop 1990;252:163—166. 3. Kannus P, Parkkari MJ, Niemi S. Age adjusted One major barrier to the use of hip protectors is the incidence of hip fractures. Lancet 1995;346:50—51. cost of the product. Until Medicare and Medicare + 4. Cooper C, Atkinson EJ, Jacobsen SJ, et al. Choice programs provide external hip protectors as a Population based study of survival afrer osteoporotic covered benefit, either facilities or residents/families fractures. Am J Epidemiol 1993;137:l001- 1005. will be responsible for purchasing the protectors. Given the current budget crisis in many states, long- 5. Sembo I, Johnell 0. Consequences of hip fracture: A term care facilities are likely to face reductions in per prospective study over 1 year. Osteoporosis Int diem rates. As of March 1, 2003, Massachusetts has 1993;3:148—153. reduced Medicaid payments to nursing facilities by 6. Keene GS, Parker MJ, Pryor GA. Mortality and over 2%, with possible further reductions. Facilities morbidity after fractures. BMJ 1993;307:1248—1250. are faced with trying to maintain quality of care despite decreased revenue, and might be less likely to 7. Melton LJ III. Epidemiology of hip fractures: offer hip protectors to high-risk residents, unless they Implications of the exponential increase with age. perceive some indirect benefits to the facility as well Bone 1996;8:1215—1225. as to the resident. Some of those indirect benefits 8. Magaziner J, Hawkes W, Hebel JR, et al. Recovery might include improved facility quality ratings, fewer from hip fracture in light areas of function. J Gerontol reports of hip fractures to state authorities, and 2000,5A:M498—M507. improved state survey results with regard to fall prevention. As more studies demonstrate the 9. Ray NF, Chan JK, Thamer M, et al. Medical effectiveness of external hip protectors in preventing expenditures for treatment of osteoporotic fractures in hip fractures in targeted populations, state or federal the United States in 1995: Report from the National regulations might change to require hip protectors for Osteoporosis Foundation. J Bone Miner Res certain high-risk, long-term care residents. 1997;12:24—35. CONCLUSION
10. Schneider EL, Guralnik JM. The aging of America: Report on health care costs. JAMA High compliance rates for hip protectors in an at-risk, 1990;263:2335—2340. long-term care population are feasible. Success depends in part on whether there is broad-based 11. Brainsky A, Glick H, Lydick E, et al. The acceptance by support staff, especially CNAs, who economic cost of hip fractures. in community- can make the hip protectors an integral part of the dwelling older adults: A prospective study. J Am daily routine for each resident. The process also Geriatr Soc l997;45:28l—287. requires a champion, a person or team, to assume accountability not only for measuring compliance, but 12. Riggs BL, Melton LJ Ill. Involutional also for attending to small details such as measuring, osteoporosis. N Engl J Med 1986;314:1676—1686. ordering, marking, and storing the hip protectors. In 13. Jacobsen SJ, Goldberg J, Miles TP, et al. Hip this study, the department of rehabilitation provided fracture incidence among the old and very old: A the leadership and accountability to sustain the population based study of 745,935 cases. Am J Public program. Elder advocates and lobbyists need to inform Health l990;80:871—873. federal and state governments of the potential benefits of hip protectors. Pending further research, insurers 14. Kane RA, Ouslander JG, Abrass lB. Essentials of should be encouraged to provide them as a covered Clinical Geriatrics, ed. New York: McGraw-Hill, benefit to targeted, high-risk patients. The authors thank Maria Barretti for her time spent typing the article and Dr. Jim Fain for his assistance Reprinted from Journal of the American Medical Directors Association September/October 2003 15. Ouslander JG, Osterweil D, Morley JE. Medical 30. Meyer G, Warnke A, Bender R, et al. Effect on hip Care in the Nurs Home, 2nd ed. New York: McGraw- fractures of increased use of hip protectors in nursing homes: cluster randomized controlled trial. BMJ 2003;326:76—78. 16. Hayes WC, Myers ER, Morris JN, et al. Impact near the hip dominates fracture risk in elderly nursing 31. Villar M, Hill P, Inskip H, etal. Will elderly rest home residents who fall. Calcif Tissue Int home residents wear hip protectors? Age Ageing 1993;52:l92—198. 1998;27:195—198. 17. Greenspan SL, Myers ER, Maitland LA, et al. Fall 32. Chan DK, Hillier G, Coore M, et al. Effectiveness severity and bone mineral density as risk factors for and acceptability of a newly designed hip protector: A hip fracture in ambulatory elderly. JAMA pilot study. Arch Gerontol Geriatr Suppl 1994;271:l28—l33. 2000;30:25—34. 18. Robinovitch SN, McMahon TA, Hayes WC. Force 33. Gross G, Chen T-H, Flaherty C. Hip pads: attenuation in trochanteric soft tissues during impact Effective fracture prevention. Adv Phys Ther 2000; from a fall. J Orthop Res 1995;956—962. 19. Greenspan SL, Myers ER, Kiel DP, et al. Fall 34. Kannus P Niemi S, Parkkari MJ, et al. Hip direction, bone mineral density, and function: Risk fractures in Finland berween 1970 and 1977 and factors for hip fracture in frail nursing home elderly. predictions for the future. Lancet 1999;353:802—805. Am J Med 1998;104:539—545. 35. American Geriatrics Society, British Geriatrics 20. Parkkari MJ, Kannus P, Palvanen M, etal. Society, and American Academy of Orthopaedic Majority of hip fractures occur as a result of a fall and Surgeons Panel on Falls Prevention. Guideline for the impact on the greater trochanter of the femur: A prevention of falls in older persons. J Am Geriatr Soc prospective controlled hip fracture study with 206 2001;49:664—672. consecutive patients Calcif Tissue Int 1999;65:183— 36. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002;18:14l— 21. Tinetti ME. Preventing falls in elderly persons. N Engl J Med 2003;348:42—49. 37. Grisso JA, Kelsey JP, Strom BL, et al. Risk factors 22. Hill-Westmoreland EE, Soeken K, Spellbring AM. for falls as a cause of hip fracture in women. The New A meta-analysis of fall prevention programs for the England Hip Fracture Study Group. N EngI J Med elderly. Nurs Res 2002;51:l—8. 1991;324:1326—1331. 23. Cumming RG. Intervention strategies and risk- 38. Tinetti ME, Speechley M, Ginter SF. Risk factors factor modification for falls prevention: A review of for falls among elderly persons living in the recent intervention studies. Clin Geriatr Med community. N Engl J Med 1988;319:1701—1707. 2002,18:175—189. 39. Liberman UA, Weiss SR, Broil J, et al. Effect of 24. Lauritzen JB, Petersen MM, Lund B. Effect of oral alendronate on bone mineral density and the external hip protectors on hip fractures. Lancet incidence of fractures in post-menopausal 1993;341 :11—13. osteoporosis. N EngI J Med 1995;333:1437—1443. 25. Ekman A, Mallmin H, Michaelsson K, et al. 40. vanSchoor N, Smit J, Twisk J, et al. Prevention of External hip protectors prevent osteoporotic hip hip fractures by external hip protectors: A randomized fractures. Lancet 1997;350:563—564. controlled trial. JAMA 2003;289: 1957—1962. 26. Harada A, Mizuno M, Takemura M. Hip fracture 41. Parkkari MJ, Heikkila J, Kannus P. Acceptability prevention trial using hip protectors in Japanese and compliance with wearing energy shunting hip nursing homes. Osteoporosis Int 2001;12:215-221. protectors: A 6-month prospective follow-up in a Finnish nursing home. Age Ageing 1998;27:225— 27. Chan DK, Hellier G, Coore M, et al. Effectiveness and acceptability of a newly designed hip protector: A pilot study. Arch Gerontol Geriatr Suppl 42. French F, Torgerson D, Porter R. Cost analysis of 2000;30:25—34. fracture of the neck of the femur. Age Ageing 1995;24:185—189. 28. Kannus P Patkkari MJ, Niemi 5, et al. Prevention of hip fracture in elderly people with use of a hip protector. N EngI J Med 2000;343: 1506— 15 13. 29. Maki-Jokela P, Valvanne J, Jantti P, et al. Experiences with external hip protectors in homes for the aged: A report from Finland. Journal of the American Medical Directors Association 2002;3:29—31. Reprinted from Journal of the American Medical Directors Association September/October 2003


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