Orthogeriatric care pathway: a prospective survey of impact on length of stay, mortality and institutionalisation

Implementing a Hospitalist Comanagement Service in Orthopaedic Surgery

➤ Hospitalist comanagement of patients undergoing orthopaedic surgery is a growing trend across the United States, yet its implementation in an academic tertiary care hospital can be complex and even contentious.➤ Hospitalist comanagement services lead to better identification of at-risk patients, optimization of patient care to prevent adverse events, and streamlining of the admission process, thereby enhancing the overall service efficiency.➤ A successful hospitalist comanagement service includes the identification of service stakeholders and leaders; frequent consensus meetings; a well-defined standardized framework, with goals, program metrics, and unified commands; and an occasional satisfaction assessment to update and improve the program.➤ In this article, we establish a step-by-step protocol for the implementation of a comanagement structure between orthopaedic and hospitalist services at a tertiary care center, outlining specific protocols and workflows for patient care and transfer procedures among various departments, particularly in emergency and postoperative situations.

Hospital episode-of-care costs for hip fractures: an activity-based costing analysis

Background

Despite the large impact of hip fracture care on hospital budgets, accurate episode-of-care costs (EOCC) calculations for this injury remains a challenge. The objective of this article was to assess EOCC for geriatric patients with hip fractures using an activity-based costing methodology and identify intraoperative, perioperative, and patient-specific factors associated with higher EOCC.

Material and Methods

This is a retrospective cohort study involving a total of 109 consecutive patients with hip fracture treated surgically at a Canadian level-1 trauma center from April 2018 to February 2019. Clinical and demographic data were extracted through the institution's centralized data warehouse. Data acquisition also included direct and indirect costs per episode of care, adverse events, and precise temporal data.

Results

The median total EOCC was $13,113 (interquartile range 6658), excluding physician fees. Out of the total cost, 75% was attributed to direct costs, which represented a median expenditure of $9941. The median indirect cost of the EOCC was $3322. Based on the multivariate analysis, patients not operated within the 48 hours guidelines had an increased length of stay by 5.7 days (P = 0.003), representing an increase in EOCC of close to 5000$. Higher American Society of Anesthesiology (ASA) scores were associated with elevated EOCC.

Conclusion

The cost of managing a patient with geriatric hip fracture from arrival in the emergency department to discharge from surgical ward represented $13,113. Main factors influencing the EOCC included adherence to the 48-hour benchmark surgical delay and ASA score. High-quality costing data are vital in assessing health care spending, conducting cost effectiveness analyses, and ultimately in guiding policy decisions.

Level of Evidence

Level III (3), retrospective cohort study.

Cost-effectiveness analysis of the Geriatric Fracture Center (GFC) concept: a prospective multicentre cohort study

INTRODUCTION

Geriatric Fracture Centers (GFCs) are dedicated treatment units where care is tailored towards elderly patients who have suffered fragility fractures. The primary objective of this economic analysis was to determine the cost-utility of GFCs compared with usual care centres.

METHODS

The primary analysis was a cost-utility analysis that measured the cost per incremental quality-adjusted life-year gained from treatment of hip fracture in GFCs compared with treatment in usual care centres from the societal perspective over a 1-year time horizon. The secondary analysis was a cost-utility analysis from a societal perspective over a lifetime time horizon. We evaluated these outcomes using a cost-utility analysis using data from a large multicentre prospective cohort study comparing GFCs versus usual care centres that took place in Austria, Spain, the USA, the Netherlands, Thailand and Singapore.

RESULTS

GFCs may be cost-effective in the long term, while providing a more comprehensive care plan. Patients in usual care centre group were slightly older and had fewer comorbidities. For the 1-year analysis, the costs per patient were slightly lower in the GFC group (-$646.42), while the quality-adjusted life-years were higher in the usual care centre group (+0.034). The incremental cost-effectiveness ratio was $18 863.34 (US$/quality-adjusted life-year). The lifetime horizon analysis found that the costs per patient were lower in the GFC group (-$7210.35), while the quality-adjusted life-years were higher in the usual care centre group (+0.02). The incremental cost-effectiveness ratio was $320 678.77 (US$/quality-adjusted life-year).

CONCLUSIONS

This analysis found that GFCs were associated with lower costs compared with usual care centres. The cost-savings were greater when the lifetime time horizon was considered. This comprehensive cost-effectiveness analysis, using data from an international prospective cohort study, found that GFC may be cost-effective in the long term, while providing a more comprehensive care plan. A greater number of major adverse events were reported at GFC, nevertheless a lower mortality rate associated with these adverse events at GFC. Due to the minor utility benefits, which may be a result of greater adverse event detection within the GFC group and much greater costs of usual care centres, the GFC may be cost-effective due to the large cost-savings it demonstrated over the lifetime time horizon, while potentially identifying and treating adverse events more effectively. These findings suggest that the GFC may be a cost-effective option over the lifetime of a geriatric patient with hip fracture, although future research is needed to further validate these findings.

LEVEL OF EVIDENCE

Economic, level 2.

TRIAL REGISTRATION NUMBER

NCT02297581.

Do we understand each other when we develop and implement hip fracture models of care? A systematic review with narrative synthesis

BACKGROUND

A hip fracture in an older person is a devastating injury. It impacts functional mobility, independence and survival. Models of care may provide a means for delivering integrated hip fracture care in less well-resourced settings. The aim of this review was to determine the elements of hip fracture models of care to inform the development of an adaptable model of care for low and middle-income countries (LMICs).

METHODS

Multiple databases were searched for papers reporting a hip fracture model of care for any part of the patient pathway from injury to rehabilitation. Results were limited to publications from 2000. Titles, abstracts and full texts were screened based on eligibility criteria. Papers were evaluated with an equity lens against eight conceptual criteria adapted from an existing description of a model of care.

RESULTS

82 papers were included, half of which were published since 2015. Only two papers were from middle-income countries and only two papers were evaluated as reporting all conceptual criteria from the existing description. The most identified criterion was an evidence-informed intervention and the least identified was the inclusion of patient stakeholders.

CONCLUSION

Interventions described as models of care for hip fracture are unlikely to include previously described conceptual criteria. They are most likely to be orthogeriatric approaches to service delivery, which is a barrier to their implementation in resource-limited settings. In LMICs, the provision of orthogeriatric competencies by other team members is an area for further investigation.

Cracking the Hip: Does Protocol Matter? A Retrospective Cohort Study Investigating the Effect of Protocol Implementation

Introduction

Approximately 300 000 hip fractures occur annually in the USA in patients >65 years old. Early intervention is key in reducing morbidity and mortality. Our institution implemented a collaborative hip fracture protocol, streamlining existing processes to reduce time to OR (TTO) and hospital length of stay (LOS). Our aim was to determine if this protocol improved these outcomes.

Study Design

We conducted a retrospective cohort study using our level-1 trauma center’s trauma registry, comparing outcomes for patients >60 years old with isolated hip fractures pre-and post-hip protocol implementation in May 2018. Our primary outcomes were TTO and in-hospital mortality. Secondary outcomes included LOS and postoperative complications. Univariate analysis was done using chi-square and T-test.

Results

We identified 176 patients with isolated hip fractures: 69 post- and 107 pre-protocol. Comparing post- to pre-protocol, TTO decreased by 18hrs (39 vs 57h; P = .013) and patients had fewer postoperative complications (9 vs 23%; P = .016) despite post-protocol patients being more likely to have diabetes (42 vs 27%, P < .05), elevated BMI (22 vs 25; P < .001), and to be current smokers (9 vs 2%; P < .05). LOS and in-hospital mortality also decreased (11 vs 20d; P = .312, 4.3 vs 7.5%; P = .402). Post-protocol patients were more likely to go to the OR within 24hrs of presentation (39 vs 16%; P < .001) and to go straight from ED to OR (32 vs 4%; P < .001).

Conclusion

TTO, LOS, and postoperative complications for isolated hip fracture patients were lower post-protocol. Though not all statistically significant, this trend indicates that the protocol was helpful in improving hip fracture outcomes but may require further improvement and institution-wide education.

Crossing quartiles: Improving time to theatre for patients with hip fractures in a large UK district general hospital; A quality improvement report

BACKGROUND

Neck of femur fractures are common injuries in the elderly population and carry significant morbidity and mortality. The introduction of a Best Practice Tariff (BPT) in 2010 laid out the criteria for optimising hip fracture care. These outcomes are audited annually by the National Hip Fracture Database. Meeting all six key targets attracts a financial uplift for each patient; one of these criteria is for an operation within 36 hours of admission.

LOCAL PROBLEM

A large district general, seeing on average 551 hip fracture patients a year. In 2017, the trust was ranked 152/160 in England for meeting the 36-hour target to surgery, although theatre capacity was sufficient. The average time to theatre was 43.68 hours, significantly above the national average. BPT was only achieved in 45.7% of cases.

METHOD

In January 2018 an anaesthetic 'hot week' was introduced with the same anaesthetist responsible for the hip fracture lists to allow for continuity of care and timely identification of potential delays to surgery. Further responsibilities include attending trauma meeting, liaising with the orthopaedic and the orthogeriatric teams, and advising on medical optimisation of patients for theatre.

RESULTS

Comparing data for 2017 (pre-intervention) with 2018 (post-implementation), the following results in key measures were noted: Surgery within 36 hours increased from 54% to 87.5% of patients. Mean time to surgery fell from 43.68 hours to 25.11 hours. Attainment of BPT targets increased from 45.7% to 84%. Trust ranking went from 152^nd to 20^th for time to surgery and from 131^st to 18^th for meeting BPT. Rescheduled operations went from 126 to 31. As a result, mean length of stay reduced by 5.1 days. Mortality remained unchanged.

CONCLUSION

Implementation of an anaesthetic 'hot week' may help trusts improve times to theatre where sufficient theatre capacity is already in place.

Evaluation of the implementation of multidisciplinary fast-track program for acute geriatric hip fractures at a University Hospital in resource-limited settings

Background

Hip fractures are common among frail, older people and associated with multiple adverse outcomes, including death. Timely and appropriate care by a multidisciplinary team may improve outcomes. Implementing a team to jointly deliver the service in resource-limited settings is challenging, particularly on the effectiveness of patient outcomes.

Methods

A retrospective cohort study to compare outcomes of hip fracture patients aged 65 or older admitted at Siriraj hospital before and after implementation of the Fast-track program for Acute Geriatric Hip Fractures. The primary outcome was the incidence of medical complications. The secondary outcomes were time to surgery, factors related to the occurrence of various complications, in-hospital mortality, and mortality at month 3, month 6 and month 12 after the operation.

Results

Three hundred two patients were enrolled from the Siriraj hospital’s database from October 2016 to October 2018; 151 patients in each group with a mean age of 80 years were analyzed. Clinical parameters were similar between groups except the Fast-track group comprising more patients with dementia (37.1% VS 23.8%, p < 0.012). In the Fast-track group, there was a significantly higher proportion of patients underwent surgery within 72-h (80.3% VS 44.7%, p < 0.001) and the length of stay was significantly shorter (11 days (8–17) VS 13 days (9–18), p = 0.017). There was no significant difference in medical complications. Stratified analysis by dementia status showed a trend in delirium reduction in both patients with dementia and without dementia groups, and a pressure injury reduction among patients with dementia after the program was implemented but without statistical significance. There was no significant difference in mortality.

Conclusions

The implementation of a multidisciplinary team for hip fracture patients is feasible in resource-limited setting. In the Fast-track program, time to surgery was reduced and the length of stay was shortened. Other outcome benefits were not shown, which may be due to incomplete uptake of all involved disciplines.

Identifying Modifiable and Non-modifiable Risk Factors of Readmission and Short-Term Mortality in Chondrosarcoma: A National Cancer Database Study

BACKGROUND

Limited data are available to inform the risk of readmission and short-term mortality in musculoskeletal oncology. The goal of this study was to identify factors independently associated with 30-day readmission and 90-day mortality following surgical resection of chondrosarcoma.

METHODS

We retrospectively reviewed 6653 patients following surgical resection of primary chondrosarcoma in the National Cancer Database (2004-2017). Both demographic and clinicopathologic variables were assessed for correlation with readmission and short-term mortality utilizing univariate and multivariate logistic regression modeling.

RESULTS

Of 220 readmissions (3.26%), risk factors independently associated with an increased risk of unplanned 30-day readmission included Charlson-Deyo Comorbidity Index (CDCC) (odds ratio [OR] 1.31; p = 0.027), increasing American Joint Committee on Cancer (AJCC) stage (OR 1.31; p = 0.004), undergoing major amputation (OR 2.38; p = 0.001), and axial skeletal location (OR 1.51; p = 0.028). A total of 137 patients died within 90 days of surgery (2.25%). Risk factors associated with increased mortality included the CDCC (OR 1.60; p = 0.001), increasing age (OR 1.06; p < 0.001), having Medicaid insurance status (OR 3.453; p = 0.005), living in a zip code with a higher educational attainment (OR 1.59; p = 0.003), increasing AJCC stage (OR 2.32; p < 0.001), longer postoperative length of stay (OR 1.015; p = 0.033), and positive surgical margins (OR 2.75; p = 0.001). Although a majority of the cohort did not receive radiation therapy (88.8%), receiving radiotherapy (OR 0.132; p = 0.010) was associated with a decreased risk of short-term mortality.

CONCLUSIONS

Several tumor, treatment, and patient factors can help inform the risk of readmission and short-term mortality in patients with surgically treated chondrosarcoma.

A bibliometric analysis of orthogeriatric care: top 50 articles

Background

Population is ageing and orthogeriatric care is an emerging research topic.

Purpose

This bibliometric review aims to provide an overview, to investigate the status and trends in research in the field of orthogeriatric care of the most influential literature.

Methods

From the Core Collection databases in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to orthogeriatric care were identified in December 2020 using a multistep approach. A total of 50 articles were included and analysed in this bibliometric review.

Results

The 50 most cited articles were published between 1983 and 2017. The number of total citations per article ranged from 34 to 704 citations (mean citations per article: n = 93). Articles were published in 34 different journals between 1983 and 2017. In the majority of publications, geriatricians (62%) accounted for the first authorship, followed by others (20%) and (orthopaedic) surgeons (18%). Articles mostly originated from Europe (76%), followed by Asia–pacific (16%) and Northern America (8%). Key countries (UK, Sweden, and Spain) and key topic (hip fracture) are key drivers in the orthogeriatric research. The majority of articles reported about therapeutic studies (62%).

Conclusion

This bibliometric review acknowledges recent research. Orthogeriatric care is an emerging research topic in which surgeons have a potential to contribute and other topics such as intraoperative procedures, fractures other than hip fractures or elective surgery are related topics with the potential for widening the field to research.

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study

OBJECTIVE

The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes.

DESIGN

Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year.

SETTING

International (six countries, three continents) multicentre study.

PARTICIPANTS

281 patients aged ≥70 with operatively treated proximal femur fractures.

INTERVENTIONS

Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy.

OUTCOME MEASURES

Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life.

RESULTS

Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002).

CONCLUSIONS

Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02297581.

Post-hospital care pathway for individuals with hip fracture: what is the optimal setting and rehabilitation intensity? An observational study

PURPOSE

Health systems are using ever-increasing resources on treating hip fractures. Optimal post-hospital care needs to be defined to design an effective care pathway. The aim of the present study was to describe the post-hospital care pathway of individuals with hip fracture and to assess its association with the degree of recovery of independence achieved four months after surgery.

MATERIALS AND METHODS

A prognostic multicentric cohort study was conducted. All patients aged 65 years and over who were admitted with a diagnosis of fragility hip fracture were enrolled. After the hospital discharge, the patients were followed either at an inpatient rehabilitation facility with an intensive or extensive regimen, a nursing home, a long-term care facility or at home. Among the various care pathways, the intensity of rehabilitation differed according to its duration, frequency of sessions, and activities proposed. Primary outcome was the patient's degree of independence achieved four months after surgery, as measured with Activities of Daily Living scale. Several covariates were collected to test the correlation between the different post-hospital care pathways and the recovery of independence.

RESULTS

A total of 923 patients completed the follow-up. A post- hospital rehabilitation pathway was indicated for 88.2% of the patients. The extensive rehabilitation pathway, indicated for 36.7% of the patients, was the most common. The intensive rehabilitation pathway gave better results in terms of independence at four-month follow up, leading to a median ADL score of 1.4 (95% CI 1.0-2.0). The other care pathways did not show significant difference between each other.

CONCLUSIONS

High-intensity rehabilitation was associated to better results in terms of recovering of Activities of Daily Living.IMPLICATIONS FOR REHABILITATIONPost-hospital care pathways that include an intensive rehabilitation treatment should be improved/supported to make them available to a larger number of hip fracture patients.Patient selection criteria for post-hospital rehabilitation pathways should be standardized to optimize available healthcare resources.A cost-effectiveness analysis should be performed to analyze the economic sustainability of each post-hospital care pathway.

Do standardized hip fracture care programs decrease mortality in geriatric hip fracture patients?

There is mounting support for the implementation of a standardized hip fracture program (SHFP) for geriatric patients. However, the current evidence to assess geriatric hip fracture outcomes following treatment in a SHFP is limited to small, single-center, observational studies. Using a large, multinational dataset, this study aims to assess whether enrollment in a SHFP was associated with improved 30-day patient-important outcomes in geriatric hip fracture patients. The secondary aim was to evaluate if the SHFP treatment effect varies by baseline mortality risk. An observational cohort study was conducted using data from the National Surgical Quality Improvement Program (NSQIP) for the years of 2016 and 2017. The study included 17,395 geriatric hip fracture patients over the age of 65. Over half (54%) of patients were enrolled in a SHFP on admission to hospital. The primary outcome was 30-day mortality. Secondary outcomes included 30-day reoperation and readmission. Multivariable logistic regression was used to estimate treatment effects, adjusting for race, anesthesia technique, and baseline mortality risk. The heterogeneity of treatment effect was determined by stratifying patients into quartiles based on their baseline mortality risk. The overall 30-day mortality risk was 6.6%. Enrollment in a SHFP did not reduce the 30-day risk of mortality (risk difference (RD): -0.2; 95% CI: -0.7, 0.3; p = 0.48), reoperation (RD: -0.2%; 95% CI: -0.6, 0.3; p = 0.36) or readmission (RD: -0.4%; 95% CI: -0.1, 0.4%; p = 0.20) when analyzed as a single sample. However, there were greater differences in the SHFP treatment effects when stratified by their preoperative mortality risk. Specifically, a 2.0% (95% CI: 4.2, 0.0%; p = 0.06) reduction in mortality was observed in the patients in the highest risk quartile for mortality and a 1.7% (95% CI: -3.2, -0.2%; p = 0.02) reduction in the medium-high risk quartile. The NSQIP data suggest that SHFPs do not significantly improve the short-term outcomes for the average geriatric hip fracture patient. However, a SHFP may significantly reduce the risk of 30-day mortality in higher risk patients. Therefore, the efficiency of SHFPs could potentially be improved with targeted deployment to high risk geriatric hip fracture patients.

Association Between Delays in Radiography and Surgery With Hip Fracture Outcomes in Elderly Patients

Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is "surgery delay" (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P=.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [Orthopedics. 2020;43(6):e609-e615.].

Impact of an orthogeriatrician on length of stay of elderly patient with hip fracture

Hip fracture patients are complex, and orthopaedic management is limited to the surgery phase. To provide better evaluation pre-operatively and an optimal level of post-operative care, an orthogeriatrician was introduced in the orthopaedic team. This ensured that time to surgery from admission consistently was below 48 h, decreasing hospitalization time after surgery and total length of stay.

INTRODUCTION

Hip fractures are a major health issue in elderly and frail patient. The integration of orthogeriatric care within the orthopaedic team could be useful to optimize the clinical conditions of these patients in perioperative phases and stabilize them after surgery, reducing hospital length of stay. The present study evaluates the role of an orthogeriatrician in the management of patients with a hip fracture.

MATERIALS AND METHODS

Data about patients admitted and operated from February to September 2018 and from February to September 2019 were collected from the San Giovanni di Dio e Ruggi d'Aragona Hospital of Salerno database. A total of 352 patients were identified and divided in two groups according to the year in which the orthogeriatrician was working in Orthopaedic Department. Records regarding age, sex, side and type of fracture, time of admission, day of surgery and discharge were collected and length of stay, days from the admission to surgery and days from surgery to discharge were calculated.

RESULTS

There were no statistically significant differences in the pre-surgery phases of both groups, and all patients were operated at a mean of 2.1 days ± 1.8 SD from admission (p > 0.05). No statistically significant difference between demographic data in both groups (p > 0.01) was observed. There was, however, statistically significant reduction of hospitalization time after surgery and total LOS from 2018 to 2019 (p < 0.01).

CONCLUSION

An Orthogeriatric doctor in an Orthopaedic and Traumatology Department may lead a multidisciplinary approach to manage elderly patients with hip fractures, ensuring that the time to surgery from admission is less than 48 h, and reducing hospitalization time after surgery and total length of stay.

Post-discharge complications in postoperative patients with hip fracture

Hip fractures often occur in elderly people and are a major global health challenge causing many consequences, both in health and socioeconomic costs. This review aimed to identify complications that occur in patients with postoperative hip fracture between 30 days and 60 months after discharge. This review was conducted on articles published from 2005 to 2017 obtained from the EBSCO, PubMed, ProQuest and Google Scholar databases. The literature search followed PRISMA Guidelines. Key search words included the terms: hip fracture, complication, postoperative, community, and nursing. Articles were considered eligible if discussed the complications of hip fracture with surgical treatment, occurring post hospital discharge and the patient was in the community. In this review, 23 articles were included that met the inclusion criteria. There were 16 articles that cohort studies, 3 were retrospective studies, 3 were randomized control trials and 1 article was an observational study. The time of observation varied from 30 days to the longest of 5 years. Quality assessment of the levels of evidence used the Oxford CEBM recommendations. The review results found that postoperative hip fracture patients after discharge still experienced various complications after 30 days and up to 1-3 years post-operation.

Fast-track care for pertrochanteric hip fracture: What impact on function and autonomy after discharge?

INTRODUCTION

Fast-track treatment of pertrochanteric fracture is being developed in traumatology. The present study hypothesis was that fast-track treatment of pertrochanteric fracture does not jeopardize patient autonomy.

MATERIAL AND METHOD

A single-center prospective comparative observational study, conducted from 2014 to 2016 in the University Hospital of Angers, France, included patients presenting with isolated A1 or A2 pertrochanteric fracture on the AO classification, managed by intramedullary nailing and requiring transfer to Post-acute Recovery (PAR). The fast-track exposure group were transferred directly on postoperative day 1, while the non-exposure group received postoperative care in the surgery department before transfer to PAR. The main endpoint was difference in Parker score between admission and discharge. Secondary endpoints comprised type of walking aid at discharge and destination of discharge from PAR.

RESULTS

109 patients were initially included, with 54 patients (27 pairs) after matching. There was a significant difference in reduction in Parker score in favor of fast-track: -1.27 (95% CI: -2.27; -0.32) (p=0.012). There were no differences in amount or type of aid at discharge or discharge destination, although there was a trend toward greater discharge to the initial place of residence with fast-track.

DISCUSSION

Orthopedics is heading to the fast-track. Previous studies reported shorter hospital stay, comparable survival and complications rates, and significant cost-saving. The present study addressed progression: fast-track patients showed significantly less loss of walking autonomy.

CONCLUSION

Fast-track management of pertrochanteric fracture significantly reduced loss of walking autonomy, without significant impact on discharge destination or walking aids.

LEVEL OF EVIDENCE

IIB, exposure/non-exposure cohort.

Hip Fracture Trends in America Between 2009 and 2016

Background

Hip fractures are a common condition associated with high morbidity and mortality. In this study, we assess (1) yearly incidences, (2) demographic factors, (3) postoperative outcomes, (4) primary diagnoses, and (5) primary procedures.

Materials and Methods

The National Inpatient Sample was queried for patients admitted with hip fractures from 2009 to 2016 (n = 2 761 850). Variables analyzed were age, sex, race, obesity status, Charlson Comorbidity Index, smoking status, osteoporosis status, lengths of stay (LOS), discharge dispositions, charges, costs, mortalities, inpatient complications, primary and secondary diagnoses, and primary procedures.

Results

From 2009 to 2016, the overall gross number of hip fractures decreased (P < .001). At the conclusion of the study, more patients were male, obese, and smokers, while fewer had a diagnosis of osteoporosis (P < .001 for all). Mean LOS significantly decreased (P < .001), while charges and costs increased (P < .001 for both). Both mortality and the overall complication rate decreased (P < .001 for both). Specifically, complications that decreased included myocardial infarctions, deep vein thromboses, pulmonary emboli, pneumoniae, hematomas/seromas, urinary tract infections, and transfusions (P < .001 for all). Complications that increased included cardiac arrests, respiratory failures, mechanical complications, and sepsis (P < .001 for all). The most common diagnosis was "closed fracture of intertrochanteric section of neck of femur." The procedure performed most often was "open reduction of fracture with internal fixation, femur."

Conclusion

An increasing number of males and smokers have sustained hip fractures, although fewer patients with osteoporosis experienced these injuries. A decreasing overall complication rate may indicate improving perioperative courses for hip fracture patients. However, several shortcomings still exist and can be improved to further decrease negative outcomes.

Impact of osteosynthesis in fracture care: a cost comparison study

Aim: To estimate the health economic impact of osteosynthesis (OS) in fracture care over six decades in 17 high-income countries. Patients & methods: Applying a decision tree model, we assumed a hypothetical absence of OS and compared OS (intervention) with conservative treatment (CONS; comparator). We included patients with femur, tibia and radius fractures (age <65 years) and for proximal femur fractures also elderly patients (≥70 years). Results: We estimated savings in direct and indirect costs of 855 billion Swiss francs in the working age population in addition to 4.6 million years of life gained. In the elderly population, 69 billion Swiss francs were saved in direct costs of proximal femur fractures in addition to 73 million years of life gained. Conclusion: OS contributed to maximize health gains of society.

Outcomes in Multidisciplinary Team-based Approach in Geriatric Hip Fracture Care: A Systematic Review

INTRODUCTION

This systematic review analyzes the literature on the treatment of geriatric hip fractures by a multidisciplinary hip fracture service including geriatricians/internists and orthopaedic surgeons and what impact this has on patient outcomes.

METHODS

A systematic review of several databases was conducted according to PRISMA guidelines. Studies comparing an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model to treat hip fractures with reported outcomes for time to surgery, length of stay, readmission rates, and postoperative mortality were included.

RESULTS

Seventeen articles fitting the inclusion criteria were included. Differences between the results of an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model were assessed using chi-squared tests. With patients admitted under a coordinated orthogeriatrics care model or a geriatrics-led care model, there is a statistically significant decrease in time to surgery (P = 0.045), length of stay (P = 0.0036), and postoperative mortality rates (P = 0.0034).

CONCLUSIONS

Although a heterogeneous group of studies, the aggregate data from several studies using an orthogeriatrics care model or a geriatrics-led care model trend toward improvements across several clinical and cost-related outcome measures: decreased time to surgery, shorter length of stay, improved postoperative clinical outcomes, decreased mortality, and lower cost.

Effectiveness of regional clinical pathways on postoperative length of stay for hip fracture patients: A retrospective observational study using the Japanese Diagnosis Procedure Combination database

BACKGROUND

Regional clinical pathways, a new type of clinical pathway, are practiced with the aim of standardizing and optimizing medical care by cooperation among multiple medical institutions in a region. However, current evaluation of the effectiveness of regional clinical pathways for hip fracture, a major health problem requiring hospitalization for orthopedic surgery, is insufficient. This study aimed to determine the association between regional clinical pathways and postoperative hospital length of stay (LOS) among hip fracture patients. In particular, we focused on the variation in postoperative LOS of hip fracture patients among hospitals and the contribution of regional clinical pathways to this variation.

METHODS

Using data from the Diagnosis Procedure Combination (DPC) database in Japan from April 2011 to March 2013, patients who were diagnosed with "fracture of head and neck of femur" (ICD10 code S72.0) or "pertrochanteric fracture" (S72.1) and received "bipolar hip arthroplasty" or "open reduction and internal fixation" were extracted. A total of 110,133 patients were included. Associations between regional clinical pathways and postoperative LOS were analyzed using cross-sectional analysis with multilevel regression models.

RESULTS

Hospitals that implemented a regional clinical pathway showed a significant reduction (13 days) in the postoperative LOS of hip fracture patients. We found a 16% inter-hospital variation in postoperative LOS, which might be explained by hospital-level implementation of regional clinical pathways. Application of regional clinical pathways at the patient level resulted in a 4-day decrease in postoperative LOS.

CONCLUSIONS

Implementation of regional clinical pathways for hip fracture patients at the hospital level was associated with reduced postoperative LOS, regardless of whether or not pathways were implemented at the patient level. This suggests that regional clinical pathways are effective for patient care management in hospitals.

The implementation of a Geriatric Fracture Centre for hip fractures to reduce mortality and morbidity: an observational study

INTRODUCTION

The aim of this study was to evaluate the effect of an orthogeriatric treatment model on elderly patients with traumatic hip fractures (THF). The Geriatric Fracture Centre (GFC) is a multidisciplinary care pathway with attention for possible age-related diseases, discharge management and out-of-hospital treatment.

MATERIALS AND METHODS

A prospective cohort study with a historical cohort group was conducted at a level I trauma centre in Switzerland. Patients over the age of 70 years with THFs who underwent surgical treatment at GFC in 2013 and 2016 were included. Primary outcomes were mortality and complications. Secondary outcomes were hospital length of stay (HLOS), time to surgery and place of discharge.

RESULTS

A total of 322 patients were included in this study. In 2016, mortality showed a reduction of 2.9% at 30 days (p = 0.42) and 3.4% at 90 days (p = 0.42) and 0.1% at 1 year (p = 0.98). The number of patients with a complicated course showed a decrease of 2.2% in 2016 (p = 0.69). A significant increase in the diagnosis of delirium by 11.2% was seen in 2016 (p < 0.001). The median HLOS was significantly reduced by 2 days (p < 0.001). An increase of 21.1% was seen in patients who were sent to rehabilitation in 2016 (p < 0.001). Day-time surgery increased by 10.2% (p = 0.04).

CONCLUSION

The implementation of the GFC leads to improved processes and outcomes for geriatric patients with THFs. Increased awareness and recognition led to an increase in the diagnosis of complications that would otherwise remain untreated. Expanding these efforts might lead to more significant effects and an increase in the reduction of morbidity and mortality in the future.

Impact of orthogeriatric care, comorbidity, and complication on 1-year mortality in surgical hip fracture patients: An observational study

After acute hip surgery, the 1-year mortality rate is high. Therefore, this study evaluated the risk factors for 1-year mortality. The purposes of this study was first to examine the effect of integrated care on 1-year mortality in surgical patients and secondly to explore magnitude of comorbidity and complication on mortality.This retrospective cohort study included 313 patients received surgery for hip fragility fracture. Patients with multiple fractures or combined trauma were excluded. The patients were grouping into integrated (n = 106) and non-integrated care group (n = 207) models. Univariate and multiple Cox regression were used to examine effect of care model, comorbidity, and complication event.One-year mortality in integrated and non-integrated patients was 4.7% and 14.0% respectively. After adjustments, patients in non-integrated care, have 2.89 times (95% confidence interval [CI] 1.07-7.81) likely to die 1-year after discharged.Patients had elevated comorbidity or postoperative complications contributed to the mortality. Our study found the effect of patients treated by integrated care models, compared with usual model, significantly reduced 1-year mortality rate. Appropriated treatment of comorbidities during hospitalization and after discharge is critical to post-surgical survival. The findings imply that the co-care for hip fracture of hip surgical patients with orthogeriatricians is strongly recommended, particularly for those with >3 comorbidities.

The impact of the AO Foundation on fracture care: An evaluation of 60 years AO Foundation

OBJECTIVES

Sixty years ago, the Association of Osteosynthesis (AO) was founded with the aim to improve fracture treatment and has since grown into one of the largest medical associations worldwide. Aim of this study was to evaluate AO's impact on science, education, patient care and the MedTech business.

DESIGN/METHODS

Impact evaluations were conducted as appropriate for the individual domains: Impact on science was measured by analyzing citation frequencies of publications promoted by AO. Impact on education was evaluated by analyzing the evolution of number and location of AO courses. Impact on patient care was evaluated with a health economic model analyzing cost changes and years of life gained through the introduction of osteosynthesis in 17 high-income countries (HICs). Impact on MedTech business was evaluated by analyzing sales data of AO-associated products.

RESULTS

Thirty-five AO papers and 2 major AO textbooks are cited at remarkable frequencies in high ranking journals with up to 2000 citations/year. The number of AO courses steadily increased with a total of 645'000 participants, 20'000 teaching days and 2'500 volunteer faculty members so far. The introduction of osteosynthesis saved at least 925 billion Swiss Francs [CHF] in the 17 HICs analyzed and had an impact on avoiding premature deaths comparable to the use of antihypertensive drugs. AO-associated products generated sales of 55 billion CHF.

CONCLUSION

AO's impact on science, education, patient care, and the MedTech business was significant because AO addressed hitherto unmet needs by combining activities that mutually enriched and reinforced each other.

[Geriatric Trauma Center DGU®: Evaluation of clinical and economic parameters : A pilot study in a german university hospital]

BACKGROUND

Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable.

OBJECTIVE

The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU).

METHODS

A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model).

RESULTS

In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035).

CONCLUSION

There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.

Fast track care for pertrochanteric hip fractures: How does it impact length of stay and complications?

INTRODUCTION

The medical and economic impact of treating pertrochanteric hip fractures is growing. We hypothesized that fast track surgery of pertrochanteric fractures would reduce the length of stay (LOS) without compromising the quality of care.

MATERIALS AND METHODS

This was a prospective, observational, single-center cohort study conducted between 2014 and 2016 at the Angers Teaching Hospital in France. The enrolled patients had an isolated A1 or A2 proximal femur fracture (AO classification) that was treated surgically by intramedullary nailing and required post-acute rehabilitation (PAR) care. The exposed FT cohort was transferred into the PAR pathway on postoperative day 1. The non-exposed (control) group was provided with postoperative care in the surgery unit before transfer to PAR. The primary outcome was the total LOS (LOS in surgery+LOS in PAR). The secondary objectives were to determine the immediate survival, 1-year survival, postoperative complications and average cost of hospitalization.

RESULTS

The study enrolled 109 patients initially, with 54 patients eligible for analysis after matching (27 pairs). The LOS in PAR and total LOS were 45.85±19.24 days and 48.56±19.36 days in the FT group (n=27), and 68.41±48.77 days and 77.85±48.80 days in the control group (n=27). Thus the LOS in PAR and total LOS were significantly lower in the FT group (p=0.022, p=0.003). There was no significant difference in the number of early deaths, complications, and 1-year survival without rehospitalization between cohorts. The mean cost per patient was lower in the FT cohort.

DISCUSSION

The FT pathway has already been adopted in orthopedics. For patient who suffer a hip fracture, it contributes to reducing the total LOS without negatively impacting the quality of care. Early health economics studies support this care pathway.

CONCLUSION

The FT approach to treating pertrochanteric fractures reduces total LOS without increasing mortality or complication rates. The 1-year survival is comparable.

LEVEL OF EVIDENCE

IIB, Exposed/Unexposed cohort.

Patient and Perioperative Factors Influencing the Functional Outcomes and Mortality in Elderly Hip Fractures

This study aimed to evaluate the functional outcomes and mortality following hip fracture surgery in elderly patients, and to identify the associated risk factors. Between January 2016 and December 2017, 480 consecutive patients were finally included for data analyses. The Harris score and Barthel index were used to evaluate the hip function and ability to perform activities of daily living (ADL). Univariate and multivariate logistics regression analyses were performed to determine the independent risk factors for mortality, poor hip function or poor ability to perform ADL. The mortality rate was 15.6% (75/480). In the survivors, poor outcome developed in 133 (32.8%) patients and poor ADL was in 72 (17.8%) patients. The independent factors that influenced mortality were advanced age (p = 0.033), male gender (0.031), living in rural area (p < 0.001), self-reported diabetes (p = 0.005), tumor (p = 0.024), preoperative delay >7 days (p = 0.020), postoperative drainage use (p = 0.034), WBC > 10 × 10⁹/L (p = 0.005), reduced RBC (p = 0.011), PLT < 100 × 10⁹/L (p < 0.001), ALB < 35 g/L (p < 0.001) and CK > 200 U/L (p = 0.003). The independent factors that influenced the hip function were male gender (p = 0.009), WBC > 10 × 10⁹/L (p < 0.001), lower HBG (p = 0.005), and ALB < 35 g/L (p < 0.001). The independent factors that influenced the ability to perform ADL were diagnosis of trochanteric fracture (p = 0.048), preoperative delay > 7 days (p = 0.027), postoperative drainage use (p = 0.010), elevated WBC (p = 0.020), lower HGB (p < 0.001), PLT < 100 × 10⁹/L (p = 0.002), and ALB < 35 g/L (p < 0.001). Although most of risk factors were not modifiable, they aid in patient individual risk evaluation, risk stratification, and counseling patients or relatives.

Increased therapy demand and impending loss of previous residence status after proximal femur fractures can be determined by continuous gait analysis - A clinical feasibility study

Proximal femur fractures account for increased healthcare costs whenever patients are unable to return to their previous state of residence. Studies suggest that patients benefit from early weight-bearing, yet compliance to weight-bearing regimes is poorly investigated. Aim of the study was thus to show the clinical feasibility of a new measurement tool able to determine continuous weight-bearing behavior after intramedullary nail osteosynthesis of intertrochanteric femur fractures, assess the influence of weight-bearing on clinical outcome and determine rehabilitation demand based on early postoperative gait performance. In an observational study, gait data of 22 patients with intertrochanteric femur fractures were evaluated. During the inpatient stay patients were continuously monitored with a gait analysis insole. Primary outcome was the amount of weight-bearing reached. Short-term functional outcome, as well as return to the previous state of living were evaluated in relation to weight-bearing and activity during the inpatient stay. With the presented technique continuous gait data of all patients during postoperative mobilization could be obtained. Only 13 patients reached full weight-bearing. The technique was feasible to determine correlations between weight-bearing and outcome, as well as between gait activity and outcome. Significant gait differences between patients able to return to their previous state of living and those who could not were seen. Dynamic insole measurements are feasible to continuously determine the postoperative gait performance. Their postoperative use showed, that the continuous compliance to permissive weight-bearing after intertrochanteric fractures is low. The presented measurement technique has the potential to identify patients at risk for reduced outcome and impending loss of previous residence status. Further studies will have to investigate the effects of technology assisted "patient at risk" identification and adapted therapy on clinical outcome.

Long-term Patient-reported Quality of Life and Pain After a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Retrospective Comparative Cohort Study

Introduction

There is an increase in incidence of hip fractures in the ageing population. The implementation of multidisciplinary clinical pathways (MCP) has proven to be effective in improving the care for these frail patients, and MCP tends to be more effective than usual care (UC). The aim of this study was to analyze potential differences in patient-reported outcome among elderly patients with hip fractures who followed MCP versus those who followed UC.

Materials and Methods

This retrospective cohort study included patients aged 65 years or older with a low-energy hip fracture, who underwent surgery in the Maastricht University Medical Center, Maastricht, the Netherlands. Two cohorts were analyzed; the first one had patients who underwent UC in 2012 and the second one contained patients who followed MCP in 2015. Collected data regarded demographics, patient-reported outcomes (Short Form 12 [SF-12] and the Numeric Rating Scale [NRS] to measure pain), and patient outcome.

Results

This cohort study included 398 patients, 182 of them were included in the MCP group and 216 were in the UC group. No differences in gender, age, or American Society of Anesthesiologists classification were found between the groups. No significant differences were found in SF-12 and the NRS data between the MCP group and UC group. In the MCP group, significantly lower rates of postoperative complications were found than in the UC group, but mortality within 30 days and one year after the hip fracture was similar in both groups.

Discussion

Although the effects of hip fractures in the elderly on patient-reported outcome, pain and quality of life have been addressed in several recent studies, the effects of MCP on long-term outcome was unclear.

Conclusion

A multidisciplinary clinical pathway approach for elderly patients with a hip fracture is associated with a reduced time to surgery and reduced postoperative complications, while no differences were found in quality of life, pain, or mortality.

Different approaches towards geriatric trauma care for hip fracture patients: an inter-hospital comparison

PURPOSE

Hip fractures in geriatric patients have high morbidity and mortality rates. The implementation of a multidisciplinary geriatric care pathway (GCP) may improve treatment for this patient population. This study focusses on two level II hospitals with a different treatment protocols. A comparison was made between a multidisciplinary GCP and extensive standard care with a focus on geriatric hip fracture patients to assess if a multidisciplinary GCP leads to lower mortality and morbidity.

METHODS

This retrospective cohort study included patients aged 70 years or older with a unilateral proximal hip fracture who underwent surgery between January 2014 and December 2015. The primary outcome measures complications and 30-day mortality. Secondary outcome measures were time to surgery, hospital length of stay (HLOS) and secondary surgical interventions.

RESULTS

This study included a total of 898 patients. No differences were found between major postoperative complications, 30-day mortality, HLOS or the amount of secondary surgical interventions.

CONCLUSIONS

Mortality, major complications, HLOS and the amount of secondary surgical interventions showed no differences between both hospitals. This inter-hospital comparison of two types of geriatric care models showed no outcome that favours one specific geriatric care model over another. This provides opportunities for future studies to get a better understanding of what specific factors of geriatric care models contribute most to an improvement in the treatment of this patient population and decide which approach is most cost effective.

Geriatric fracture centers-improved patient care and economic benefits : English Version

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.

The orthogeriatric comanagement improves clinical outcomes of hip fracture in older adults

Treatment of older adults with hip fracture is a healthcare challenge. Orthogeriatric comanagement that is an integrated model of care with shared responsibility improves time to surgery and reduces the length of hospital stay and mortality compared with orthopedic care with geriatric consultation service and usual orthopedic care, respectively.

INTRODUCTION

Treatment of fractures in older adults is a clinical challenge due partly to the presence of comorbidity and polypharmacy. The goal of orthogeriatric models of care is to improve clinical outcomes among older people with hip fractures. We compare clinical outcomes of persons with hip fracture cared according to orthogeriatric comanagement (OGC), orthopedic team with the support of a geriatric consultant service (GCS), and usual orthopedic care (UOC).

METHODS

This is a single-center, pre-post intervention observational study with two parallel arms, OGC and GCS, and a retrospective control arm. Hip fracture patients admitted to the trauma ward were assigned by the orthopedic surgeon to the OGC (n = 112) or GCS (n = 108) group. The intervention groups were compared each with others and both with the retrospective control group (n = 210) of older adults with hip fracture. Several clinical indicators are considered, including time to surgery, length of stay, in-hospital, and 1-year mortality.

RESULTS

Patients in the OGC (OR 2.62; CI 95% 1.40-4.91) but not those in the GCS (OR 0.74; CI 95% 0.38-1.47) showed a higher probability of undergoing surgery within 48 h compared with those in the UOC. Moreover, the OGC (β, - 1.08; SE, 0.54, p = 0.045) but not the GCS (β, - 0.79; SE, 0.53, p = 0.148) was inversely associated with LOS. Ultimately, patients in the OGC (OR 0.31; CI 95 % 0.10-0.96) but not those in the GCS (OR 0.37; CI 95% 0.10-1.38) experienced a significantly lower 1-year mortality rate compared with those in the UOC. All analyses were independent of several confounders.

CONCLUSIONS

Older adults with hip fracture taken in care by the OGC showed better clinical indicators, including time to surgery, length of stay and mortality, than those managed by geriatric consultant service or usual orthopedic care.

Modifiable Factors as Current Smoking, Hypoalbumin, and Elevated Fasting Blood Glucose Level Increased the SSI Risk Following Elderly Hip Fracture Surgery

Objective: Surgical site infection (SSI) following hip fractures represents an important complication. This study aimed to investigate the incidence rate after surgery of hip fractures in the elderly and to identify the associated risk factors. Patients: Patients' demographic, injury, and surgery-related data and biochemical indexes were retrospectively reviewed and recorded during their hospitalization, between July 2015 and June 2017. After their discharge from hospital, patients were prospectively followed up at postoperative 1, 3, 6, and 12 months. SSIs were identified by review of patients' medical records and post-discharge telephone follow-up. Univariate and multivariate analyses were performed to determine the independent risk factors associated with SSI. Results: A total of 611 patients undergoing surgery for hip fractures with complete data were included for analysis. During the postoperative one year, 27 SSIs (19 superficial and 8 deep SSIs) developed, indicating the cumulative incidence of 4.4% (95%CI, 2.8-6.0%). Of them, 21 (77.8%) SSIs were detected during patients' hospitalization, and the 6 (22.2%) cases were confirmed via telephone during the post-discharge follow-up. After adjustment of multiple variables, BMI, current smoking, surgical duration, preoperative hospital stay, ASA class of III-IV, ALB <35g/L, and FBG > 110mg/dL were identified as independent risk factors for SSI. Conclusions: Three modifiable factors as smoking, preoperative ALB <35g/L, and FBG > 110mg/dL should be optimized preoperatively to reduce the SSIs. Other factors, although not modifiable, could be used for screening of at-risk patients, patient risk stratification, or for counseling of patients.

Changing trends in the mortality rate at 1-year post hip fracture - a systematic review

BACKGROUND

Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.

AIM

To address recent 1-year post hip fracture mortality rates in the literature.

METHODS

Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation (2013-2017), cohorts > 100, studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.

RESULTS

Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.

CONCLUSION

There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.

Minimally invasive anterior muscle-sparing versus a transgluteal approach for hemiarthroplasty in femoral neck fractures-a prospective randomised controlled trial including 190 elderly patients

BACKGROUND

The relevance of femoral neck fractures (FNFs) increases with the ageing of numerous societies, injury-related decline is observed in many patients. Treatment strategies have evolved towards primary joint replacement, but the impact of different approaches remains a matter of debate. The aim of this trial was to evaluate the benefit of an anterior minimally-invasive (AMIS) compared to a lateral Hardinge (LAT) approach for hemiarthroplasty in these oftentimes frail patients.

METHODS

Four hundred thirty-nine patients were screened during the 44-months trial, aiming at the evaluation of 150 patients > 60 yrs. of age. Eligible patients were randomised using an online-tool with completely random assignment. As primary endpoint, early mobility, a predictor for long-term outcomes, was evaluated at 3 weeks via the "Timed up and go" test (TUG). Secondary endpoints included the Functional Independence Measure (FIM), pain, complications, one-year mobility and mortality.

RESULTS

A total of 190 patients were randomised; both groups were comparable at baseline, with a predominance for frailty-associated factors in the AMIS-group. At 3 weeks, 146 patients were assessed for the primary outcome. There was a reduction in the median duration of TUG performance of 21.5% (CI [- 41.2,4.7], p = 0.104) in the AMIS-arm (i.e., improved mobility). This reduction was more pronounced in patients with signs of frailty or cognitive impairment. FIM scores increased on average by 6.7 points (CI [0.5-12.8], p = 0.037), pain measured on a 10-point visual analogue scale decreased on average by 0.7 points (CI: [- 1.4,0.0], p = 0.064). The requirement for blood transfusion was lower in the AMIS- group, the rate of complications comparable, with a higher rate of soft tissue complications in the LAT-group. The mortality was higher in the AMIS-group.

CONCLUSION

These results, similar to previous reports, support the concept that in elderly patients at risk of frailty, the AMIS approach for hemiarthroplasty can be beneficial, since early mobilisation and pain reduction potentially reduce deconditioning, morbidity and loss of independence. The results are, however, influenced by a plethora of factors. Only improvements in every aspect of the therapeutic chain can lead to optimisation of treatment and improve outcomes in this growing patient population.

TRIAL REGISTRATION

www.clinicaltrials.gov : NCT01408693 (registered August 3rd 2011).

Functional outcomes and mortality in geriatric and fragility hip fractures-results of an integrated, multidisciplinary model experienced by the "Florence hip fracture unit"

PURPOSE

The aim of this study was to evaluate the outcomes of an integrated multidisciplinary hip fracture unit through the following parameters: time to surgery, mortality, return to activities of daily living, adherence to re-fractures prevention programs.

METHODS

Six hundred seventy-seven consecutive patients with hip fracture were included in the study. We calculated the time to surgery as the time in hours from admission until surgery. The in-hospital mortality was calculated as the number of deaths that occurred before discharge. Each patient was then evaluated post-operatively at six weeks, three months, and one year. We studied basic activity of daily living (BADL) and the New Mobility Scale (NMS). Adherence to re-fractures prevention programs was also evaluated.

RESULTS

88.9% of patients underwent surgery within two calendar days from admission. In-hospital mortality was 2.4%, and the overall mortality at one year from the intervention was 18.7%. Full mobility status or a low impairment of the mobility status was reached in 32.1% of the patients at one year and a level ≥ 3 of autonomy in BADL was reached in 62.4% (338/542) of patients. Three hundred forty-two patients were prescribed a specific therapy for secondary prevention of re-fracture.

CONCLUSIONS

An integrated, multidisciplinary model for the treatment of hip fragility fractures was effective in reducing time to surgery and mortality, increasing the level autonomy and mobility status and promoting adherence to re-fracture therapy.

Beyond orthogeriatric co-management model: benefits of implementing a process management system for hip fracture

Hip fracture is a major health care problem worldwide. Business process management systems (PMSs) have made significant contributions in health care environments to improve patient care standards. The effectiveness of PMS applied to hip fracture in older adults in the acute phase has been demonstrated.

INTRODUCTION

Fragility fracture is a major health care problem worldwide. Business PMSs have made significant contributions in health care environments to improve patient care standards. It is a new way of management that defines a homogeneous application procedure involving eliminating steps that add no value and developing explicit supervision criteria, in addition to identifying the appropriate managers.

PURPOSE

The aim of our trial was to assess the effectiveness of the PMS applied to hip fracture versus the orthogeriatric co-management model in the acute phase.

METHODS

All consecutive patients aged ≥ 65 who were admitted to Hospital Universitario Infanta Leonor between January 1, 2009, and December 31, 2016, for acute hip fracture surgery were included. We compared the effectiveness indicators in the acute phase between the preprocess period (orthogeriatric co-management) and the process period.

RESULTS

One thousand two hundred twenty-two patients were included (76.6% women). Mean age (SD) was 83.9 (6.4) years. Effectiveness management indicators are the following: length of hospital stay, time to admission to the ward from the emergency department, preoperative stay, surgery in < 48 h, and the operating room availability which were all improved in the process period with statistical significance. Effectiveness clinical indicators are the following: the numbers of patients with operated limb loading approved after surgery, discharged to home, and with osteoporosis treatment postfracture at the time of discharge which were statistically significantly higher in the process period, and the number of patients who suffered from delirium was statistically significantly lower in the process period. The number of in-hospital deaths was lower during the process period without statistical significance.

CONCLUSION

Our results demonstrated the effectiveness of the PMS applied to hip fracture in older adults compared with an orthogeriatric co-management model in the acute phase, based on both management indicators and clinical indicators.

Which is the optimal orthogeriatric care model to prevent mortality of elderly subjects post hip fractures? A systematic review and meta-analysis based on current clinical practice

BACKGROUND

While there is a general consensus of the impact of an orthogeriatric organisation in terms of elderly patient mortality post hip fracture, it is unclear which, among these various care models, is the most optimal.

METHODS

A systematic review of the literature was undertaken using the keywords "Femoral fractures or total hip replacements or Accidental, falls" and "Aged, 80 and over" and "Mortality". The review is presented following PRISMA guidance.

RESULTS

Eighteen studies were identified, published between 1988 and 2015. The number of elderly subjects participating in these studies was between 37 and 951; their mean age was 82.6 ± 7.4 years, and average mortality in these studies was 17.7%. The odds ratio (OR) and 95% CI for association between implementation of the orthogeriatric model and mortality in all patients studied were 0.85 (0.74-0.97). In the analysis by subgroup on the type of orthogeriatric model, the group "Orthogeriatric ward" gave homogenous results, with ORs and 95% CIs of 0.62 (0.48-0.80) unlike other models: "Shared care by orthopaedists and geriatricians "and "Geriatric advice in orthopaedic ward".

CONCLUSIONS

Elderly patients with hip fracture admitted early into any sort of orthogeriatric models or more specifically to a dedicated orthogeriatric ward had reduced long-term mortality. This study has to be completed by RCT showing the efficacy of orthogeriatric ward compared to other models using outcomes such as quality of life or functional recovery.

Association of orthogeriatric services with long-term mortality in patients with hip fracture

PURPOSE

To assess the impact of the comprehensive orthogeriatric care model (OGM) on 2-year survival, length of stay (LOS), discharges to nursing homes, and antiosteoporotic treatment (AOT) in patients with hip fracture.

METHODS

Retrospective cohort study. Hospitals were classified as OGM if the patient was cared for in a comprehensive orthogeriatric unit. We included data from patients ≥ 65 years old discharged between 2012 and 2013. The main outcome was 12- and 24-month mortality. The variables collected were sex, type of fracture, comorbidities, AOT, LOS, and discharge to nursing homes. Survival analysis was performed with Kaplan-Meier method and comparison with Mantel-Haenszel test. Factors associated with death were determined by logistic regression.

RESULTS

First admissions in the 12 (out of 32) hospitals with OGM were 3580 of 9215 (38.8%). Patients in OGM had more comorbidities and discharges to nursing homes, shorter LOS, and less prescription of AOT. Two years after the admission the deceased patients were 3000 (32.6%). The survival was lower in males (p < 0.001), in the older age groups (p < 0.001), and in patients with Charlson > 1 (p < 0.001). Factors associated with increased risk of death at 12 and 24 months (logistic regression) were male gender, age and Charlson > 1, while care in the OGM decreased the risk. OGM benefited more patients > 80 years and those with Charlson < 1.

CONCLUSIONS

Patients admitted in OGM have shorter stays, more discharges to nursing homes, lower prescription of AOT, and better 12- and 24-month survival adjusted by sex, age, and comorbidities compared to non-OGM care.

Quality indicators for in-hospital geriatric co-management programmes: a systematic literature review and international Delphi study

OBJECTIVE

To find consensus on appropriate and feasible structure, process and outcome indicators for the evaluation of in-hospital geriatric co-management programmes.

DESIGN

An international two-round Delphi study based on a systematic literature review (searching databases, reference lists, prospective citations and trial registers).

SETTING

Western Europe and the USA.

PARTICIPANTS

Thirty-three people with at least 2 years of clinical experience in geriatric co-management were recruited. Twenty-eight experts (16 from the USA and 12 from Europe) participated in both Delphi rounds (85% response rate).

MEASURES

Participants rated the indicators on a nine-point scale for their (1) appropriateness and (2) feasibility to use the indicator for the evaluation of geriatric co-management programmes. Indicators were considered appropriate and feasible based on a median score of seven or higher. Consensus was based on the level of agreement using the RAND/UCLA Appropriateness Method.

RESULTS

In the first round containing 37 indicators, there was consensus on 14 indicators. In the second round containing 44 indicators, there was consensus on 31 indicators (structure=8, process=7, outcome=16). Experts indicated that co-management should start within 24 hours of hospital admission using defined criteria for selecting appropriate patients. Programmes should focus on the prevention and management of geriatric syndromes and complications. Key areas for comprehensive geriatric assessment included cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers. Key outcomes for evaluating the programme included length of stay, time to surgery and the incidence of complications.

CONCLUSION

The indicators can be used to assess the performance of geriatric co-management programmes and identify areas for improvement. Furthermore, the indicators can be used to monitor the implementation and effect of these programmes.

Estimate of the Costs Caused by Adverse Effects in Hospitalised Patients Due to Hip Fracture: Design of the Study and Preliminary Results

Introduction: Hip fracture is a health problem that presents high morbidity and mortality, negatively influencing the patient’s quality of life and generating high costs. Structured analysis of quality indicators can facilitate decision-making, cost minimization, and improvement of the quality of care. Methods: We studied 1571 patients aged 70 years and over with the diagnosis of hip fracture at Hospital Universitario de la Ribera in the period between 1 January 2012 and 31 December 2016. Demographic, clinical, functional, and quality indicator variables were studied. An indirect analysis of the costs associated with adverse events arising during hospital admission was made. A tool based on the “Minimum Basic Data Set (CMBD)” was designed to monitor the influence of patient risk factors on the incidence of adverse effects (AE) and their associated costs. Results: The average age of the patients analysed was 84.15 years (SD 6.28), with a length of stay of 8.01 days (SD 3.32), a mean preoperative stay of 43.04 h (SD 30.81), and a mortality rate of 4.2%. Likewise, the percentage of patients with AE was 41.44%, and 11.01% of patients changed their cost as a consequence of these AEs suffered during hospital admission. The average cost of patients was €8752 (SD: 1,864) and the average cost increase in patients with adverse events was €2321 (SD: 3,164). Conclusions: Through the analysis of the main clinical characteristics and the indirect estimation of the complexity of the patients, a simple calculation of the average cost of the attention and its adverse events can be designed in patients who are admitted due to hip fracture. Additionally, this tool can fit the welfare quality indicators by severity and cost.

Is the modified Harris hip score valid and responsive instrument for outcome assessment in the Indian population with pertrochanteric fractures?

Introduction

The original Harris hip score (HHS) does not contain ability to perform squatting and sitting cross legged as items in the questionnaire and hence a need was felt to modify the Harris hip score so that it could stay relevant in functional assessment of Indian patients in the rural setting. Validity, responsiveness and ceiling floor effect of the Harris hip score after internal fixation of pertrochanteric fracture has not been previously described. The objective of the study was to investigate construct validity, responsiveness and ceiling floor effects of the modified Harris hip score (mHHS).

Methods

For evaluation of construct validity two hypotheses were formulated: first, there would be no difference in mHHS in cohort of patients treated with short or long proximal femoral nail and second, patients younger than 65 years will have higher mHHS compared to patients older than 65 years postoperatively. Proportion of patients obtaining lowest score of 0 point (floor effect) and those obtaining highest score of 100 points (ceiling effect) was evaluated at one, three and six months postoperatively. It is recommended that the proportion of ceiling and floor effect should be lower than 15% in order to deduce satisfactory internal and content validity of an outcome instrument. Responsiveness was evaluated using distribution based methods (effect size and standardised response mean) and anchor based method (area under the curve using receiver operating curve). Ability to perform cross leg sitting and squatting at six months postoperatively were chosen as two different external anchors. Effect size and standardised response mean values higher than 0.80 and area under the curve value higher than 0.70 are indicators of adequate responsiveness of an outcome instrument.

Results

Eighty one consecutive patients with pertrochanteric hip fractures and treated with long and short proximal femoral nail were included in this prospective observational study. Six patients were lost to follow-up due to mortality and complete functional outcome data was available in 75 patients (92.6%). The mean age was 68 years (range: 38-89 years). The mHHS at one, three and six months postoperatively was 39.9 ± 9.5, 61.6 ± 14.7 and 81.0 ± 15.9 respectively. The improvement in mHHS was significant at all time intervals. In accordance with the hypothesis, there was no significant difference in mHHS at one, three and six months postoperatively in patients treated with short or long proximal femoral nail. In accordance with the hypothesis, patients younger than 65 years had significantly better mHHS at one, three and six months postoperatively as compared to patients older than 65 years. There were no floor or ceiling effects at one, three and six months postoperatively. mHHS showed adequate internal responsiveness (Effect size = 4.34; standardised response mean = 4.26) and adequate external responsiveness (Area under curve = 0.77 and 0.89) using different external anchors.

Conclusion

The mHHS has adequate construct validity, internal validity and responsiveness to evaluate functional outcome of intramedullary nail fixation in pertrochanteric hip fractures in the Indian population.

Effectiveness of in-hospital geriatric co-management: a systematic review and meta-analysis

Background

geriatric consultation teams have failed to impact clinical outcomes prompting geriatric co-management programmes to emerge as a promising strategy to manage frail patients on non-geriatric wards.

Objective

to conduct a systematic review of the effectiveness of in-hospital geriatric co-management.

Data sources

MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to 6 May 2016. Reference lists, trial registers and PubMed Central Citations were additionally searched.

Study selection

randomised controlled trials and quasi-experimental studies of in-hospital patients included in a geriatric co-management study. Two investigators performed the selection process independently.

Data extraction

standardised data extraction and assessment of risk of bias were performed independently by two investigators.

Results

twelve studies and 3,590 patients were included from six randomised and six quasi-experimental studies. Geriatric co-management improved functional status and reduced the number of patients with complications in three of the four studies, but studies had a high risk of bias and outcomes were measured heterogeneously and could not be pooled. Co-management reduced the length of stay (pooled mean difference, -1.88 days [95% CI, -2.44 to -1.33]; 11 studies) and may reduce in-hospital mortality (pooled odds ratio, 0.72 [95% CI, 0.50-1.03]; 7 studies). Meta-analysis identified no effect on the number of patients discharged home (5 studies), post-discharge mortality (3 studies) and readmission rate (4 studies).

Conclusions

there was low-quality evidence of a reduced length of stay and a reduced number of patients with complications, and very low-quality evidence of better functional status as a result of geriatric co-management.

Predictive factors of hospital stay, mortality and functional recovery after surgery for hip fracture in elderly patients

OBJECTIVES

Due to its high prevalence and serious consequences it is very important to be well aware of factors that might be related to medical complications, mortality, hospital stay and functional recovery in elderly patients with hip fracture.

MATERIAL AND METHODS

A prospective study of a group of 130 patients aged over 75 years admitted for osteoporotic hip fracture. Their medical records, physical and cognitive status prior to the fall, fracture type and surgical treatment, medical complications and functional and social evolution after hospitalization were evaluated.

RESULTS

Patients with greater physical disability, more severe cognitive impairment and those who lived in a nursing home before the fracture had worse functional recovery after surgery. Treatment with intravenous iron to reduce transfusions reduced hospital stay and improved walking ability. Infections and heart failure were the most frequent medical complications and were related to a longer hospital stay. The prescription of nutritional supplements for the patients with real indication improved their physical recovery after the hip fracture CONCLUSIONS: Evaluation of physical, cognitive and social status prior to hip fracture should be the basis of an individual treatment plan because of its great prognostic value. Multidisciplinary teams with continuous monitoring of medical problems should prevent and treat complications as soon as possible. Intravenous iron and specific nutritional supplements can improve functional recovery six months after hip fracture.

Patient and system factors of time to surgery after hip fracture: a scoping review

OBJECTIVES

It is disputed whether the time a patient waits for surgery after hip fracture increases the risk of in-hospital death. This uncertainty matters as access to surgery following hip fracture may be underprioritised due to a lack of definitive evidence. Uncertainty in the available evidence may be due to differences in characteristics of patients, their injury and their care. We summarised the literature on patients and system factors associated with time to surgery, and collated proposed mechanisms for the associations.

METHODS

We used the framework developed by Arksey and O'Malley and Levac et al for synthesis of factors and mechanisms of time to surgery after hip fracture in adults aged >50 years, published in English, between 1 January 2000 and 28 February 2017, and indexed in MEDLINE, EMBASE, CINAHL or Ageline. Proposed mechanisms for reported associations were extracted from discussion sections.

RESULTS

We summarised evidence from 26 articles that reported on 24 patient and system factors of time to surgery post hip fracture. In total, 16 factors were reported by only one article. For 16 factors we found proposed mechanisms for their association with time to surgery which included surgical readiness, available resources, prioritisation and out-of-hours admission.

CONCLUSIONS

We identified patient and system factors associated with time to surgery after hip fracture. This new knowledge will inform evaluation of the putative timing-death association. Future interventions should be designed to influence factors with modifiable mechanisms for delay.

Prospective randomized study comparing two cephalomedullary nails for elderly intertrochanteric fractures: Zimmer natural nail versus proximal femoral nail antirotation II

OBJECTIVES

Although both clinical and biomechanical studies suggest that cephalomedullary implants have a mechanical advantage over extramedullary implants, a high rate of complications or implant failure remains in elderly patients with osteoporosis. In an attempt to address some of these challenges, new implants with improved designs named proximal femoral nail antirotation II (PFNA II) and Zimmer natural nail (ZNN) were developed for elderly patients. Although the PFNA II reportedly has good clinical outcomes, it is unclear which implant achieves better safety and efficacy for treating intertrochanteric hip fractures. The primary objective of this prospective, randomized trial involved 353 patients was to evaluate Harris Hip Score (HHS). The secondary objective was to compare results associated with clinical outcome such as operation time, fluoroscopy time, lateral hip pain, walking ability, and reoperation rate as well as the incidence of cut-out by using implant position and fracture reduction quality.

METHODS

353 patients with an intertrochanteric fracture amenable to either ZNN implant or PFNA II with a mean age of 77.0 years and a mean follow-up period of 12.3 months were included. We analyzed 353 patients with an intertrochanteric fracture treated using a ZNN implant (n=172, group I) or a PFNA II (n=181, group II) between January 2011 and August 2014.

RESULTS

There were no significant inter-group differences in HHS, walking ability, and reoperation rate were observed. However, operation and fluoroscopy time were significantly different between the two groups as well as group I showed a higher incidence of lateral hip pain than group II. In addition, no significant inter-group differences in cut-out rate determined by implant position and fracture reduction quality. We also found that cut-out was associated with lag screw position in the femoral head measured by Tip-apex distance (TAD) but not with reduction quality.

CONCLUSIONS

Although group I had significant longer operation and fluoroscopy time than group II, both implants are useful tools in the treatment of elderly intertrochanteric fractures as well as only TAD, but not Cleveland zone significantly correlated with lag screw cut-out.

Orthogeriatric Combined Management of Elderly Patients With Proximal Femoral Fracture: Results of a 1-Year Follow-Up

Introduction:

According to the expected demographical changes, the number of elderly trauma patients will increase exponentially over the next decades. Different models of an interdisciplinary orthogeriatric care have been developed. But there is only limited evaluation of their benefit without clear and evidence-based results. In 2011, we monitored the results of our orthogeriatric combined management by conducting a 1-year follow-up.

Methods:

We treated 231 patients presenting a proximal femoral fracture on our orthogeriatric ward. We obtained the epidemiological data and the geriatric assessments from all these patients. One year after discharge, we sent them a written questionnaire. Primary end points were the mortality and the functional outcome, measured by Barthel score, the requirement of care, and the residential status.

Results:

One hundred sixty-seven (72%) of the 231 patients completed the follow-up. The average age at admission was 81.5 years (70-99 years). The mortality rate was 2.4% during hospital stay and 31.4% after 1 year. The average Barthel score was 44 points at the time of admission, 55 points at discharge, and 72 points after 1 year. Forty-five percent of the patients were in requirement of care at the time of their admission. At the 1-year follow-up, 63% of the patients had some form of care, thus showing an increase of 18%. At the moment of the fracture, 77% of the patients were living in their own home and 23% in a nursing home. After 1 year, the surviving patients show nearly unchanged conditions (75% own home vs 25% nursing home). Eighty-six percent of the patients coming from their own home were able to continue living there independently.

Conclusion:

The orthogeriatric care is successful in reducing the short-time mortality without showing any effect on 1-year mortality. But the surviving patients seem to benefit from an improved functional outcome.

Scoping review of potential quality indicators for hip fracture patient care

OBJECTIVE

The purpose of this study is to identify existing or potential quality of care indicators (ie, current indicators as well as process and outcome measures) in the acute or postacute period, or across the continuum of care for older adults with hip fracture.

DESIGN

Scoping review.

SETTING

All care settings.

SEARCH STRATEGY

English peer-reviewed studies published from January 2000 to January 2016 were included. Literature search strategies were developed, and the search was peer-reviewed. Two reviewers independently piloted all forms, and all articles were screened in duplicate.

RESULTS

The search yielded 2729 unique articles, of which 302 articles were included (11.1%). When indicators (eg, in-hospital mortality, acute care length of stay) and potential indicators (eg, comorbidities developed in hospital, walking ability) were grouped by the outcome or process construct they were trying to measure, the most common constructs were measures of mortality (outcome), length of stay (process) and time-sensitive measures (process). There was heterogeneity in definitions within constructs between studies. There was also a paucity of indicators and potential indicators in the postacute period.

CONCLUSIONS

To improve quality of care for patients with hip fracture and create a more efficient healthcare system, mechanisms for the measurement of quality of care across the entire continuum, not just during the acute period, are required. Future research should focus on decreasing the heterogeneity in definitions of quality indicators and the development and implementation of quality indicators for the postacute period.

[Geriatric intervention in elderly hip fracture patients admitted to University Hospital of Guadalajara: Clincal, healthcare and economical repercussions]

OBJECTIVE

To evaluate the healthcare outcomes and economic impact of geriatric intervention in patients over 75 years old with hip fracture in acute phase.

MATERIAL AND METHODS

Retrospective study of patients admitted to the University Hospital of Guadalajara (HUGU) due to hip fracture. An analysis was made of the number of cases per year, preoperative period, hospital stay, and mortality of all the patients over 75 years admitted to the HUGU due to hip fracture between 2002 and 2013.

RESULTS

A total of 2942 patients were included. Comparing the activity of 2013 to that of 2006, the mean hospital stay fell from 18.5 to 11.2 days (-39.2%), and mortality from 8.9% to 6.8% (-23%). In contrast, the mean preoperative stay remained at a mean of 2.7 days versus 2.4 in previous years in the early post-intervention period. Hospital stay decreased, despite a progressive annual increase in the daily cost of hospitalisation due to hip fracture surgery, the reduced stay led to a reduction of the total cost by more than 900,000 euros each year. Geriatric intervention has gradually reduced mean hospital stay and mortality, although with a tendency to increase mean preoperative stay.

CONCLUSIONS

Geriatric intervention in patients with hip fracture reduces mortality and length of hospital stay, and decreasing costs.

Geriatric Hip Fracture Care: Fixing a Fragmented System

CONTEXT

Fragmentation in geriatric hip fracture care is a growing concern because of the aging population. Patients with hip fractures at our institution historically were admitted to multiple different services and units, leading to unnecessary variation in inpatient care. Such inconsistency contributed to delays in surgery, discharge, and functional recovery; hospital-acquired complications; failure to adhere to best practices in osteoporosis management; and poor coordination with outpatient practitioners.

OBJECTIVE

To describe a stepwise approach to systems redesign for this patient population.

DESIGN

We designed and implemented a comprehensive geriatric hip fracture program for patients aged 65 years and older at our academic Medical Center in October 2014. Key interventions included admission of all ward-status patients to the Orthopedics Service with hospitalist comanagement; geographic placement on the Orthopedics Unit; and standardized, evidence-based electronic order sets bundling geriatric best practices and a streamlined workflow for discharge planning.

MAIN OUTCOME MEASURES

Hospital length of stay.

RESULTS

We identified 271 admissions among 267 patients between January 1, 2012, and March 31, 2016; of those, 154 were before and 117 were after program implementation. Mean hospital length of stay significantly improved from 6.4 to 5.5 days (p = 0.004). The 30-day all-cause readmission rate and discharge disposition remained stable. The percentage of patients receiving osteoporosis evaluation and treatment increased significantly. The rate of completed 30-day outpatient follow-up also improved.

CONCLUSION

Our comprehensive geriatric hip fracture program achieved and sustained gains in the quality and efficiency of care by improving fragmentation in the health care system.