Preventing New Injuries after Upper Extremity Fracture in Older Adults: Opportunities in Orthopaedics and Physical Therapy Referrals

Research Objectives: To understand the scope of fragility fracture and to develop tools for referral to evidence-based balance exercise and gait training for older adults after new upper extremity fracture.

Design: We conducted a cohort study. Health system data from 2015-2020 were used to estimate the baseline prevalence of UE fractures, frequency of PT referral, and subsequent fracture by one year.

Setting: Ambulatory care and orthopaedic clinics in one integrated health system.

Participants: The sample included 8,335 patients age>=65 with an UE fracture within the past 6 months.

Interventions: We developed a case finding algorithm and best practice alert (BPA) to identify patients with recent upper extremity fragility fracture within the electronic health record based on International Classification of Diseases (ICD-10), Common Procedural and Treatment (CPT), and imaging codes for UE fracture. The algorithm was piloted in 2 orthopaedic practices. Data was collected over a 20-month period to assess BPA accuracy. Semi-structured interviews with physicians (n=10) and PTs (n=10), and patient focus groups (n=32) are being conducted to understand barriers and facilitators to implementation.

Main Outcome Measures: The primary outcomes are the proportion of patients who 1) had a new upper extremity fracture, 2) are referred to PT for assessment and management of balance and gait disorders within 3 months of fracture, 3) had a subsequent fracture within 1 year, and 4) the accuracy of the BPA.

Results: Among 6,295 patients with UE fracture, 12% received a referral for physical therapy within 3 months, and 11.2% experienced a subsequent fracture. The BPA accuracy in identifying patients with new UE fracture was 22.7% among 2,040 patients.

Conclusions: Similar to national practice patterns, in our study of one large health system very few older adults with new UE fracture receive a referral for PT evaluation of balance and gait disorders, indicating a major opportunity for improvement in care and patient outcomes. The BPA identified patients with new UE fracture with a high false positive rate. Future work should refine the algorithm.

Author(s) Disclosures: None