The value of an organized fracture program for the elderly: early results

Hip fracture programs: are they effective?

This manuscript will evaluate the published evidence on efficacy of organized hip fracture programs to determine if they improve patient outcomes. A detailed literature search was conducted to find manuscripts published in the past 20 years about organized hip fracture care programs. Seventeen programs with published results were identified from this detailed search and these were evaluated and synthesized in the following manuscript. Organized hip fracture programs offer significant benefits to patients, care providers and health systems. The more complex program designs have a more profound effect on improvement in outcomes for hip fracture patients. Most programs have reported reduced length of stay, reduced in-hospital mortality rates, and reduced complications. Some programs have reported reduced costs and reduced readmission rates after implementing an organized hip fracture program.

[Geriatric fracture centers. Improved patient care and economic benefits]

The world's population is aging resulting in changes in the way we manage geriatric care. Furthermore, this population has a considerable risk of fragility fractures, most notably hip fractures. Hip fractures are associated with significant morbidity and mortality and have large economic consequences. It is due to these factors that the concept of an elderly trauma center was developed. These trauma centers utilize the expertise in orthopedic and geriatric disciplines to provide coordinated care to the elderly hip fracture patient. As a result, studies have demonstrated improvements in clinical outcomes within the hospital stay, a reduction in iatrogenic complications, and improvements in 1-year mortality rates compared to the usual care given at a similar facility. Furthermore, economic models have demonstrated that there is a role for regionalized hip fracture centers that can be both profitable and provide more efficient care to these patients.

Effect of Preoperative Transthoracic Echocardiogram on Mortality and Surgical Timing in Elderly Adults with Hip Fracture

OBJECTIVES

To evaluate the effect of preoperative transthoracic echocardiogram (TTE) on mortality, postoperative complications, surgical timing, and length of stay in individuals with surgically treated hip fracture.

DESIGN

Retrospective chart review of hospital records.

SETTING

Level I and II trauma centers.

PARTICIPANTS

Individuals consecutively surgically treated for hip fracture (N = 694).

MEASUREMENTS

Demographic and injury characteristic, operative timing, preoperative echocardiogram, complications, mortality. Primary outcome measure was in hospital, 30-day, and 1-year mortality. Secondary outcome measures were complications (particularly cardiovascular) and time required for medical clearance and operative treatment.

RESULTS

Preoperative TTE was performed on 131 individuals (18.9%). There was no difference between the TTE group and the control group in hospital (3.8% vs 1.8%, P = .18), 30-day (6.9% vs 6.6%, P = .90), or 1-year (20.6% versus 20.1%, P = .89) mortality. There was no significant difference in major cardiac complications. Average time from admission to operative treatment was 66.5 hours in the TTE group and 34.8 hours in the control group (P < .001). Average time from admission to medical clearance was 43.2 hours in the TTE group and 12.4 hours in the control group (P < .001). The TTE group also had a significantly longer length of stay (8.68 vs 6.44 days, P < .001).

CONCLUSION

Preoperative TTE was not associated with lower mortality in elderly adults with hip fracture in the short- or long-term postoperative period. TTE was associated with delayed surgical treatment and longer length of stay and resulted in no cardiac intervention (e.g., cardiac catheterization, stent, stress test).

Operative Mortality After Arthroplasty for Femoral Neck Fracture and Hospital Volume

Background:

The purpose of the present study is to use a statewide, population-based data set to identify mortality rates at 30-day and 1-year postoperatively following total hip arthroplasty (THA) and hemiarthroplasty (HA) for displaced femoral neck fractures. The secondary aim of the study is to determine whether arthroplasty volume confers a protective effect on the mortality rate following femoral neck fracture treatment.

Methods:

New York’s Statewide Planning and Research Cooperative System was used to identify 45 749 patients older than 60 years of age with a discharge diagnosis of femoral neck fracture undergoing THA or HA from 2000 through 2010. Comorbidities were identified using the Charlson comorbidity index. Mortality risk was modeled using Cox proportional hazards models while controlling for demographic and comorbid characteristics. High-volume THA centers were defined as those in the top quartile of arthroplasty volume, while low-volume centers were defined as the bottom quartile.

Results:

Patients undergoing THA for femoral neck fracture rather than HA were younger (79 vs 83 years, P < .001), more likely to have rheumatoid disease, and less likely to have heart disease, dementia, cancer, or diabetes (all P < .05). Thirty-day mortality after HA was higher (8.4% vs 5.7%; P < .001) as was 1-year mortality (25.9% vs 17.8%; P < .001). After controlling for age, gender, ethnicity, and comorbidities, risk of mortality following THA was 21% lower (hazard ratio [HR] 0.79; P = .003) at 30 days and 22% lower (HR 0.78; P < .001) at 1 year than HA. Patients undergoing THA at high-volume arthroplasty centers had improved 1-year mortality when compared to those undergoing THA at low-volume hospitals (HR 0.55; P = .008).

Conclusions:

Based on this large, population-based study, there is no basis to assume THA carries a greater mortality risk after hip fracture than does standard HA, even when accounting for institutional volume of hip arthroplasty.

[Proximal femoral fractures in the elderly]

Proximal femoral fractures represent an increasing major healthcare problem due to the demographic changes in this aging population and are associated with the highest mortality among fractures in elderly patients after suffering insufficiency injuries (so-called fragility fractures). The main aim in the treatment of orthogeriatric patients who suffered from a proximal femoral fracture is the preservation of function and independency. Given the high prevalence of comorbidities in these patients, interdisciplinary and interprofessional approaches are required. The use of modern osteosynthesis procedures can provide an improved, individualized surgical treatment with early full weight bearing of the affected extremity. Another aspect is the accompanying geriatric treatment which is associated with a significant reduction of perioperative and postoperative complications. In addition to acute treatment, the organization of secondary fracture prevention is a crucial pillar of treatment. This article provides an overview of the essential elements of orthogeriatric trauma surgery in elderly patients following proximal femoral fractures.

Redefining the Economics of Geriatric Orthopedics

Introduction:

The heath care system in the United States is in the midst of a transition, in large part to help accommodate an older and more medically complex population. Central to the current evolution is the reassessment of value based on the cost utility of a particular procedure compared to alternatives. The existing contribution of geriatric orthopedics to the societal burden of disease is substantial, and literature focusing on the economic value of treating elderly populations with musculoskeletal injuries is growing.

Materials and Methods:

A literature review of peer-reviewed publications and abstracts related to the cost-effectiveness of treating geriatric patients with orthopedic injuries was carried out.

Results:

In our review, we demonstrate that while cost-utility studies generally demonstrate net society savings for most orthopedic procedures, geriatric populations often contribute to negative net society savings due to decreased working years and lower salaries while in the workforce. However, the incremental cost-effective ratio for operative intervention has been shown to be below the financial willingness to treat threshold for common procedures including joint replacement surgery of the knee (ICER US$8551), hip (ICER US$17 115), and shoulder (CE US$957) as well as for spinal procedures and repair of torn rotator cuffs (ICER US$12 024). We also discuss the current trends directed toward improving institutional value and highlight important complementary next steps to help overcome the growing demands of an older, more active society.

Conclusion:

The geriatric population places a significant burden on the health care system. However, studies have shown that treating this demographic for orthopedic-related injuries is cost effective and profitable for providers under certain scenarios.

Geriatric Patients With Fractures Below the Hip are Medically Similar to Geriatric Patients With Hip Fracture

The objective of this study was to compare a cohort of geriatric patients with operatively managed isolated fractures below the hip to a cohort of geriatric patients with operatively managed isolated hip fractures. All patients greater than 59 years of age admitted to our institution for surgical care of an isolated lower extremity fracture during a 3-year period were included. Patients were divided into 2 cohorts: BTH (fracture below the subtrochanteric region of the femur) and HIP (proximal femoral fracture at subtrochanteric region or proximal). We identified 141 patients included in cohort BTH and 205 patients included in cohort HIP. HIP patients were older (P < .01) and less obese (P < .01) but were otherwise very similar. An extensive comorbidity review revealed that the 2 cohorts were similar, with the exception of an increased incidence of dementia (P = .012) or glaucoma (P = .04) in HIP patients and of peripheral neuropathy (P = .014) in BTH patients. HIP patients were more likely to be under active antiosteoporotic medication management and were more likely to be receiving pharmacological anticoagulation at the time of admission. HIP patients and BTH patients were similar with regard to necessity of assistance with ambulation preinjury, but HIP patients were less likely to reside independently at home than were BTH patients (P < .001). HIP patients were also less likely to be discharged directly home from the hospital (P < .001). Geriatric patients with fractures below the hip are medically similar to geriatric patients with hip fracture. Medical comanagement protocols have been extensively published that improve care of geriatric patients with hip fracture; consideration should be given to similar protocol-driven medical comanagement programs for geriatric patients with fractures below the hip.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

A growing problem: acetabular fractures in the elderly and the combined hip procedure

Acetabular fractures in the elderly are most frequently the result of low-energy trauma and present unique management challenges to orthopedic surgeons. Evaluation and treatment should be performed in a multidisciplinary fashion with early involvement of internal medicine subspecialists and geriatricians. Distinct fracture patterns and pre-existing osteoarthritis and osteoporosis necessitate careful preoperative planning. The role of total hip arthroplasty should also be considered when surgical treatment is indicated. The outcomes of acetabular fractures in the elderly have improved, but complications remain higher and results less satisfactory than in younger individuals. The lack of randomized controlled trials has limited the ability to establish an evidence-based treatment algorithm.

Fragility fracture programs: are they effective and what is the surgeon's role?

Fragility fractures are occurring at an ever-increasing rate, creating an enormous economic and societal impact. Outpatient-based fragility fracture programs have been developed to identify at-risk patients, initiate effective treatment of metabolic bone disease, and improve coordination between members of the patient's care team with the goal of reducing future fractures. Inpatient programs focus on effective, efficient management of patients presenting with acute fractures. Both have proven successful in reducing the impact of fragility fractures, but many challenges exist. The orthopedic surgeon, as part of an integrated team of providers, is integral in identifying at-risk patients, ensuring appropriate care of acute fractures, and initiating treatment protocols to reduce the risk of further injuries.

A new future for hip fracture care--orthogeriatrician lead in an 'Acute' Hip Unit

Although surgery is the definitive treatment for almost all hip fractures, there is evidence that outcomes such as morbidity and mortality are not determined by the type of surgery but by comorbidities and postoperative complications. A team approach, especially the involvement of an orthogeriatrician in managing medical issues, has been shown to improve surgical outcomes and should be encouraged in hospitals worldwide. An Acute Hip Unit is able to address the complex challenging needs of a frail older high-risk population soon after admission, therefore minimising delays. An orthogeriatrician-led unit can deal with the preoperative and complex postoperative medical, social, ethical, physical, and mental health issues that are associated with 'hip fracture syndrome', providing structured standardised evidence-based care by trained staff. This could be the model of care for the future.

Management in high-risk patients

Injuries to the foot and ankle are often missed or underestimated in patients with polytrauma and are a source of long-term limitations. Injures below the knee are among the highest causes for unemployment, longer sick leave, more pain, more follow-up appointments, and decreased overall outcome. As mortalities decrease for patients with polytrauma a greater emphasis on timely diagnosis and treatment of foot and ankle injuries is indicated. Geriatric patients represent nearly one-quarter of trauma admissions in the United States. This article discusses perioperative management and complications associated with foot and ankle injuries in polytrauma, and in diabetic and geriatric patients.

Geriatric syndromes predict postdischarge outcomes among older emergency department patients: findings from the interRAI Multinational Emergency Department Study

OBJECTIVES

Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context.

METHODS

A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression.

RESULTS

A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved.

CONCLUSIONS

Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

Principles of comanagement and the geriatric fracture center

This article describes the principles of comanagement in an optimized geriatric fracture center. This is a collaborative model of care that uses patient-centered, protocol-driven care to standardize the care for most patient fragility fractures. This model also uses shared decision making and frequent communication to improve clinically relevant outcomes. The orthopedic and medical teams are equally responsible from admission to discharge and are responsible for daily evaluation and clinical management of the patient.

Literature review of outcome parameters used in studies of Geriatric Fracture Centers

INTRODUCTION

A variety of multidisciplinary treatment models have been described to improve outcome after osteoporotic hip fractures. There is a tendency toward better outcomes after implementation of the most sophisticated model with a shared leadership for orthopedic surgeons and geriatricians; the Geriatric Fracture Center. The purpose of this review is to evaluate the use of outcome parameters in published literature on the Geriatric Fracture Center evaluation studies.

MATERIALS AND METHODS

A literature search was performed using Medline and the Cochrane Library to identify Geriatric Fracture Center evaluation studies. The outcome parameters used in the included studies were evaluated.

RESULTS

A total of 16 outcome parameters were used in 11 studies to evaluate patient outcome in 8 different Geriatric Fracture Centers. Two of these outcome parameters are patient-reported outcome measures and 14 outcome parameters were objective measures.

CONCLUSION

In-hospital mortality, length of stay, time to surgery, place of residence and complication rate are the most frequently used outcome parameters. The patient-reported outcomes included activities of daily living and mobility scores. There is a need for generally agreed upon outcome measures to facilitate comparison of different care models.

Economic viability of geriatric hip fracture centers

Management of geriatric hip fractures in a protocol-driven center can improve outcomes and reduce costs. Nonetheless, this approach has not spread as broadly as the effectiveness data would imply. One possible explanation is that operating such a center is not perceived as financially worthwhile. To assess the economic viability of dedicated hip fracture centers, the authors built a financial model to estimate profit as a function of costs, reimbursement, and patient volume in 3 settings: an average US hip fracture program, a highly efficient center, and an academic hospital without a specific hip fracture program. Results were tested with sensitivity analysis. A local market analysis was conducted to assess the feasibility of supporting profitable hip fracture centers. The results demonstrate that hip fracture treatment only becomes profitable when the annual caseload exceeds approximately 72, assuming costs characteristic of a typical US hip fracture program. The threshold of profitability is 49 cases per year for high-efficiency hip fracture centers and 151 for the urban academic hospital under review. The largest determinant of profit is reimbursement, followed by costs and volume. In the authors’ home market, 168 hospitals offer hip fracture care, yet 85% fall below the 72-case threshold. Hip fracture centers can be highly profitable through low costs and, especially, high revenues. However, most hospitals likely lose money by offering hip fracture care due to inadequate volume. Thus, both large and small facilities would benefit financially from the consolidation of hip fracture care at dedicated hip fracture centers. Typical US cities have adequate volume to support several such centers.

Measures of clinical outcome before, during, and after implementation of a comprehensive geriatric hip fracture program: is there a learning curve?

OBJECTIVES

To evaluate the effects of implementing a multidisciplinary geriatric hip fracture program on clinical outcome measures at our institution.

DESIGN

Retrospective comparative cohort study of consecutive patients treated before, during, and after implementation of this program, including patient data from electronic medical records and state death records.

SETTING

Single metropolitan level 2 regional trauma center and community hospital.

PATIENTS/PARTICIPANTS

Patients aged 60 years and older with operatively treated low-energy hip fractures were included. Patients with active cancer or a high-energy mechanism (motor vehicle crash or fall >3 ft) were excluded.

INTERVENTION

Patients were divided into 1 of 3 groups: (1) those treated before our hip fracture program (July 2008-April 2009), (2) during implementation of the hip fracture program (May 2009-Feb 2010), and (3) after the hip fracture program was instituted and participation was well established (March 2010-Dec 2010).

MAIN OUTCOME MEASURES

Patient demographics, injury factors, and clinical outcomes, including performance measures (eg, time to medical clearance and surgery and length of stay) and patient deaths (in-hospital, 30 days, and 1 year), were compared.

RESULTS

There was significant improvement in clinical performance measures, including time to surgery and length of stay during and after implementation of our geriatric hip fracture program. The in-hospital mortality rate increased during the implementation phase of this program (P = 0.04). Once established, however, the in-hospital mortality decreased to a more typical level. Thirty-day and 1-year mortality rates were not significantly different among the 3 groups.

CONCLUSIONS

Most clinical outcome measures improved significantly with implementation of our geriatric hip fracture program. Increased in-hospital mortality, however, was an unintended consequence seen while establishing this program and may represent a learning curve by health care providers. Patient demise in the longer term seemed to be unaffected by implementation of the program.

LEVEL OF EVIDENCE

Therapeutic level III.

[Procedural organisation: surgical and anaesthesiological management in hip fractures]

In patients with hip fractures, in order to reduce the high number of general complications and those associated with the specific treatment, the functional loss and cognitive impairment, implementation of co-ordinated, multidisciplinary treatment pathways, and rehabilitation, is mandatory. The imminent treatment of proximal femoral fracture consists of major orthopaedic surgery in most cases (total or partial hip arthroplasty, osteosynthesis). After the diagnosis of a hip fracture, an adequate pain medication should be initiated. The decision making for the fracture treatment includes fracture type, patient's age, cognitive function, mobility before the fall and functional demands of the patient in the context of patients life expectancy and goals of care. The anaesthesiological evaluation focuses on risk assessment. Medical abnormalities should be optimized within 24 to 48 h, or an increased perioperative risk due to comorbidities has to be accepted. The timing and the course of further preoperative diagnostic examinations and therapeutic interventions should be co-ordinated between the involved medical disciplines. After the operation a structured screening for delirium should be initiated and further evaluation of patient's nutrition, fall-associated medication, living conditions and osteoporosis treatment has to be performed.

Implementation of a co-managed Geriatric Fracture Center reduces hospital stay and time-to-operation in elderly femoral neck fracture patients

PURPOSE

To evaluate changes in hospital length-of-stay and time-to-operation of older hip fracture patients before and after the foundation of a co-managed Geriatric Fracture Center (GFC).

METHODS

A co-managed GFC was established in a German level-1 trauma center. In a retrospective cohort study, we analyzed femoral neck fracture patients >60 years treated with hemiarthroplasty. Patients treated within the first year after foundation of the GFC were compared to the patients treated during the year before. One-way ANOVA was performed to identify differences regarding time-to-operation and hospital length-of-stay.

RESULTS

One hundred and fourteen patients of the GFC were compared to 169 patients previously treated without co-management. Mean patient age did not significantly differ (81.9 vs. 81.5 years; p = 0.7), nor did gender distribution. Hospital length-of-stay was significantly shorter after foundation of the GFC (13.9 vs. 16.8 days; p = 0.007). The same is true for the interval between hospital admission and operation, which decreased from 3.1 to 2.1 days (p = 0.029). Early surgical complication rate was not significantly affected by GFC foundation (7.7 % pre-GFC vs. 9.6 % GFC; p = 0.6), nor was inpatient mortality (5.9 % pre-GFC vs. 4.4 % GFC; p = 0.6). Subgroup analysis revealed that GFC patients without early surgical complications displayed a reduced length-of-stay (LOS), whereas LOS was even prolonged in GFC patients with surgical complications.

CONCLUSIONS

A co-managed GFC offering an organized fracture program for the elderly can reduce hospital length-of-stay and time-to-operation in hip fracture patients. A significant effect can be observed within the first year after establishment of a GFC.

Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures

BACKGROUND AND PURPOSE

Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Different models of orthogeriatric co-management are currently in use worldwide. These models differ for instance by the health-care professional who has the responsibility for care in the acute and early rehabilitation phases. There is no international consensus regarding the best model of care and which outcome parameters should be used to evaluate these models. The goal of this project was to identify which outcome parameters and assessment tools should be used to measure and compare outcome changes that can be made by the implementation of orthogeriatric co-management models and to develop recommendations about how and when these outcome parameters should be measured. It was not the purpose of this study to describe items that might have an impact on the outcome but cannot be influenced such as age, co-morbidities and cognitive impairment at admission.

METHODS

Based on a review of the literature on existing orthogeriatric co-management evaluation studies, 14 outcome parameters were evaluated and discussed in a 2-day meeting with panellists. These panellists were selected based on research and/or clinical expertise in hip fracture management and a common interest in measuring outcome in hip fracture care.

RESULTS

We defined 12 objective and subjective outcome parameters and how they should be measured: mortality, length of stay, time to surgery, complications, re-admission rate, mobility, quality of life, pain, activities of daily living, medication use, place of residence and costs. We could not recommend an appropriate tool to measure patients' satisfaction and falls. We defined the time points at which these outcome parameters should be collected to be at admission and discharge, 30 days, 90 days and 1 year after admission.

CONCLUSION

Twelve objective and patient-reported outcome parameters were selected to form a standard set for the measurement of influenceable outcome of patients treated in different models of orthogeriatric co-managed care.

The usefulness of lean six sigma to the development of a clinical pathway for hip fractures

AIMS AND OBJECTIVES

The objective of this study was to show the usefulness of lean six sigma (LSS) for the development of a multidisciplinary clinical pathway.

METHODS

A single centre, both retrospective and prospective, non-randomized controlled study design was used to identify the variables of a prolonged length of stay (LOS) for hip fractures in the elderly and to measure the effect of the process improvements--with the aim of improving efficiency of care and reducing the LOS.

RESULTS

The project identified several variables influencing LOS, and interventions were designed to improve the process of care. Significant results were achieved by reducing both the average LOS by 4.2 days (-31%) and the average duration of surgery by 57 minutes (-36%). The average LOS of patients discharged to a nursing home reduced by 4.4 days.

CONCLUSION

The findings of this study show a successful application of LSS methodology within the development of a clinical pathway. Further research is needed to explore the effect of the use of LSS methodology at clinical outcome and quality of life.

Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study

The objective of this 3-year retrospective, controlled, cohort study is to characterize an interdisciplinary method of managing geriatric patients with hip fracture. All patients aged 65 years or older admitted to a single academic level I trauma center during a 3-year period with an isolated hip fracture were included as participants for this study. Thirty-one geriatric patients with hip fracture were treated with historical methods of care (cohort 1). The comparison group of 115 similar patients was treated under a newly developed, institutional comanagement hip fracture protocol (cohort 2). There were no differences in age, sex distribution, or comorbidity distribution between the 2 cohorts. Patients requiring intensive care unit (ICU) admission decreased significantly from 48% in cohort 1 to 23% in cohort 2 (P = .0091). Length of ICU stay for patients requiring ICU admission also decreased significantly, from a mean of 8.1 days in cohort 1 to 1.8 days in cohort 2 (P = .024). Total hospital stay decreased significantly, from a mean of 9.9 days in cohort 1 to 7.1 days in cohort 2 (P = .021). Although no decrease in in-hospital mortality rates was noted from cohort 1 to cohort 2, a trend toward decreased 1-year mortality rates was seen after implementation of the hip fracture protocol. Hospital charges decreased significantly, from US$52 323 per patient in cohort 1 to US$38 586 in cohort 2 (P = .0183). Implementation of a comanagement protocol for care of geriatric patients with hip fracture, consisting of admission to a geriatric primary care service, standardized perioperative assessment regimens, expeditious surgical treatment, and continued primary geriatric care postoperatively, resulted in reductions in lengths of stay, ICU admissions, and hospital costs per patient. On an annualized basis, this represented a savings of over US$700 000 for our institution.

Why veteran orthopaedic trauma surgeons are being fired and what we can do about it?

The financial realities of providing trauma care to injured patients can make it difficult to produce an accurate assessment of the cumulative value orthopaedic trauma surgeons provide to healthcare and university institutions. As with many political battles in the field of medicine, physicians who have been diligently focused on providing patient care were completely unaware of the impending upheaval around them. Whether orthopaedic trauma surgeons are employed or in some type of partnership with hospitals, too often surgeons find the relationship one-sided. In order to effectively negotiate with hospitals, surgeons must demonstrate the comprehensive value they provide to their respective healthcare institutions and universities. Orthopaedic trauma surgeons make direct and indirect financial contributions to the hospital in addition to educational and community services. The sum total of these valued contributions helps fund non-revenue generating programs, provides marketing opportunities, and improves the regional and national reputation of the healthcare institution. This paper provides a comprehensive review of the value contributed to healthcare institutions by orthopaedic trauma surgeons and will serve as a blueprint for all surgeons to accurately account for and demonstrate their value to hospitals while providing efficient and compassionate care to our patients.

Geriatric fracture center: a multidisciplinary treatment approach for older patients with a hip fracture improved quality of clinical care and short-term treatment outcomes

OBJECTIVE

Since April 1, 2008, patients aged ≥65 years presenting with a hip fracture at Ziekenhuisgroep Twente, Almelo (ZGT-A), The Netherlands, have been admitted to the geriatric fracture center (GFC) and treated according to the multidisciplinary treatment approach. The objective of this study was to evaluate how implementation of the treatment approach has influenced the quality of care given to older patients with hip fracture.

DESIGN

Prospective cohort study with historical control group.

METHOD

Two groups of patients with hip fracture were compared, 1 group was treated according to the new multidisciplinary treatment approach in 2009-2010, and the other group received the usual treatment in 2007-2008. The number of readmissions within 30 days after discharge was compared, and an analysis was carried out regarding the number of complications, the number of consultations with various specialists and with the geriatrician, and the duration of hospital stay.

RESULTS

In all, 140 patients from 2009 to 2010 group and 90 patients from 2007 to 2008 group were included. In 2009-2010 group, the number of readmissions within 30 days dropped by 11 percentage points (P = .001). The incidence of the number of complications decreased with a median of 1 compared with 2007-2008 (P = .017) group. Delirium was diagnosed to be 6 percentage points more frequent. The median number of consultations with various specialists per patient decreased by 1 percentage point as a result of geriatrician cotreatment (P = .002). The median duration of hospital stay was 1 day shorter than that in 2007-2008 group.

CONCLUSION

The use of the multidisciplinary treatment approach led to a significant reduction in the number of readmissions within 30 days after discharge. It appears to be associated with improved short-term treatment outcomes for older patients with a hip fracture.

Comparison of an organized geriatric fracture program to United States government data

OBJECTIVE

This study describes the financial impact of an organized hip fracture program for elderly patients age 65 years and older.

METHODS

This is a retrospective study of 797 fractures in 776 consecutive patients over a 50-month period (May 2005 to July 2009) treated in an organized hip fracture program for the elderly identified from a quality management database. Financial, demographic, and quality-of-care data were collected. The length of hospital stay, in-hospital complications, and Charlson comorbidity scores were collected from patient records, and all data were evaluated using standard statistical methods.

SETTING

261-bed community-based, university-affiliated teaching hospital in an urban setting with a catchment area of approximately 1 million persons. This is a level 3 trauma center.

RESULTS

The average total net revenue per hip fracture was $12 159, with an average total cost to hospital of $8264. Physicians' fees consisted of fees collected by surgeons, anesthesiologists, medical specialty consultants, and consulting geriatricians and averaged $2024 per case. Thus, the average hospital charge to payers was $15 188. Compared to Agency for Healthcare Research and Quality average inpatient hospital costs in 2005 of $33 693, a savings of more than $18 000 was realized per patient. The average length of stay was 4.6 days, markedly less than the national average of 6.2 days.

CONCLUSIONS

This organized geriatric fracture care model with geriatrics comanagement resulted in significant cost savings over a 50-month period, with associated increased quality. With an estimated 330 000 hip fractures annually in the United States, a large cost savings could potentially be realized if this model were more widely applied.

Management of high-energy acetabular fractures in the elderly individuals: a current review

Acetabular fractures in the elderly individuals are increasing in prevalence. Although there is evidence in the literature that acetabular fractures in elderly patients sustained as a result of low-energy mechanisms can be well treated by nonoperative management, open reduction and internal fixation, or even acute arthroplasty, almost no literature exists that may appropriately guide the treatment of elderly acetabular fractures that occur as a result of high-energy mechanisms. In spite of this lack of evidence, specific principles for providing the best care in adult trauma patients may reasonably be adopted. These principles include aggressive resuscitation and medical optimization; surgical care that focuses on a patient's survival but does not sacrifice skeletal stability; and early mobilization. Best practices that guide the care of hip fracture patients, such as a team approach to care, the use of protocols to guide treatment, and the timing of surgery to occur as soon as is safely possible also should be employed to guide care in patients who have sustained acetabular fractures. Opportunity exists to better study these higher energy fractures and to, thereby, affect outcomes in patients who have sustained them.

Barriers to implementation of an organized geriatric fracture program

INTRODUCTION

There has been a recent increase in interest in implementing organized geriatric fracture programs for care of older adults with fragility fractures in order to improve both the quality and costs of care. Because such programs are relatively new, there are no standardized methods for implementation and no published descriptions of barriers to implementation.

MATERIALS AND METHODS

An online survey tool was sent to 185 surgeons and physicians practicing in the United States, who are involved with geriatric fracture care. Sixty-eight responses were received and evaluated.

RESULTS

Barriers identified included lack of medical and surgical leadership, need for a clinical case manager, lack of anesthesia department support, lack of hospital administration support, operating room time availability, and difficulty with cardiac clearance for surgery. Other issues important to implementation included quality improvement, cost reductions, cost to the hospital, infection prevention, readmission prevention, and dealing with competing interest groups and competing projects mandated by the government. Physicians and surgeons felt that a site visit to a functioning program was most important when considering implementing a hip fracture program.

CONCLUSIONS

This study provides useful insights into barriers to implementing an organized hip fracture program. The authors offer suggestions on ways to mitigate or overcome these barriers.

Hip fracture protocols: what have we changed?

Early surgical intervention is thought to reduce in-hospital morbidity and mortality as well as short-term mortality rates for elderly patients with hip fractures. However, hip fractures are also thought to be a symptom of progressive decline in elderly patients with multiple medical comorbidities. A measured approach to medical optimization, which may preclude rapid surgical intervention, is often required to improve the patient's ability to resume a prefracture standard of living. Of late, new models of geriatric hip-fracture care have emerged, most of which entail early involvement of geriatricians and interdisciplinary care pathways, while continuing to focus on rapid surgical treatment.

Volume-outcome relationship in neurotrauma care

Object

A positive correlation between outcomes and the volume of patients seen by a provider has been supported by numerous studies. Volume-outcome relationships (VORs) have been well documented in the setting of both neurosurgery and trauma care and have shaped regionalization policies to optimize patient outcomes. Several authors have also investigated the correlation between patient volume and cost of care, known as the volume-cost relationship (VCR), with mixed results. The purpose of the present study was to investigate VORs and VCRs in the treatment of common intracranial injuries by testing the hypotheses that outcomes suffer at small-volume centers and costs rise at large-volume centers.

Methods

The authors performed a cross-sectional cohort study of patients with neurological trauma using the 2006 Nationwide Inpatient Sample, the largest nationally representative all-payer data set. Patients were identified using ICD-9 codes for subdural, subarachnoid, and extradural hemorrhage following injury. Transfers were excluded from the study. In the primary analysis the association between a facility's neurotrauma patient volume and patient survival was tested. Secondary analyses focused on the relationships between patient volume and discharge status as well as between patient volume and cost. Analyses were performed using logistic regression.

Results

In-hospital mortality in the overall cohort was 9.9%. In-hospital mortality was 14.9% in the group with the smallest volume of patients, that is, fewer than 6 cases annually. At facilities treating 6–11, 12–23, 24–59, and 60+ patients annually, mortality was 8.0%, 8.3%, 9.5%, and 10.0%, respectively. For these groups there was a significantly reduced risk of in-hospital mortality as compared with the group with fewer than 6 annual patients; the adjusted ORs (and corresponding 95% CIs) were 0.45 (0.29–0.68), 0.56 (0.38–0.81), 0.63 (0.44–0.90), and 0.59 (0.41–0.87), respectively. For these same groups (once again using < 6 cases/year as the reference), there were no statistically significant differences in either estimated actual cost or duration of hospital stay.

Conclusions

A VOR exists in the treatment of neurotrauma, and a meaningful threshold for significantly improved mortality is 6 cases per year. Emergency and interfacility transport policies based on this threshold might improve national outcomes. Cost of care does not differ significantly with patient volume.

High-energy skeletal trauma in the elderly

Despite the increasing prevalence of high-energy skeletal trauma in the elderly (i.e., sixty years or older), there is a lack of prospective data regarding best care for these injuries.Elderly patients with multiple injuries are often undertriaged to trauma centers and underresuscitated.Aggressive early resuscitation can improve outcomes in elderly patients who have sustained skeletal trauma.Comanagement by orthopaedic surgeons and geriatricians of elderly patients with skeletal trauma can lead to a lower length of hospital stay, lower readmission rates, shorter time to operation, lower complication rates, and lower mortality.

Co-managed care: the gold standard for geriatric fracture care

With a worldwide aging population, the incidence and consequences of geriatric fractures are assuming an increasing importance to health care providers and institutions. Studies have shown that optimal efficient management ensures the best outcome for the patient, at the least cost to the institution. A review of the recent literature was performed to establish the current best evidence ie, gold standard, for geriatric fracture care. Given the complexities of the subject, randomized controlled trials are difficult and confounded by the multiple medical issues of the population being studied. RCT's are best suited to study individual questions, rather than systems of care. Hence, the importance of peer-reviewed models of care, as well as prospective population registries is established in defining what the gold standard of care should be for this vulnerable population.

Regional anesthesia as compared with general anesthesia for surgery in geriatric patients with hip fracture: does it decrease morbidity, mortality, and health care costs? Results of a single-centered study

INTRODUCTION

Hip fracture in geriatric patients has a substantial economic impact and represents a major cause of morbidity and mortality in this population. At our institution, a regional anesthesia program was instituted for patients undergoing surgery for hip fracture. This retrospective cohort review examines the effects of regional anesthesia (from mainly after July 2007) vs general anesthesia (mainly prior to July 2007) on morbidity, mortality and hospitalization costs.

METHODS

This retrospective cohort study involved data collection from electronic and paper charts of 308 patients who underwent surgery for hip fracture from September 2006 to December 2008. Data on postoperative morbidity, in-patient mortality, and cost of hospitalization (as estimated from data on hospital charges) were collected and analyzed. Seventy-three patients received regional anesthesia and 235 patients received general anesthesia. During July 2007, approximately halfway through the study period, a regional anesthesia and analgesia program was introduced.

RESULTS

The average cost of hospitalization in patients who received surgery for hip fracture was no different between patients who receive regional or general anesthesia ($16,789 + 631 vs $16,815 + 643, respectively, P = 0.9557). Delay in surgery and intensive care unit (ICU) admission resulted in significantly higher hospitalization costs. Age, male gender, African American race and ICU admission were associated with increased in-hospital mortality. In-hospital mortality and rates of readmission are not statistically different between the two anesthesia groups.

CONCLUSIONS

There is no difference in postoperative morbidity, rates of rehospitalization, in-patient mortality or hospitalization costs in geriatric patients undergoing regional or general anesthesia for repair of hip fracture. Delay in surgery beyond 3 days and ICU admission both increase cost of hospitalization.

Outcome of the dynamic helical hip screw system for intertrochanteric hip fractures in the elderly patients

INTRODUCTION

The dynamic helical hip system (DHHS; Synthes, Paoli, Pennsylvania) differs from the standard dynamic sliding hip screw (SHS) in that in preparing for its insertion, reaming of the femoral head is not performed, thereby preserving bone stock. It also requires less torque for insertion of the helical screw. The associated plate has locking options to allow locking screw fixation in the femoral shaft, thereby decreasing the chance of the plate pulling off. While biomechanical studies have shown improved resistance to cutout and increased rotational stability of the femoral head fragment when compared with traditional hip lag screws, there is limited information on clinical outcome of the implant available in the literature.

METHODS

We report a single surgeon series of 87 patients who were treated for their per-trochanteric hip fractures with this implant to evaluate their clinical outcome and compare it with a cohort of 344 patients who were treated with the standard SHS. All data were prospectively collected, most as part of a structured Geriatric Fracture Care Program.

RESULTS

The 2 groups were similar demographically, and medically, with similar rates of in-hospital complications and implant failure. Failure in the DHHS group was attributable to use of the implant outside its indications and repeated fall of the patient.

CONCLUSION

This limited case series showed that the DHHS outcomes are comparable with that of the SHS. Whether there is any benefit to its use will require larger, prospective randomized controlled trials.

The 1-year mortality of patients treated in a hip fracture program for elders

Comanagement of geriatric hip fracture patients with standardized protocols has been shown to improve short-term outcomes after surgery. A standardized, patient-centered, comanaged Hip Fracture Program for Elders is examined for 1-year mortality. Patients ≥60 years of age who were treated in the Hip Fracture Program for Elders were comanaged by orthopaedic surgeons and geriatricians. Data including age, place of origin, procedure, length of stay, 1-year mortality, Charlson score, and activities of daily living (ADLs) were retrospectively collected. A total of 758 patients ≥60 years of age with hip fractures between April 15, 2005, and March 1, 2009, were included. Their data were analyzed, and the Social Security Death Index and the hospital data system were searched for mortality data. Seventy-eight percent were female, with a mean age of 84.8 years. The mean Charlson score was 3. Fifty percent were admitted from an institutional setting. The overall 1-year mortality was 21.2%. Age (odds ratio [OR] = 1.03, 95% confidence interval [CI] = 1.00-1.05; P = .02), male gender (OR = 1.55, 95% CI = 1.01-2.36; P = .04), low Parker mobility score (OR = 2.94, 95% CI = 1.31-6.57; P = .01), and a Charlson score of 4 or greater (OR = 2.15, 95% CI = 1.30-3.55; P = .002) were predictive of 1-year mortality. ADL dependence was a borderline predictor, as was medium Parker mobility score. Prefracture residence and moderate comorbidity (Charlson score of 2-3) were not independently predictive of mortality at 1 year after adjusting for other characteristics. A comprehensive comanaged hip fracture program for elders not only improves the short-term outcomes but also demonstrates a low 1-year mortality rate, particularly in patients from nursing facilities.