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Mazarello Paes V, Ting A, Masters J, Paes MVI, Graham SM, Costa ML, HIPCARE investigators. A systematic review of the association between early comprehensive geriatric assessment and outcomes in hip fracture care for older people. Bone Joint J 2025; 107-B:595-603. [PMID: 40449538 DOI: 10.1302/0301-620x.107b6.bjj-2024-1255.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2025]
Abstract
Aims Performance indicators are increasingly used to improve the quality of healthcare provided to hip fracture patients. Joint care, under orthopaedic surgeons and physicians with an interest in older patients, is one of the more common indicators of high-quality care. In this systematic review, we investigated the association between 'comprehensive geriatric assessment' and patient outcomes following hip fracture injury. Methods In total, 12 electronic databases and other sources were searched for evidence, and the methodological quality of studies meeting the inclusion criteria was assessed. The protocol for this suite of related systematic reviews was registered with PROSPERO (ID: CRD42023417515). Results A total of 24,591 articles were reviewed, and 39 studies met the inclusion criteria for the review, involving a total of 25,363 patients aged over 60 years with a hip fracture. There were five randomized clinical trials, three quasi-experimental studies, two non-randomized parallel group control trials, 22 pre-/post-intervention studies, and seven retrospective cohort studies, conducted between January 1992 and December 2021. The timing and content of a comprehensive geriatric assessment was ill-defined in many studies and care pathways were heterogeneous, which precluded meta-analysis of the data. Early comprehensive geriatric assessment was associated with improved outcomes in 31 of the 36 (86%) patient-reported outcomes, including improved mobility (acute/long-term), functional status, and better quality of life. In total, 155 out of 219 (70.78%) clinical outcomes derived from hospital records showed a positive association with early comprehensive geriatric review, including reduced preoperative time and length of hospital stay, reduced incidence of postoperative complications, fewer hospital readmissions, and lower mortality. Conclusion Early comprehensive geriatric assessments after hip fracture in older people is associated with improved patient-reported outcomes and better clinical outcomes such as reduced incidence of complications, length of hospital stay, preoperative waiting time, and mortality. Standardization of the definitions of 'early' and 'comprehensive' geriatric assessments and consistent reporting of care pathway models would improve future evidence synthesis.
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Affiliation(s)
- Veena Mazarello Paes
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | - Andrew Ting
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
- Kingston Hospital NHS Foundation Trust, London, UK
| | - James Masters
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | | | - Simon Mathew Graham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
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Mazarello Paes V, Ting A, Masters J, Paes MVI, Tutton E, Graham SM, Costa ML, on behalf of the HIPCARE investigators*. Which performance indicators are used globally for evaluating healthcare in patients with a hip fracture? : a mixed methods systematic review. Bone Jt Open 2025; 6:275-290. [PMID: 40043739 PMCID: PMC11882308 DOI: 10.1302/2633-1462.63.bjo-2024-0104.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2025] Open
Abstract
Aims Performance indicators are increasingly used to evaluate the quality of healthcare provided to patients with a hip fracture. The aim of this review was to map the variety of performance indicators used around the world and how they are defined. Methods We present a mixed methods systematic review of literature on the use of performance indicators in hip fracture care. Evidence was searched through 12 electronic databases and other sources. A Mixed Methods Appraisal Tool was used to assess methodological quality of studies meeting the inclusion criteria. A protocol for a suite of related systematic reviews was registered at PROSPERO (CRD42023417515). Results A total 24,634 articles were reviewed, of which 171 met the criteria of the review. Included studies were heterogenous in design and came from varied healthcare systems in 34 different countries. Most studies were conducted in high-income countries in Europe (n = 118), followed by North America (n = 33), Asia (n = 21), Australia (n = 10), and South America (n = 2). The highest number of studies in one country came from the UK (n = 45). Only seven of the 171 studies (< 2,000 participants) were conducted across ten low- and middle-income countries (LMICs). There was variation in the performance indicators reported from different healthcare systems, and indicators were often undefined or ambiguously defined. For example, there were multiple definitions of 'early' in terms of surgery, different or missing definitions of 'mobilization', and variety in what was included in an 'orthogeriatric assessment' in hip fracture care. However, several performance indicators appeared commonly, including time to surgery (n = 142/171; 83%), orthogeriatric review (n = 30; 17%), early mobilization after surgery (n = 58; 34%), and bone health assessment (n = 41; 24%). Qualitative studies (n = 18), mainly from high-income countries and India, provided evidence on the experiences of 192 patients and 138 healthcare professionals with regard to the use of performance indicators in clinical care and rehabilitation pathways. Themes included the importance of education and training in parallel with the introduction of performance indicators, clarity of roles with the clinical team, and the need for restructuring or integration of care pathways. Conclusion This review identified a large number of performance indicators related to the delivery of healthcare for patients with a hip fracture. However, their definitions and thresholds varied across studies and countries. Evidence from LMICs is sparse. Both qualitative and quantitative evidence indicates that there remains a pressing need for further research into the use and standardization of performance indicators in hip fracture care and their influence on patient outcomes and economic costs.
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Affiliation(s)
- Veena Mazarello Paes
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | - Andrew Ting
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
- Epsom and St Helier University Hospitals NHS Trust, London, UK
| | - James Masters
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | | | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | - Simon M. Graham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | - on behalf of the HIPCARE investigators*
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
- Epsom and St Helier University Hospitals NHS Trust, London, UK
- Queen Mary University of London, London, UK
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Nadaud J, Heidel E, Daley B, McKnight C. Outcomes After Implementation of a Fragility Fracture Pathway in Ground Level Falls. J Surg Res 2024; 301:704-708. [PMID: 39168043 DOI: 10.1016/j.jss.2024.07.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/09/2024] [Accepted: 07/19/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Fragility fractures occur due to low energy mechanisms and result in significant morbidity and mortality. This study reviews the implementation of a fragility fracture program at a level I trauma center. In this pathway, trauma surgery provides clearance followed by admission and management with medical service and orthopedic consultation for injuries which meet fragility fracture criteria. METHODS This pathway, implemented in July 2021, includes patients with isolated fractures secondary to a low energy mechanism. We compared cohorts 2-ys before (PRE) and after (POS) pathway implementation. Demographics (age, sex, fracture location, injury severity score, American Society of Anesthesiologists score) and outcome data were collected and analyzed using between-subjects analyses. Measured outcomes included deep vein thrombosis/pulmonary embolism, hospital mortality, disposition to hospice, nonoperative rate, unplanned intensive care unit admission, time to surgery (TTS), and length of stay (LOS). RESULTS The study included n = 1137 patients (n = 564 PRE and n = 573 POS). POS patients had a higher injury severity score (P = 0.003) and different fracture location (P = 0.017), but no other demographics were different. Trauma admission decreased after implementation (P < 0.001; PRE: 21.5%, POS: 1.8%) with no differences in outcomes except increases in LOS (P < 0.001; PRE: 114 h, POS: 124 h) and TTS (P < 0.001; PRE: 15 h, POS: 18 h). CONCLUSIONS Morbidity and mortality did not correlate with pathway implementation; however, TTS and LOS increased. Although TTS increased, it remained under the American Academy of Orthopedic Surgery 48-h recommendation. The TTS and LOS increases were potentially from COVID-19 or cohort demographic differences. Decreased trauma as admitting service demonstrates pathway adherence. These findings highlight the need for investigation to better understand fragility fracture pathways.
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Affiliation(s)
- Jack Nadaud
- University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee.
| | - Eric Heidel
- University of Tennessee Medical Center Department of Surgery, Knoxville, Tennessee
| | - Brian Daley
- University of Tennessee Medical Center Department of Surgery, Knoxville, Tennessee
| | - Catherine McKnight
- University of Tennessee Medical Center Department of Surgery, Knoxville, Tennessee
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Krickl J, Ittermann T, Thannheimer A, Schmidt W, Willauschus M, Ruether J, Loose K, Gesslein M, Millrose M. The Rising Problem of Hip Fractures in Geriatric Patients-Analysis of Surgical Influences on the Outcome. J Pers Med 2023; 13:1271. [PMID: 37623521 PMCID: PMC10455730 DOI: 10.3390/jpm13081271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/13/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Hip fractures in geriatric patients often have a poor outcome in terms of mortality, mobility as well as independence. Different surgical influence factors are known that improve the outcome. METHODS In this observational cohort study, 281 patients of a geriatric trauma unit were analyzed prospectively. Demographic factors, as well as data regarding the trauma mechanism and perioperative treatment, were recorded. The nutritional status was also analyzed. The follow-up was set to 120 days. RESULTS The key conclusion of this study is that a high ASA classification, the use of anticoagulatory medicine and malnutrition are significantly associated with higher mortality together with worse independence (p < 0.05). There is no significant difference in outcome concerning the time to surgery within the first 24 h. CONCLUSIONS Malnutrition seems to be an important risk factor for an adverse outcome of geriatric patients and therefore warrants a focus in multidisciplinary treatment. The risk factor ASA cannot be improved during the pre-surgery phase, but requires intensified care by a multidisciplinary team specialized in orthogeriatrics.
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Affiliation(s)
- Julian Krickl
- Department of Trauma Surgery and Sports Medicine, Garmisch-Partenkirchen Medical Centre, 82467 Garmisch-Partenkirchen, Germany; (J.K.); (A.T.); (W.S.)
| | - Till Ittermann
- Institute for Community Medicine, SHIP/Clinical-Epidemiological Research, University of Greifswald, 17489 Greifswald, Germany;
| | - Andreas Thannheimer
- Department of Trauma Surgery and Sports Medicine, Garmisch-Partenkirchen Medical Centre, 82467 Garmisch-Partenkirchen, Germany; (J.K.); (A.T.); (W.S.)
| | - Wolfgang Schmidt
- Department of Trauma Surgery and Sports Medicine, Garmisch-Partenkirchen Medical Centre, 82467 Garmisch-Partenkirchen, Germany; (J.K.); (A.T.); (W.S.)
| | - Maximilian Willauschus
- Department of Orthopedics and Traumatology, Paracelsus Medical University, 90471 Nuremberg, Germany; (M.W.); (J.R.); (K.L.); (M.G.)
| | - Johannes Ruether
- Department of Orthopedics and Traumatology, Paracelsus Medical University, 90471 Nuremberg, Germany; (M.W.); (J.R.); (K.L.); (M.G.)
| | - Kim Loose
- Department of Orthopedics and Traumatology, Paracelsus Medical University, 90471 Nuremberg, Germany; (M.W.); (J.R.); (K.L.); (M.G.)
| | - Markus Gesslein
- Department of Orthopedics and Traumatology, Paracelsus Medical University, 90471 Nuremberg, Germany; (M.W.); (J.R.); (K.L.); (M.G.)
| | - Michael Millrose
- Department of Trauma Surgery and Sports Medicine, Garmisch-Partenkirchen Medical Centre, 82467 Garmisch-Partenkirchen, Germany; (J.K.); (A.T.); (W.S.)
- Department of Orthopedics and Traumatology, Paracelsus Medical University, 90471 Nuremberg, Germany; (M.W.); (J.R.); (K.L.); (M.G.)
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Magida N, Myezwa H, Mudzi W. Factors Informing the Development of a Clinical Pathway and Patients' Quality of Life after a Non-Union Fracture of the Lower Limb. Healthcare (Basel) 2023; 11:1810. [PMID: 37372927 DOI: 10.3390/healthcare11121810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/03/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
Patients with non-union fractures spend extended periods of time in the hospital following poor healing. Patients have to make several follow-up visits for medical and rehabilitation purposes. However, the clinical pathways and quality of life of these patients are unknown. This prospective study aimed to identify the clinical pathways (CPs) of 22 patients with lower-limb non-union fractures whilst determining their quality of life. Data were collected from hospital records from admission to discharge, utilizing a CP questionnaire. We used the same questionnaire to track patients' follow-up frequency, involvement in activities of daily living, and final outcomes at six months. We used the Short Form-36 questionnaire to assess patients' initial quality of life. The Kruskal-Wallis test compared the quality of life domains across different fracture sites. We examined CPs using medians and inter-quantile ranges. During the six-month follow-up period, 12 patients with lower-limb non-union fractures were readmitted. All of the patients had impairments, limited activity, and participation restrictions. Lower-limb fractures can have a substantial impact on emotional and physical health, and lower-limb non-union fractures may have an even greater effect on the emotional and physical health of patients, necessitating a more holistic approach to patient care.
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Affiliation(s)
- Nontembiso Magida
- Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria, Private Bag x323, Arcadia, Pretoria 0007, South Africa
- Department of Physiotherapy, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Hellen Myezwa
- Department of Physiotherapy, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Witness Mudzi
- Centre for Graduate Support, University of Free State, Bloemfontein 9301, South Africa
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Tewari P, Sweeney BF, Lemos JL, Shapiro L, Gardner MJ, Morris AM, Baker LC, Harris AS, Kamal RN. Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review. JAMA Netw Open 2022; 5:e2231911. [PMID: 36112373 PMCID: PMC9482052 DOI: 10.1001/jamanetworkopen.2022.31911] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors. OBJECTIVE To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS. EVIDENCE REVIEW A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components. FINDINGS Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements. CONCLUSIONS AND RELEVANCE In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.
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Affiliation(s)
- Pariswi Tewari
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Brian F. Sweeney
- Stanford University School of Medicine, Mountain View, California
| | - Jacie L. Lemos
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lauren Shapiro
- Department of Orthopaedic Surgery, University of California, San Francisco
| | - Michael J. Gardner
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Arden M. Morris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Laurence C. Baker
- Department of Health Research and Policy, Stanford University, Stanford, California
| | - Alex S. Harris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Robin N. Kamal
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- VOICES Health Policy Research Center, Stanford University, Stanford, California
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Li Y, Tung KK, Cho YC, Lin SY, Lee CH, Chen CH. Improved outcomes and reduced medical costs through multidisciplinary co-management protocol for geriatric proximal femur fractures: a one-year retrospective study. BMC Geriatr 2022; 22:318. [PMID: 35410173 PMCID: PMC8996524 DOI: 10.1186/s12877-022-03014-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/24/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND To manage the rapidly growing incidence of, and related medical burden resulting from hip fractures in older adults in an aging society, studies involving orthogeriatric co-management treatment models have reported improved outcomes, including reduced medical costs. The treatment gap for osteoporosis was however seldom emphasized in the published treatment protocols. Aiming to improve the existing orthogeriatric protocol, we have established a patient-centered protocol for elderly patient hip fractures, which simultaneously focuses on fracture care and anti-osteoporosis agent prescription in regarding to healthcare quality and medical expense. METHODS This was a retrospective study comparing patients who enrolled in the multidisciplinary co-managed protocol for geriatric hip fractures and those who did not. The inclusion criteria for this study were: (a) single-sided hip fractures treated from 1 to 2018 to 30 June 2020, (b) patients who were 60-years or older (c) trauma treated within 3 days from time of injury, and (d) minimal follow-up period of 12 months after surgery. RESULTS From 1 to 2018 to 30 June 2020, 578 patients were included (267 patients in the protocol group vs. 331 patients in the conventional group). The protocol group was associated with significantly reduced lengths of hospital stay (p = 0.041), medical expenditures (p = 0.006), and mortality (p = 0.029) during their acute in-hospital admission period. Early osteoporosis diagnosis and anti-osteoporosis agent prescription were achieved in the protocol group, with a significantly wider coverage for BMD assessment (p < 0.001) and prescriptions for anti-osteoporosis medication (p < 0.001). Yet, there was no significant decline in the one-year refracture rate in the protocol group. CONCLUSIONS The implementation of a multidisciplinary co-managed care protocol for geriatric proximal femur fractures successfully improved patient outcomes with significantly reduced lengths of stay, medical expenditures, and mortality during the acute in-hospital admission period. The high prescription rate of anti-osteoporosis medication after hip fractures in the protocol group was not associated with a significantly lower re-fracture rate in the 12-month follow-up. However, the association between early anti-osteoporosis agent prescription and reduced long-term medical expenses in this group of patients has provided a direction for future research.
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Affiliation(s)
- Yang Li
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuan-Kai Tung
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Cheng Cho
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Yi Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hung Lee
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Hui Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Department of Orthopedics, Changhua Christian Hospital, Changhua, Taiwan. .,, No. 135, Nanxiao St, Changhua County, 50006, Changhua City, Taiwan.
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Liu G, Yang MH, Zhu SW, Zhang P, Wang G, Wang MY, Wu XB. Effect of Orthogeriatric Co-Management on Geriatric Hip Fractures in China. Orthop Surg 2022; 14:671-677. [PMID: 35174660 PMCID: PMC9002067 DOI: 10.1111/os.13233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Although geriatric hip fracture is a serious public health problem in China, the result of orthogeriatric co‐management (OGC) is rarely reported. This study aimed to evaluate the effect of OGC in Chinese patients aged ≥65 years. Methods In this single‐centre, pre‐post intervention, retrospective study, traditional orthopaedic care (TOC) was used until OGC was implemented in May 2015, a multidisciplinary team was organized, and clinical protocol was designed. Consecutive hip fracture patients who were ≥65 years and injured within 3 weeks were included in this study. Demographic characteristics, comorbidities, fracture patterns, surgical procedure, time to surgery, length of hospital stay, inpatient complications, and in‐hospital mortality were extracted and examined. At 1‐year after surgery, data on patients' mobility and mortality were collected. The time to surgery, incidence of inpatient complications, mortality and functional outcomes were compared between the groups. Results There were no significant differences in sex, fracture type, and surgical pattern between OGC (n = 434) and TOC (n = 452) groups. Patients in OGC group were significantly older (P < 0.001) and had a higher age‐adjusted Charlson comorbidity index (P < 0.001). However, waiting time between admission and operation was significantly lower in OGC group (P < 0.001). There was no significant difference in the mortality rate at the time of the patient being in‐hospital and at 1, 3, and 6 months after surgery. Although 1‐year mortality was higher in OGC group (P = 0.036), Cox regression analysis showed no significant correlation of OGC with 1‐year mortality. There was no significant difference in pre‐injury mobility and 1‐year follow‐up mobility assessed by Parker score. Only approximately half of the patients in both groups completely returned to their pre‐injury mobility level. Conclusion OGC significantly shortens time to surgery for geriatric hip fractures compared with TOC. However, there is no significant effect on mortality rate within 1 year and functional status at 1 year of follow‐up.
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Affiliation(s)
- Gang Liu
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Ming-Hui Yang
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Shi-Wen Zhu
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Ping Zhang
- Department of Geriatric Medicine, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Geng Wang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Man-Yi Wang
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Xin-Bao Wu
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
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Allsop S, Morphet J, Lee S, Cook O. Exploring the roles of advanced practice nurses in the care of patients following fragility hip fracture: A systematic review. J Adv Nurs 2021; 77:2166-2184. [PMID: 33320350 DOI: 10.1111/jan.14692] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/26/2020] [Accepted: 11/05/2020] [Indexed: 12/20/2022]
Abstract
AIM This study aimed to explore the role and impact of advanced practice nurses (APNs) in care of patients following fragility hip fracture by systematically reviewing the available evidence. REVIEW DESIGN Systematic review. DATA SOURCES A search of the databases Ovid Medline, CINAHL, Embase, Emcare, Cochrane Library, and Google Scholar was conducted from January-February 2019. METHOD This systematic review adhered to The PRISMA Statement. Study selection was managed using the Covidence software platform and quality was assessed using JBI Critical appraisal tools. Studies included adults >18 years and described the role and impact of APNs in care of patients following fragility hip fracture on clinical and non-clinical outcomes. RESULTS There were 19 papers identified that met the inclusion/exclusion criteria. Quality was graded as moderate to low risk of bias. Six characteristics of APNs were identified: (1) coordination; (2) collaboration; (3) education; (4) assessment, investigation and treatment recommendations; (5) discharge planning, support and follow up; and (6) documentation. Overall mortality and LOS improved when characteristics of the APN role were present. CONCLUSION Key findings from this systematic review showed: (1) The APN title and role are not clearly defined, but characteristics of the APN role are evident; (2) characteristics of APNs promote the delivery of best practice hip fracture care and have a positive impact on mortality and LOS; and (3) innovative service delivery models involving APNs should be considered to address future projections of hip fracture rates and improve outcomes. IMPACT This systematic review provides evidence of the role characteristics of APNs in fragility hip fracture and the impact of the role on outcomes. Findings from this research could be used to develop service delivery models using APNs to care for patients following fragility hip fracture and to inform practice where APN roles may improve outcomes for other patient cohorts.
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Affiliation(s)
- Sharon Allsop
- Nursing & Midwifery, Monash University, Frankston, Vic, Australia
- Peninsula Health, Frankston, Vic, Australia
| | - Julia Morphet
- Nursing & Midwifery, Monash University, Frankston, Vic, Australia
| | - Susan Lee
- Nursing & Midwifery, Monash University, Frankston, Vic, Australia
| | - Olivia Cook
- Nursing & Midwifery, Monash University, Frankston, Vic, Australia
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Hip fractures in the elderly Chilean population: a projection for 2030. Arch Osteoporos 2020; 15:116. [PMID: 32720199 DOI: 10.1007/s11657-020-00794-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/21/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Using national databases, we projected the magnitude of hip fractures among the elderly Chilean population by 2030. Hip fractures will increase by 27.5% from 2018 to 9862 cases (95% CI = 8760 to 10,965). The most substantial growth is expected to occur in patients older than 80 years of age. INTRODUCTION There is scarce information regarding the magnitude of hip fractures that will be observed in Latin American countries in the near future. The aim of this study is to project the volume of hip fractures in the elderly Chilean population by the year 2030. METHODS The database of the Chilean Department of Statistics and Health Information, which includes all hospital discharges within Chile, was employed to evaluate the volume of hip fractures observed from 2012 to 2018 in the elderly population (≥ 65 years old). The annual incidence was determined by combining the volume of fractures with census data. Linear regression analysis was performed to determine the projected volume of hip fractures for 2030. RESULTS For 2030, hip fractures among the elderly population are projected to grow 27.5% (R2 = 0.92) to 9862 cases (95% CI = 8760 to 10,965). In the group from 65 to 79 years old, hip fractures are expected to grow 21.6% (R2 = 0.87) to 3046 cases (95% CI = 2686 to 3405). In patients ≥ 80 years of age, hip fractures are expected to grow 30.1% (R2 = 0.9) to 6817 cases (95% CI = 5889 to 7744). CONCLUSIONS A substantial growth in the volume of hip fractures is expected for the next decade among the elderly Chilean population, especially in patients ≥ 80 years of age. A national healthcare strategy should consider efforts to mitigate the impact of the future burden related to patients' care.
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Werner M, Krause O, Macke C, Herold L, Ranker A, Krettek C, Liodakis E. Orthogeriatric co-management for proximal femoral fractures. Can two additions make a big difference? BMC Musculoskelet Disord 2020; 21:371. [PMID: 32527237 PMCID: PMC7291750 DOI: 10.1186/s12891-020-03392-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proximal femoral fractures are a major socioeconomic burden and they occur mainly in geriatric patients. High mortality and complication rates are reported. To reduce the mortality and morbidity of these patients, co-management with geriatricians has been recommended. Most previous studies have focused on relatively comprehensive care models. Models with only a few additions to the usual care have not been extensively evaluated. METHODS This retrospective observational study included all patients aged ≥70 years (mean age: 84.5 ± 7.1 years, 70% women) with an isolated proximal femoral fracture treated surgically in our institution from May 2018 to October 2019. In the first 9 months, patients were treated with the usual care (control group, n = 103). In the second 9 months, patients were treated with our multidisciplinary care model (intervention group, n = 104), which included the usual care, plus: (1) one multidisciplinary ward round per week and (2) one "elective" operation slot per day reserved for proximal femoral fractures. Baseline characteristics and outcome measures of the hospital stay were extracted from electronic health records. A 3-month follow-up was conducted by phone. RESULTS Baseline characteristics were comparable between groups (p > 0.05). The hospital stay was shorter in the intervention group than in the control group (7.8 ± 4.3 vs. 9.1 ± 4.5; p = 0.022). The intervention reduced the waiting time for surgery by more than 10 h (intervention: 25.4 ± 24.5 vs. control: 35.8 ± 34.1 h; p = 0.013). A structured phone interview was not performed in 30.9% of the cases. The model reduced the overall dissatisfaction rate by more than half (12.9% vs. 32.4%; p = 0.008). On the other hand, the groups had similar perioperative complication rates (25% vs. 24.3%; p > 0.9999) and mortality (4.8% vs. 3.9%; p > 0.9999) and they remained similar at the 3-month follow-up (complications: 20.3% vs. 17.6% p = 0.831, mortality: 18.2% vs. 15.0% p = 0.573). CONCLUSION We found that two additions to the usual proximal femoral fracture regimen could significantly improve the overall satisfaction rate, reduce the length of hospital stay and shorten the waiting time for surgery. In contrast to previous studies, we observed no significant improvements in complication or mortality rates. Further changes in the standard care might be needed for this purpose.
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Affiliation(s)
- Maic Werner
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Olaf Krause
- Institute for General Medicine, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Macke
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Lambert Herold
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Alexander Ranker
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Emmanouil Liodakis
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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12
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Brink O. Hip fracture clearance: How much optimisation is necessary? Injury 2020; 51 Suppl 2:S111-S117. [PMID: 32081388 DOI: 10.1016/j.injury.2020.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.
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Affiliation(s)
- Ole Brink
- Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
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13
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Patel JN, Klein DS, Sreekumar S, Liporace FA, Yoon RS. Outcomes in Multidisciplinary Team-based Approach in Geriatric Hip Fracture Care: A Systematic Review. J Am Acad Orthop Surg 2020; 28:128-133. [PMID: 31977613 DOI: 10.5435/jaaos-d-18-00425] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Jay N Patel
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center, RWJBarnabas Health (Dr. Patel, Dr. Klein, Dr. Liporace, and Dr. Yoon); and Department of Internal Medicine, Jersey City Medical Center, RWJBarnabas Health (Dr. Sreekumar), Jersey City, NJ
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14
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Neuerburg C, Förch S, Gleich J, Böcker W, Gosch M, Kammerlander C, Mayr E. Improved outcome in hip fracture patients in the aging population following co-managed care compared to conventional surgical treatment: a retrospective, dual-center cohort study. BMC Geriatr 2019; 19:330. [PMID: 31775659 PMCID: PMC6880371 DOI: 10.1186/s12877-019-1289-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 09/23/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Hip fracture patients in the aging population frequently present with various comorbidities, whilst preservation of independency and activities of daily living can be challenging. Thus, an interdisciplinary orthogeriatric treatment of these patients has recognized a growing acceptance in the last years. As there is still limited data on the impact of this approach, the present study aimed to evaluate the long-term outcome in elderly hip fracture patients, by comparing the treatment of a hospital with integrated orthogeriatric care (OGC) with a conventional trauma care (CTC). METHODS We conducted a retrospective, two-center, cohort study. In two maximum care hospitals all patients presenting with a hip fracture at the age of ≥ 70 years were consecutively assigned within a 1 year period and underwent follow-up examination 12 months after surgery. Patients treated in hospital site A were treated with an interdisciplinary orthogeriatric approach (co-managed care), patients treated in hospital B underwent conventional trauma care. Main outcome parameters were 1 year mortality, readmission rate, requirement of care (RC) and personal activities of daily living (ADL). RESULTS A total of 436 patients were included (219 with OGC / 217 with CTC). The mean age was 83.55 (66-99) years for OGC and 83.50 (70-103) years for CTC (76.7 and 75.6% of the patients respectively were female). One year mortality rates were 22.8% (OGC) and 28.1% (CTC; p = 0.029), readmission rates were 25.7% for OGC compared to 39.7% for CTC (p = 0.014). Inconsistent data were found for activities of daily living. After 1 year, 7.8% (OGC) and 13.8% (CTC) of the patients were lost to follow-up. CONCLUSIONS Interdisciplinary orthogeriatric management revealed encouraging impact on the long-term outcome of hip fracture patients in the aging population. The observed reduction of mortality, requirements of care and readmission rates to hospital clearly support the health-economic impact of an interdisciplinary orthogeriatric care on specialized wards. TRIAL REGISTRATION The study was approved and registered by the bavarian medical council (BLAEK: 7/11192) and the local ethics committee of munich university (Reg. No. 234-16) and was conducted as a two-center, cohort study at a hospital with integrated orthogeriatric care and a hospital with conventional trauma care.
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Affiliation(s)
- Carl Neuerburg
- Department of General, Trauma and Reconstructive Surgery, University Hospital Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, D-81377, Munich, Germany.
| | - Stefan Förch
- Department of Trauma, Orthopedic, Hand and Reconstructive surgery, University Hospital Augsburg, Augsburg, Germany
| | - Johannes Gleich
- Department of General, Trauma and Reconstructive Surgery, University Hospital Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, D-81377, Munich, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, D-81377, Munich, Germany
| | - Markus Gosch
- Department of Medicine 2/Geriatrics, General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, D-81377, Munich, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopedic, Hand and Reconstructive surgery, University Hospital Augsburg, Augsburg, Germany
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Abstract
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.
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16
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Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay. J Am Acad Orthop Surg 2019; 27:e293-e300. [PMID: 30358636 PMCID: PMC6411423 DOI: 10.5435/jaaos-d-17-00447] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway. METHODS A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016. RESULTS LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications. DISCUSSION Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program. LEVEL OF EVIDENCE III.
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17
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Marcantonio AJ, Pace M, Brabeck D, Nault KM, Trzaskos A, Anderson R. Team Approach: Management of Postoperative Delirium in the Elderly Patient with Femoral-Neck Fracture. JBJS Rev 2019; 5:e8. [PMID: 29064845 DOI: 10.2106/jbjs.rvw.17.00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew J Marcantonio
- Departments of Orthopaedics (A.J.M.), Anesthesiology (M.P.), Hospital Medicine (D.B.), and Rehabilitation Services (A.T.), and Surgical Critical Care Clinical Pharmacy (K.M.N. and R.A.), Lahey Hospital and Medical Center, Burlington, Massachusetts
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18
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Gleich J, Pfeufer D, Zeckey C, Böcker W, Gosch M, Kammerlander C, Neuerburg C. Orthogeriatric treatment reduces potential inappropriate medication in older trauma patients: a retrospective, dual-center study comparing conventional trauma care and co-managed treatment. Eur J Med Res 2019; 24:4. [PMID: 30670088 PMCID: PMC6341562 DOI: 10.1186/s40001-019-0362-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/12/2019] [Indexed: 02/06/2023] Open
Abstract
Background Multimorbidity and polypharmacy are common challenges in the treatment of older trauma patients. Therefore, various integrated care models were developed over the last few years, merging the expertise of geriatricians and trauma surgeons. The aim of this study was to evaluate, if the number of prescriptions of potentially inappropriate medication (PIM) could be reduced in these patients by an interdisciplinary co-managed concept compared to conventional trauma care. Methods We conducted a retrospective, dual-center cohort study, including all patients aged 70 years and older admitted with a fracture of the hip or the proximal humerus within the study period. Patients were treated in the universities department of trauma surgery with two different hospital sites, one with conventional trauma care (CTC) and the other one with a certified orthogeriatric trauma unit (OGC). Based on the STOPP/START criteria by O´Mahony et al., PIMs were defined, which should be avoided in (ortho)geriatric patients. Medical records of each patient were analyzed at discharge. Besides patients basic information, all prescribed drugs, changes in the medication plan and who carried out these changes were collected. For statistical analysis based on the data quality and distribution, the t test, Mann–Whitney U test and the Chi-square test were used. Results A total of 95 patients were included, 73 of them females, with an average age of 82.59 years (SD ± 6.96). Mean length of hospital stay was 12.98 at CTC and 13.36 days at OGC (p = 0.536). Among conventional care (41 patients), prescription of one or more PIMs was found in 85.4% of the patients, whereas at the orthogeriatric ward (54 patients) only in 22.2% (p < 0.001). Besides that, changes in medication were made for 48.1% of the patients during their stay on the orthogeriatric ward. Conclusions Our findings show that an integrated care concept can reduce the number of prescriptions of PIMs significantly and potentially avoids adverse drug reactions and additional burdens in older trauma patients.
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Affiliation(s)
- Johannes Gleich
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Daniel Pfeufer
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christian Zeckey
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Markus Gosch
- Department of Medicine 2/Geriatrics, Paracelsus Private Medical University, General Hospital Nuremberg, Nuremberg, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Carl Neuerburg
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
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Implementation of a Hip Fracture Care Pathway Using Lean Six Sigma Methodology in a Level I Trauma Center. J Am Acad Orthop Surg 2018; 26:881-893. [PMID: 30289794 DOI: 10.5435/jaaos-d-16-00947] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The application of Lean Six Sigma (LSS) methodology with regard to hip fracture care remains unexamined. The aim of this study is to illustrate the application of LSS principles in the implementation of a hip fracture integrated care pathway (ICP). METHODS A multidisciplinary team at a level I trauma center formed a hip fracture ICP using LSS principles. An ICP aimed toward decreasing time to surgery to <48 hours was implemented in April 2012. RESULTS A total of 505 hip fracture patients met inclusion criteria. A total of 221 patients entered the preimplementation cohort, and 284 were incorporated in the postimplementation cohort. The percentage of patients who received surgical fixation beyond 48 hours significantly decreased (9.50% versus 4.23%; P = 0.01). Significantly more complications were detected in the postimplementation cohort (62.44% versus 80.10%; P < 0.01). The postimplementation cohort showed a significantly shorter length of stay (P = 0.02) and decreased hospital cost (P = 0.016). CONCLUSION Our findings suggest that using LSS methods in an ICP at our institution resulted in markedly greater percentage of patients receiving surgical care within 48 hours, greater detection of complication, and reduced resource consumption.
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Dixon J, Ashton F, Baker P, Charlton K, Bates C, Eardley W. Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol. Geriatr Orthop Surg Rehabil 2018; 9:2151459318806443. [PMID: 30377550 PMCID: PMC6202735 DOI: 10.1177/2151459318806443] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/06/2018] [Accepted: 09/19/2018] [Indexed: 11/15/2022] Open
Abstract
Introduction As the number of patients sustaining hip fractures increases, interventions aimed at improving patient comfort and reducing complication burden acquire increased importance. Frailty, cognitive impairment, and difficulty in assessing pain control characterize this population. In order to inform future care, a review of pain assessment and the use of preoperative intravenous paracetamol (IVP) is presented. Materials and Methods Systematic review of preoperative IVP administration in patients presenting with a hip fracture. Results Intravenous paracetamol is effective in the early management of pain control in the hip fracture population. There is a considerable decrease in use of breakthrough pain medications when compared with other pain relief modalities. Additionally, IVP reduces the incidence of opioid-induced complications, reduces length of stay, and lowers mean pain scores. Another significant finding of this study is the poor administration of all analgesics to patients with hip fracture with up to 72% receiving no prehospital analgesia. Discussion The potential benefits of IVP as routine in the early management of hip fracture-related pain are clear. Studies of direct comparison between analgesia regimes to inform optimum bundles of analgesic care are sparse. This study highlights the need for properly constructed pathway-driven comparator studies of contemporary analgesia regimes, with IVP as a central feature to optimize pain control and minimize analgesia-related morbidity in this vulnerable population.
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Affiliation(s)
- Ján Dixon
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Fiona Ashton
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Paul Baker
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Karl Charlton
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Charlotte Bates
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - William Eardley
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
- William Eardley, Department of Trauma & Orthopaedics, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, England, United Kingdom.
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Casey SD, Stevenson DE, Mumma BE, Slee C, Wolinsky PR, Hirsch CH, Tyler K. Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program. West J Emerg Med 2017; 18:585-591. [PMID: 28611877 PMCID: PMC5468062 DOI: 10.5811/westjem.2017.3.32853] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 11/30/2016] [Accepted: 03/02/2017] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Over 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures. METHODS We performed a retrospective study including patients age ≥65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation. RESULTS We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45-63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%; p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs. 10mg, p<0.001) than patients in the pre-GFP period. CONCLUSION Implementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes.
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Affiliation(s)
- Scott D Casey
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Dane E Stevenson
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Bryn E Mumma
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Christina Slee
- UC Davis Medical Center, Department of Quality and Safety, Sacramento, California
| | - Philip R Wolinsky
- University of California, Davis School of Medicine, Department of Orthopaedic Surgery, Sacramento, California
| | - Calvin H Hirsch
- University of California, Davis School of Medicine, Department of Internal Medicine, Sacramento, California
| | - Katren Tyler
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
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22
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Pitzul KB, Munce SEP, Perrier L, Beaupre L, Morin SN, McGlasson R, Jaglal SB. Scoping review of potential quality indicators for hip fracture patient care. BMJ Open 2017; 7:e014769. [PMID: 28325859 PMCID: PMC5372037 DOI: 10.1136/bmjopen-2016-014769] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/17/2017] [Accepted: 02/21/2017] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Kristen B Pitzul
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sarah E P Munce
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Laure Perrier
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Beaupre
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Susan B Jaglal
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
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Geriatric hip fracture management: keys to providing a successful program. Eur J Trauma Emerg Surg 2016; 42:565-569. [PMID: 27241865 DOI: 10.1007/s00068-016-0685-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hip fractures are a common event in older adults and are associated with significant morbidity, mortality and costs. This review examines the necessary elements required to implement a successful geriatric fracture program and identifies some of the barriers faced when implementing a successful program. INTERVENTION The Geriatric Fracture Center (GFC) is a treatment model that standardizes the approach to the geriatric fracture patient. It is based on five principles: surgical fracture management; early operative intervention; medical co-management with geriatricians; patient-centered, standard order sets to employ best practices; and early discharge planning with a focus on early functional rehabilitation. Implementing a geriatric fracture program begins with an assessment of the hospital's data on hip fractures and standard care metrics such as length of stay, complications, time to surgery, readmission rates and costs. Business planning is essential along with the medical planning process. CONCLUSION To successfully develop and implement such a program, strong physician leadership is necessary to articulate both a short- and long-term plan for implementation. Good communication is essential-those organizing a geriatric fracture program must be able to implement standardized plans of care working with all members of the healthcare team and must also be able to foster relationships both within the hospital and with other institutions in the community. Finally, a program of continual quality improvement must be undertaken to ensure that performance outcomes are improving patient care.
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Kates SL. CORR Insights(®): Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis. Clin Orthop Relat Res 2016; 474:234-6. [PMID: 26324835 PMCID: PMC4686487 DOI: 10.1007/s11999-015-4538-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 08/20/2015] [Indexed: 01/31/2023]
Affiliation(s)
- Stephen L Kates
- Department of Orthopaedics, University of Rochester, 601 Elmwood Ave., Box 665, Rochester, NY, 14620, USA.
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Abstract
This manuscript will evaluate the published evidence on efficacy of organized hip fracture programs to determine if they improve patient outcomes. A detailed literature search was conducted to find manuscripts published in the past 20 years about organized hip fracture care programs. Seventeen programs with published results were identified from this detailed search and these were evaluated and synthesized in the following manuscript. Organized hip fracture programs offer significant benefits to patients, care providers and health systems. The more complex program designs have a more profound effect on improvement in outcomes for hip fracture patients. Most programs have reported reduced length of stay, reduced in-hospital mortality rates, and reduced complications. Some programs have reported reduced costs and reduced readmission rates after implementing an organized hip fracture program.
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Affiliation(s)
- Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA.
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Abstract
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.
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Affiliation(s)
- S L Kates
- Department of Orthopaedic Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, 14642, Box 665, Rochester, NY, USA.
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Bollinger AJ, Butler PD, Nies MS, Sietsema DL, Jones CB, Endres TJ. Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures? Geriatr Orthop Surg Rehabil 2015; 6:202-8. [PMID: 26328237 PMCID: PMC4536513 DOI: 10.1177/2151458515588560] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hip fractures have significant effects on the geriatric population and the health care system. Prior studies have demonstrated both the safety of intravenous (IV) acetaminophen and its efficacy in decreasing perioperative narcotic consumption. The purpose of this study is to evaluate the effect of scheduled IV acetaminophen for perioperative pain control on length of hospital stay, pain level, narcotic use, rate of missed physical therapy (PT) sessions, adverse effects, and discharge disposition in geriatric patients with hip fractures. METHODS A retrospective review was performed of all patients 65 years and older admitted to a level I trauma center, who received operative treatment for a hip fracture over a 2-year period. Demographic data, in-hospital variables, and outcome measures were analyzed. Three hundred thirty-six consecutive fractures in 332 patients met inclusion criteria. These patients were divided into 2 cohorts. Group 1 (169 fractures) consisted of patients treated before the initiation of a standardized IV acetaminophen perioperative pain control protocol, and group 2 (167 fractures) consisted of those treated after the protocol was initiated. RESULTS Group 2 had a statistically significant shorter mean length of hospital stay (4.4 vs 3.8 days), lower mean pain score (4.2 vs 2.8), lower mean narcotic usage (41.3 vs 28.3 mg), lower rate of PT sessions missed (21.8% vs 10.4%), and higher likelihood of discharge home (7% vs 19%; P ≤ .001). Use of IV acetaminophen was also consistently and independently predictive of the same variables (P < .01). CONCLUSION The utilization of scheduled IV acetaminophen as part of a standardized pain management protocol for geriatric hip fractures resulted in shortened length of hospital stay, decreased pain levels and narcotic use, fewer missed PT sessions, and higher rate of discharge to home. LEVEL OF EVIDENCE Therapeutic level III.
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Affiliation(s)
- Alexander J. Bollinger
- Grand Rapids Medical Education Partners, Department of Orthopaedic Surgery, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Paul D. Butler
- Grand Rapids Medical Education Partners, Department of Orthopaedic Surgery, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Matthew S. Nies
- Department of Orthopaedic Surgery, University of Wisconsin, Madison, WI, USA
| | - Debra L. Sietsema
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | - Clifford B. Jones
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | - Terrence J. Endres
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
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Mears SC, Kates SL. A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2. Geriatr Orthop Surg Rehabil 2015; 6:58-120. [PMID: 26246957 DOI: 10.1177/2151458515572697] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.
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Lynch G, Tower M, Venturato L. Identifying outcomes associated with co-managed care models for patients who have sustained a hip fracture: an integrative literature review. Int J Orthop Trauma Nurs 2015; 19:140-54. [DOI: 10.1016/j.ijotn.2014.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 06/27/2014] [Accepted: 07/06/2014] [Indexed: 11/28/2022]
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Ventura C, Trombetti S, Pioli G, Belotti LMB, De Palma R. Impact of multidisciplinary hip fracture program on timing of surgery in elderly patients. Osteoporos Int 2014; 25:2591-7. [PMID: 25011985 DOI: 10.1007/s00198-014-2803-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/01/2014] [Indexed: 11/30/2022]
Abstract
UNLABELLED The effect of patient characteristics and organizational and system factors on time to surgery were studied using Emilia Romagna Region database and hospital survey. The results showed that the implementation of a Hip Fracture Program significantly increased the probability of early surgery while single intervention had only slight effect INTRODUCTION The purpose of this study is to evaluate the effect of formal Hip Fracture Program (HFP) on timing of surgery in hip fracture older patients. METHODS This is a retrospective cohort study based on Emilia Romagna administrative databases. Data on organizational and system factor were also obtained through a hospital survey. A multilevel logistic regression analysis was carried out to assess the effect of covariates on early surgery, taking into account patient level, hospital level, and trust level variability. RESULTS From 1 January to 31 December 2011, 5,520 subjects over 65 years old underwent surgical repair for hip fracture in Emilia Romagna. The mean waiting time to surgery was 3.4 ± 12.3 days, and the overall percentage of patients operated within 2 days was 52.2%. In the adjusted multilevel logistic model, significant risk factors affecting the timing of surgical intervention at patient level were age, comorbidity, day of admission, and antiplatelet or warfarin therapy while no significant single variables were found at hospital level including dedicated operation theater, hospital volume, dedicated orthogeriatric beds, and geriatrician involvement. The most significant variable was the implementation of HFP at trust level that increased three times the probability of early surgery after adjusting for confounding variables (OR 3.216, 95% CI 0.582-6.539). CONCLUSIONS Several modifiable organizational factors may affect the proportion of patients with hip fracture undergoing early surgery. This study suggests that the development and the implementation of an evidence-based HFP at trust level are a key point of the strategy of quality of care.
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Affiliation(s)
- C Ventura
- Regional Agency for Health and Social Care of Emilia-Romagna , Viale A. Moro, 21, Bologna, 40127, Italy
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Doshi HK, Ramason R, Azellarasi J, Naidu G, Chan WLW. Orthogeriatric model for hip fracture patients in Singapore: our early experience and initial outcomes. Arch Orthop Trauma Surg 2014; 134:351-7. [PMID: 24297214 DOI: 10.1007/s00402-013-1900-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The aging population is growing rapidly in Asia resulting in an increased number of fragility fractures. Studies have shown that an integrated model of care for the elderly can improve the quality of patient care and outcomes. This report describes our concept, initial experience and short-term outcomes of the integrated model of care that was established in managing geriatric hip fractures in Tan Tock Seng Hospital, Singapore. PATIENT AND METHODS An integrated care pathway model was implemented. The principle of the model is based on (a) timely admission, review, surgery, rehabilitation, transfer, (b) multidisciplinary approach and (c) integration of a care manager. Hip fracture patients (>60 years) were included in our study and were followed up for 1 year. Demographic data, Charlson comorbidity index (CCI), time to surgery, length of stay and modified Barthel index (MBI) scores were recorded. RESULTS The mean age was 82 years (62-108) with a female predominance (75 %). The mean CCI was 1.8. Time to admission was 3.7 h and mean time taken to be reviewed by an integrated care manager was 21.7 h. Close to 40 % of patients were operated within 48 h with a median time to surgery of 36.7 h. Mean length of stay was 10 days with an inpatient and 1-year mortality rate of 2.3 and 5.9 %, respectively. Complication rate was 5.1 % (urinary tract infection and wound infection) and MBI scores at 1 year revealed significant functional improvement of 95 % (p < 0.01). CONCLUSION Our integrated model of care for hip fractures can lead to satisfactory outcomes. Though the time to surgery and length of stay can be improved further, our initial results have shown a reasonable time to admission and review by a care manager. Besides a low complication and mortality rate, functional improvement was significant post-operatively.
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Affiliation(s)
- Hitendra K Doshi
- Department of Orthopaedics and Traumatology, Tan Tock Seng Hospital, National Health Group, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore,
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Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients. INTERNATIONAL ORTHOPAEDICS 2013; 38:1045-50. [PMID: 24337751 DOI: 10.1007/s00264-013-2218-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/17/2013] [Indexed: 01/17/2023]
Abstract
PURPOSE Modern management of the elderly with a hip fracture is complex and costly. The aim of this study was to compare the treatment-related hospital length of stay (HLOS) before and after implementing a clinical pathway for patients undergoing hip fracture surgery. METHODS This was a retrospective, before-and-after study. The first period ranged from June 21, 2008 to November 1, 2009 (N = 212), and the second was from January 7, 2010 to July 7, 2011 (N = 314). The electronic hospital system and patients records were reviewed for demographics, HLOS, mortality, complications and readmissions. RESULTS In the first period 53 % had a femoral neck fracture, of which 57 % were treated with hemiarthroplasty. In the second period this was 46 % and 71 %. Pertrochanteric fractures were treated with a Gamma nail in 85 % in the first period, and in 92 % in the second period. The median HLOS decreased from nine to six days (p < 0.001). For the hemiarthroplasty group HLOS decreased from nine to seven days (p < 0.001); for internal fixation there was no significant difference (five versus six days, p = 0.557) and after Gamma nailing it decreased from ten to six days (p < 0.001). For mortality no statistically significant difference was found (6 % versus 5 %, p = 0.698). Complications decreased for the Gamma nail group (44 % versus 31 %, p = 0.049). Readmissions for the total group were not different (16 % versus 17 %, p = 0.720). CONCLUSIONS Implementing a clinical pathway for hip fractures is a safe way to reduce the HLOS and it improves the quality of care.
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