Identifying outcomes associated with co-managed care models for patients who have sustained a hip fracture: an integrative literature review

Construction and validation of a risk prediction model for delayed discharge in elderly patients with hip fracture

BACKGROUND

Because of their poor physical state, elderly hip fracture patients commonly require prolonged hospitalization, resulting in a drop in bed circulation rate and an increased financial burden. There are currently few predictive models for delayed hospital discharge for hip fractures. This research aimed to develop the optimal model for delayed hospital discharge for hip fractures in order to support clinical decision-making.

METHODS

This case-control research consisted of 1259 patients who were continuously hospitalized in the orthopedic unit of an acute hospital in Tianjin due to a fragility hip fracture between January and December 2021. Delayed discharge was defined as a hospital stay of more than 11 days. The prediction model was constructed through the use of a Cox proportional hazards regression model. Furthermore, the constructed prediction model was transformed into a nomogram. The model's performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). the STROBE checklist was used as the reporting guideline.

RESULTS

The risk prediction model developed contained the Charlson Comorbidity Index (CCI), preoperative waiting time, anemia, hypoalbuminemia, and lower limbs arteriosclerosis. The AUC for the risk of delayed discharge was in the training set was 0.820 (95% CI,0.79 ~ 0.85) and 0.817 in the testing sets. The calibration revealed that the forecasted cumulative risk and observed probability of delayed discharge were quite similar. Using the risk prediction model, a higher net benefit was observed than when considered all patients were at high risk, demonstrating good clinical usefulness.

CONCLUSION

Our prediction models could support policymakers in developing strategies for the optimal management of hip fracture patients, with a particular emphasis on individuals at high risk of prolonged LOS.

Recommended care received by geriatric hip fracture patients: where are we now and where are we heading?

INTRODUCTION

Despite the availability of clinical guidelines on the prevention and treatment of geriatric hip fractures, the percentage of recommended care received by patients is low. We conducted an importance-performance analysis for prioritizing interventions to improve the in-hospital management of these patients.

MATERIALS AND METHODS

A secondary data analysis was conducted on the in-hospital treatment of 540 geriatric hip fracture patients in 34 hospitals in Belgium, Italy, and Portugal. First, we assessed the level of expert consensus on the process indicators composing international guidelines on hip fracture treatment. Second, guideline adherence on in-hospital care was evaluated within and across hospitals. Third, an importance-performance analysis was conducted, linking expert consensus to guideline adherence.

RESULTS

Level of expert consensus was high (above 75%) for 12 of 22 process indicators identified from the literature. There is large between and within hospital variation in guideline adherence for these indicators and for none of the 540 patients were all 22 process indicators adhered to. Importance-performance analysis demonstrated that three indicators that had a high level of expert consensus also had a high level of adherence (above 80%). Nine indicators, most of which have been previously linked to patient outcomes, had a high level of expert consensus but a consistently low level of adherence across hospitals and are identified as priority areas for improvement.

CONCLUSIONS

Guideline adherence for the treatment of geriatric hip fracture patients is remarkably suboptimal. Importance-performance analysis is a useful strategic approach to assist practitioners and healthcare managers to improve the quality of care.

Minimal impact of a care pathway for geriatric hip fracture patients

BACKGROUND

Adherence to guidelines for patients with proximal femur fracture is suboptimal.

OBJECTIVE

To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes.

DESIGN

The European Quality of Care Pathways study is a cluster randomized controlled trial.

SETTING

26 hospitals in Belgium, Italy and Portugal.

SUBJECTS

Older adults with a proximal femur fracture (n = 514 patients) were included.

METHODS

Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures.

RESULTS

In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team.

DISCUSSION

Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00962910.

Building multidisciplinary health workforce capacity to support the implementation of integrated, people-centred Models of Care for musculoskeletal health

To address the burden of musculoskeletal (MSK) conditions, a competent health workforce is required to support the implementation of MSK models of care. Funding is required to create employment positions with resources for service delivery and training a fit-for-purpose workforce. Training should be aligned to define "entrustable professional activities", and include collaborative skills appropriate to integrated and people-centred care and supported by shared education resources. Greater emphasis on educating MSK healthcare workers as effective trainers of peers, students and patients is required. For quality, efficiency and sustainability of service delivery, education and research capabilities must be integrated across disciplines and within the workforce, with funding models developed based on measured performance indicators from all three domains. Greater awareness of the societal and economic burden of MSK conditions is required to ensure that solutions are prioritised and integrated within healthcare policies from local to regional to international levels. These healthcare policies require consumer engagement and alignment to social, economic, educational and infrastructure policies to optimise effectiveness and efficiency of implementation.

Using Care Bundles to Improve Surgical Outcomes and Reduce Variation in Care for Fragility Hip Fracture Patients

Introduction:

Fragility hip fractures constitute a large proportion of orthogeriatric admissions to orthopedic wards. This study looked at reducing variation in care in fragility hip fracture patients using a novel approach with care bundles. The care bundle comprises 5 elements targeted at providing adequate analgesia, early mobilization, improving recognition of delirium, and decreasing rates of urinary infections.

Methods:

A total of 198 patients who sustained a fragility hip fracture during the intervention period were included in the study. The primary outcome measure was compliance in applying the bundle to the study population, and secondary outcome measures were in-hospital mortality, acute length of stay, delirium and duration of delirium, and urinary tract infections.

Results:

During the 12-month intervention period, compliance to the bundle of care was 47% (n = 92) based on the “all-or-none” approach. This was 28% higher than the preintervention rate. Overall, there was an increased rate of compliance across all individual elements of the bundle in the intervention group when compared to the preintervention group (P = .01). The most significant clinical result was a 10.5% reduction in “in-hospital mortality” in the intervention group (P < .001).

Conclusion:

This study demonstrated that the implementation of specific care bundle in patients with fragility hip fracture significantly reduces variation in care.

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.

The SCHHS hip fracture clinical network experience-Improving care and outcomes through an interprofessional approach

BACKGROUND

Hip fractures are a major global health care issue, with the 1.26 million estimated cases in 1990 predicted to increase to 4.5 million by 2050. Varying models of care have been developed to improve outcomes following fragility hip fractures. Most of these care models embrace an interprofessional approach to care. Specialist orthopedic nurses play an important role in the management of fragility hip fracture patients and their contribution to the interprofessional health care team is an important predictor of patient outcomes.

ASSESSMENT OF THE PROBLEM

The Sunshine Coast Hospital and Health Service (SCHHS) is compromised of four hospitals in South East Queensland, Australia however only one large regional hospital provides specialist hip fracture services. Approximately, 350 older hip fracture patients present to the Sunshine Coast Hospital & Health Service (SCHHS) each year. We used Hospital Health round table (HHRT) data to identify and assess key performance care and management of hip fracture patient and outcomes at SCHHS. The HHRT is a nonprofit membership organisation of health services across Australia and New Zealand that aims to provide opportunity for Health Services to achieve best practice, collect analyse and publish information, identify ways to improve and promote collaboration and networking. Exemplars of best practice are also identified in the data so that organizations can adopt similar models of care. HHRT data identified underperformance in management of hip fracture patients in a number of quality indicators at the study site, including length of stay (LOS), time to surgery and relative stay index (RSI).

STRATEGIES FOR QUALITY IMPROVEMENT

Following review of HHRT data key stakeholders undertook a quality improvement project and formed the Hip Fracture Clinical Network Group (HFCNG). This was established in 2013 with the aim of improving outcomes and achieving key performance indicators for all elderly patients who sustain a hip fracture through active collaboration and regular communication between a broad group of key clinical stakeholders.

RESULTS OF THE QUALITY IMPROVEMENT PROJECT

Following the implementation of the initiative the Relative Stay Index reduced from 88% in 2012/13 to 78% in 2014/15, and the average LOS reduced from 10.4 days to 8.6 days. The percentage of patients receiving surgery within 2 days rose from 85% to 96%; demonstrating consistent outperformance of the time to surgery key performance indicator of 80%. The percentage of patients discharged to their place of usual residence increased from 45% to 54%. The rate of complications reduced slightly from 69% to 66%. Rates of hospital acquired anaemia reduced from 20.7% to 15%. Detection of delirium rose over the reporting period from 22% to 34%, enabling rapid management. We noted during this period that there was no corresponding increase in readmission rates for this group of patients. These data reflect improvement to clinical documentation and the appropriate identification of cognitive changes.

CONCLUSION

In this quality improvement report, we describe how key stakeholders were engaged to improve communication and collaboration, and how the use of a national benchmarking dataset enabled health care providers to identify care gaps and inconsistencies in clinical practice. This quality improvement project markedly improved collaboration, clinical practice and patient outcomes.