An effective team approach to improve postoperative hip fracture care

Implementation and operationalization of Integrated People-Centred Health Services delivery strategies in integrated osteoporosis care (IOC) initiatives: a systematic review

Integrated Osteoporosis Care (IOC) has been emerging over the past decade. To support integrated care initiatives, the World Health Organisation (WHO) has developed the Integrated People Centred Health Services (IPCHS) framework, which consists of five interdependent strategies. Five electronic databases (PubMed, Embase, World of Science, CINAHL, and Scopus) were searched for relevant studies published from January 1, 2010 to December 2022. Initiatives implementing collaborative practices and at least two IPCHS strategies were included. Quality assessment was performed using the Effective Public Health Practice Project checklist. Seventy-six publications describing 69 implementations met the inclusion criteria; 90% of them were implemented at the hospital level, and over half focused on secondary fracture prevention. Three implementations captured all five IPCHS strategies, and half applied three. Substrategies targeting individuals as beneficiaries were frequently employed. Substrategies requiring fundamental shifts (e.g., systemic coordination and updating) were seldomly implemented. Substantive heterogeneity in substrategy operationalization was observed. Patient education, standardized care, team-based care, care coordinators, and health care provider training were commonly pursued. IOC interventions have focused mainly on secondary fracture prevention in a hospital setting and have been narrowly operationalized. Future implementation should: employ all five IPCHS strategies; better align programmes, providers, and regulatory frameworks, while adapting funding mechanisms; and operationalize broader and more innovative substrategies.Registration: This review has been registered at the international prospective register of systematic reviews PROSPERO (CRD42021250244).

Improvement of Osteoporosis Medication after Multimodal Intervention in Patients with Hip Fracture: Prospective Multicenter Study

Background

The authors had earlier conducted a retrospective cohort study from 2008 to 2011 in Jeju Island, among 945 hip fracture patients above 50 years of age. Of these 945 patients, 344 patients (36.4%) underwent a bone mineral density test and 218 patients (23.1%) received treatment for osteoporosis. The purpose of this study was to determine whether a patient education program could improve osteoporosis management after hip fracture. The data of the previous study was used for comparison.

Methods

From November 1, 2014 to September 30, 2015, 190 patients above 50 years of age who were admitted for hip fractures at six different hospitals, were enrolled in the present study. During the hospitalization period, patients underwent education sessions and were provided brochures. Patients were evaluated for diagnosis and treatment of osteoporosis at six months after discharge and were followed-up for at least a year.

Results

Of the 222 patients with hip fractures, 190 patients (37 men, 153 women) were enrolled at six hospitals in 2015. Dual energy X-ray absorptiometry was performed on 115 patients (60.5%) and 92 patients (48.4%) were prescribed medication for osteoporosis at the time of discharge. A total of 43.7% and 40.2% of the patients were found to be compliant with osteoporosis medication at 6 months and 12 months follow-up respectively.

Conclusions

This interventional multicenter study demonstrated that a patient education program in patients with hip fractures can improve compliance to osteoporosis medication up to 12 months of follow-up.

Treatment of Hypovitaminosis D in an Orthopaedic Trauma Population

OBJECTIVES

To determine the incidence of hypovitaminosis D and to evaluate a supplementation intervention. We hypothesized that patients would exhibit high adherence with a free sample, and levels would become sufficient.

DESIGN

Prospective observational study.

SETTING

Level 1 trauma center.

PATIENTS

One hundred forty-four consecutive, skeletally mature patients treated for acute fractures.

INTERVENTION

All were provided 600 mg calcium and 800 IU vitamin D3 capsules twice daily.

MAIN OUTCOME MEASUREMENTS

Serum 25(OH) D levels were obtained on presentation and after supplementation. Patient surveys determined adherence, vitamin D intake, and sun exposure.

RESULTS

Ninety-one men and 53 women, mean age 45 years, mean body mass index 28.1, were studied. Mean baseline 25(OH) D level was 20.2 ng/mL, including 9 patients taking vitamin D supplements before injury. All others (mean baseline 16.9 ng/mL) were prescribed calcium and vitamin D and were offered free supplements when discharged. Seventy-seven patients completed surveys, and mean 25(OH) D level was 36.7 ng/mL after a mean of 7.0 weeks of supplementation (P < 0.0001). Seventy-nine percent reported adherence to supplement recommendations. All adherent patients achieved normal levels. Sixteen patients were nonadherent, with 10 who forgot to take the supplement, 4 choosing not to use it, 1 choosing to sell the sample, and 1 losing the sample.

CONCLUSION

Hypovitaminosis D was present in 97% of orthopaedic trauma patients who were not already taking supplements. The intervention was effective in reducing hypovitaminosis D within several weeks, with all supplemented patients achieving normal levels. Seventy-nine percent of patients adhered to recommendations. Further study to determine the long-term cost-effectiveness of this strategy seems warranted.

LEVEL OF EVIDENCE

Therapeutic, Level II. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Insurance Type on Fragility Fracture Patient Access to Endocrinology Under the Affordable Care Act

OBJECTIVES

To assess the effect of insurance type (Medicaid, Medicare, and private insurance) on fragility fracture patients' access to endocrinology specialists in the postoperative period.

MATERIALS AND METHODS

The research team called 247 board-certified endocrinologists in 8 representative states. The caller requested an appointment for her fictitious mother to be evaluated for osteoporosis after suffering a hip fracture that required surgery. The caller stated that her mother had an abnormal level of parathyroid hormone and her mother's orthopedic surgeon believed she needed to see an endocrinologist. Each office was called 3 times to assess the responses for each insurance type. For each call, we documented whether the patient was able to receive an appointment and the barriers the patient confronted to receiving an appointment.

RESULTS

About 15.8% of offices scheduled an appointment for a patient with Medicaid, compared to 48.6% for Medicare and 54.3% for BlueCross (P < .0001). Medicaid patients confronted more barriers to receiving appointments. There was no statistically significant difference in access for Medicaid patients in states that had expanded Medicaid versus states that had not expanded Medicaid. Medicaid reimbursement for a new level 3 patient visit did not significantly correlate with appointment success rates or wait times.

CONCLUSION

Despite the passage of the Affordable Care Act, Medicaid patients have reduced access to endocrinologists and more complex barriers to receiving appointments. A more robust strategy for increasing access to care for Medicaid patients would be more equitable.

The orthopaedist's role in healthcare system governance

BACKGROUND

Historically, physicians as participants in healthcare governance were shunned because of perceived potential for conflict of interest. This maxim is being revisited as health systems begin to appreciate the value presented by physician leaders.

QUESTIONS/PURPOSES

This overview of the orthopaedist's role in healthcare governance will be addressed in three sections: first to identify the need for change in American healthcare, second to examine the role that physicians should play in governing over this inevitable change, and third to outline strategies for effective participation for those physicians wishing to play a role in healthcare governance.

METHODS

The PubMed data set was queried applying the search commands "governance AND (healthcare OR hospital) AND (doctor OR physician OR surgeon)" for the time period 1969 to 2012. In addition, the bibliographies of relevant articles were reviewed. This search strategy returned 404 titles. Abstract and article review identified 19 relevant to the topic. Bibliographic review identified five more articles of relevance forming the foundation for this review.

RESULTS

The delivery of American health care will require change to face current economic realities. Organizations that embrace this change guided by the insight of physician governors are well positioned to recognize the simultaneous improvement in value and quality. Although few physicians are formally trained for these roles, multiple paths to becoming effective governors are available.

CONCLUSIONS

In this environment of rapid change in healthcare delivery, the medical insight of physician leadership will prove invaluable. Governing bodies should reach out to talented physicians and administratively talented physicians should rise to this challenge.