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Zhou H, Ngune I, Roberts PA, Della PR. Integrated clinical pathways for lower limb orthopaedic surgeries: An updated systematic review. J Clin Nurs 2023; 32:2433-2454. [PMID: 35703679 DOI: 10.1111/jocn.16344] [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: 01/06/2022] [Revised: 03/20/2022] [Accepted: 04/25/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of the study was to comprehensively synthesise the components of integrated clinical pathways (ICPs) and post-operative outcomes of patients undergone total hip and knee arthroplasty (THA & TKA) and hip fracture surgeries. BACKGROUND Previous systematic reviews examined components and effectiveness of ICPs for lower limb joint replacement and hip fracture surgeries. DESIGN AND METHODS An updated systematic review guided by the Whittemore and Knafl (2005) framework. Electronic databases, Ovid MEDLINE, EBSCOhost-CINAHL, the Cochrane Reviews and Trails, EMBASE and PubMed, were searched from 2007 to 31 January 2021. Due to the heterogeneity of the methods and data collection tools of included studies, pooling of the quantitative data was not possible. Therefore, the included studies were synthesised and presented narratively under subthemes of arthroplasty and hip fracture surgeries. The PRISMA checklist for systematic reviews was used. RESULTS Twenty-four studies met selection criteria with 11 examined ICPs for hip fracture and 13 for the THA and TKA. Twenty-one ICPs were reviewed, and 33 components were extracted. The most frequently included components for hip fracture subgroup were 'discharge disposition arrangement' and 'dedicated personnel and resources'. 'Exercise plan' and 'pain management' were for the arthroplasty subgroup. A significant reduction in the length of stay and post-operative complications were associated with the ICPs. Results were mixed for the effectiveness of ICPs in reducing unplanned hospital admissions, mortality rates, post-operative complications and hospital costs. CONCLUSION The number of ICP components varied across studies. This review could not recommend a one size-fits-all ICP that could be adapted for use for patients undergoing hip fracture and joint replacement surgeries. RELEVANCE FOR CLINICAL PRACTICE This review identified research evidence-based components considered as essential for the inclusion in ICP's for hip fracture and arthroplasty surgeries. Further research is suggested to determine the patient experience and healthcare providers' acceptance of ICPs.
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Affiliation(s)
- Huaqiong Zhou
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Irene Ngune
- School of Nursing, Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - Pam A Roberts
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Phillip R Della
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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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: 6] [Impact Index Per Article: 3.0] [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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Houserman DJ, Raszewski JA, Palmer B, Chavan B, Sferrella A, Campbell M, Santanello S. The Impact of the Fascia Iliaca Block Beyond Perioperative Pain Control in Hip Fractures: A Retrospective Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221099107. [PMID: 35794869 PMCID: PMC9251979 DOI: 10.1177/21514593221099107] [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: 03/16/2022] [Revised: 04/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Geriatric hip fractures are common injuries that are associated with high morbidity and mortality. Adequate pain control remains a challenge as the altered physiology in elderly patients makes use of traditional analgesics challenging. The use of regional anesthetics, specifically the fascia iliaca compartment block (FICB), in the perioperative period has been shown to decrease opioid use in this population. This study aimed to investigate the effect the FICB had on pain control, length of stay, readmissions, and complications in a 30-day postoperative period. Methods This was a retrospective cohort study comparing patients who sustained hip fractures; one cohort (110 patients) received a preoperative fascia iliaca block with continuous infusion (FICB), whereas the other cohort (110 patients) did not receive a block (NO-FICB). Both cohorts were from level II trauma centers. Data were collected between 2016 and 2019. Descriptive statistics was performed to describe and summarize the data. Bivariate analysis was performed using chi-square test, with 2 tailed P-values ≤ .05 were considered statistically significant. Results The FICB group had a lower length of stay (3.9 days vs 4.8 days; P < .001), and lower pain scores on post-operative days 2 and 3 (P = .019). There was no difference in time from admission to surgery (P = .112) or narcotic use between cohorts (P = .304). However, the FICB group was more likely to discharge to a skilled nursing facility (P=.002), and more likely to be readmitted within 30 days (P = .047). There were no differences in medical complications or mortality between the 2 groups. Conclusions The primary study endpoint, length of stay, was found to be significantly shorter in the patients who underwent the FICB vs the group who did not undergo the FICB. Pain scores on POD2 and POD3 were lower in patients who received a FICB. This study adds to the body of evidence that the FICB is an effective addition to a multimodal pain pathway. Level of Evidence Level III Evidence – Retrospective Cohort Study
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Affiliation(s)
| | | | - Brandi Palmer
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA
| | | | - Abby Sferrella
- College of Osteopathic Medicine, Marian University, Indianapolis, IN, USA
| | - Melody Campbell
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA
| | - Steven Santanello
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA.,Parkview Health, Parkview Regional Medical Center, Fort Wayne, IN, USA
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Armstrong E, Yin X, Razee H, Pham CV, Sa-Ngasoongsong P, Tabu I, Jagnoor J, Cameron ID, Yang M, Sharma V, Zhang J, Close JCT, Harris IA, Tian M, Ivers R. Exploring Barriers to, and Enablers of, Evidence-Informed Hip Fracture Care in Five Low- Middle-Income Countries: China, India, Thailand, the Philippines and Vietnam. Health Policy Plan 2022; 37:1000-1011. [PMID: 35678318 DOI: 10.1093/heapol/czac043] [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: 11/11/2021] [Revised: 05/02/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Globally, populations are ageing and the estimated number of hip fractures will increase from 1.7 million in 1990 to more than 6 million in 2050. The greatest increase in hip fractures is predicted in Low- and Middle‑Income Countries (LMICs), largely in the Asia-Pacific region where direct costs are expected to exceed $US15 billion by 2050. The aims of this qualitative study are to identify barriers to, and enablers of, evidence informed hip fracture care in LMICs, and to determine if the Blue Book standards, developed by the British Orthopaedic Association and British Geriatrics Society to facilitate evidence informed care of patients with fragility fractures, are applicable to these settings. This study utilised semi-structured interviews with clinical and administrative hospital staff to explore current hip fracture care in LMICs. Transcribed interviews were imported into NVivo 12 and analysed thematically. Interviews were conducted with 35 participants from eleven hospitals in five countries. We identified five themes-costs of care and the capacity of patients to pay, timely hospital presentation, competing demands on limited resources, delegation and defined responsibility, and utilisation of available data-and within each theme, barriers and enablers were distinguished. We found a mismatch between patient needs and provision of recommended hip fracture care, which in LMICs must commence at the time of injury. This study describes clinician and administrator perspectives of the barriers to, and enablers of, high quality hip fracture care in LMICs; results indicate that initiatives to overcome barriers (in particular, delays to definitive treatment) are required. While the Blue Book offers a starting point for clinicians and administrators looking to provide high quality hip fracture care to older people in LMICs, locally developed interventions are likely to provide the most successful solutions to improving hip fracture care.
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Affiliation(s)
| | - Xuejun Yin
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - Husna Razee
- School of Population Health, UNSW Sydney, Australia
| | - Cuong Viet Pham
- Centre for Injury Policy and Prevention Research, Hanoi University of Public Health, Hanoi, Vietnam
| | - Paphon Sa-Ngasoongsong
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Irewin Tabu
- Orthopedic Trauma Division and Arthroplasty Service, University of the Philippines Manila -Philippine General Hospital, The Philippines
| | - Jagnoor Jagnoor
- Injury Division, The George Institute for Global Health, New Delhi, India.,UNSW Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, University of Sydney, St Leonards, Australia
| | - Minghui Yang
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Vijay Sharma
- Department of Orthopaedics, JPN Apex Trauma Centre, AIIMS, New Delhi, India
| | - Jing Zhang
- School of Population Health, UNSW Sydney, Australia
| | - Jacqueline C T Close
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Sydney, Australia; Prince of Wales Clinical School, UNSW Sydney, Australia
| | - Ian A Harris
- South Western Sydney Clinical School, UNSW Sydney, Liverpool, Australia; Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Healt, UNSW Sydneyh, Australia.,School of Public Health, Harbin Medical University, Harbin, China
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Payedimarri AB, Ratti M, Rescinito R, Vasile A, Seys D, Dumas H, Vanhaecht K, Panella M. Development of a Model Care Pathway for Myasthenia Gravis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11591. [PMID: 34770107 PMCID: PMC8582978 DOI: 10.3390/ijerph182111591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/29/2021] [Accepted: 10/31/2021] [Indexed: 12/21/2022]
Abstract
Myasthenia Gravis (MG) is a chronic, life-lasting condition that requires high coordination among different professionals and disciplines. The diagnosis of MG is often delayed and sometimes misdiagnosed. The goal of the care pathway (CP) is to add value to healthcare reducing unnecessary variations. The quality of the care received by patients affected with MG could benefit from the use of CP. We conducted a study aimed to define an inclusive, comprehensive, and multidisciplinary CP for the diagnosis, treatment, and care of MG. The development of the model CP, key interventions, and process indicators is based on the literature review and 85 international MG experts were involved in their evaluation, expressing a judgment of relevance through the Delphi study. 60 activities are included in the model CP and evaluated by the MG experts were valid and feasible. The 60 activities were then translated into 14 key interventions and 24 process indicators. We believe that the developed model CP will help for MG patients to have a timely diagnosis and high-quality, accessible, and cost-effective treatments and care. We also believe that the development of model CPs for other rare diseases is feasible and could aid in the integration of evidence-based knowledge into clinical practice.
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Affiliation(s)
- Anil babu Payedimarri
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Matteo Ratti
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Riccardo Rescinito
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Alessandra Vasile
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Deborah Seys
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, 3000 Leuven, Belgium
| | | | - Kris Vanhaecht
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, 3000 Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, University of Leuven, 3000 Leuven, Belgium
| | - Massimiliano Panella
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
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Minimizing Nonessential Follow-up for Hip Fracture Patients. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202106000-00002. [PMID: 34077401 PMCID: PMC8174547 DOI: 10.5435/jaaosglobal-d-21-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/30/2021] [Indexed: 11/23/2022]
Abstract
Hip fractures pose a significant burden to patients and care providers. The
optimal protocol for postoperative care across all surgically treated hip
fracture patients is unknown. The purpose of this study was to investigate the
effect that routine follow-up had on changing the clinical course.
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7
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Blauth M, Joeris A, Rometsch E, Espinoza-Rebmann K, Wattanapanom P, Jarayabhand R, Poeze M, Wong MK, Kwek EBK, Hegeman JH, Perez-Uribarri C, Guerado E, Revak TJ, Zohner S, Joseph D, Gosch M. Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study. BMJ Open 2021; 11:e039960. [PMID: 33972329 PMCID: PMC8112430 DOI: 10.1136/bmjopen-2020-039960] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 03/24/2021] [Accepted: 04/15/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes. DESIGN Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year. SETTING International (six countries, three continents) multicentre study. PARTICIPANTS 281 patients aged ≥70 with operatively treated proximal femur fractures. INTERVENTIONS Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy. OUTCOME MEASURES Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life. RESULTS Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002). CONCLUSIONS Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT02297581.
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Affiliation(s)
- Michael Blauth
- Formerly: Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Innsbruck, Austria
- Preclinical Clinical Medical, Depuy Synthes, Zuchwil, Switzerland
| | - Alexander Joeris
- AO Innovation Translation Center (AOITC), AO Foundation, Dübendorf, Switzerland
| | - Elke Rometsch
- AO Innovation Translation Center (AOITC), AO Foundation, Dübendorf, Switzerland
| | | | | | | | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Merng K Wong
- Orthopedic Surgery, Singapore General Hospital, Singapore
| | | | | | | | - Enrique Guerado
- Hospital Universitario Costa del Sol, Faculty of Medicine, University of Malaga, Marbella, Spain
| | - Thomas J Revak
- Department of Orthopaedic Surgery, Division of Orthopedic Trauma, Saint Louis University, Saint Louis, Missouri, USA
| | - Sebastian Zohner
- Klinik für Unfallchirurgie und Sporttraumatologie, Kepler Universitätsklinikum Med Campus III, Linz, Austria
| | - David Joseph
- Orthopedics, Elmhurst Hospital Center, Elmhurst, New York, USA
| | - Markus Gosch
- Paracelsus Medizinischen Privatuniversität für Geriatrie, Paracelsus Universitat Nurnberg, Nurnberg, Germany
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8
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National study: Most elderly patients benefit from earlier hip fracture surgery despite co-morbidity. Injury 2021; 52:905-909. [PMID: 33082028 DOI: 10.1016/j.injury.2020.10.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/24/2020] [Accepted: 10/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients. BACKGROUND Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival. METHODS A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015-2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age. RESULTS Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment. CONCLUSIONS Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account.
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9
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Sepehri A, O'Hara NN, Slobogean GP. Do standardized hip fracture care programs decrease mortality in geriatric hip fracture patients? Injury 2021; 52:541-547. [PMID: 33046253 DOI: 10.1016/j.injury.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 09/02/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
There is mounting support for the implementation of a standardized hip fracture program (SHFP) for geriatric patients. However, the current evidence to assess geriatric hip fracture outcomes following treatment in a SHFP is limited to small, single-center, observational studies. Using a large, multinational dataset, this study aims to assess whether enrollment in a SHFP was associated with improved 30-day patient-important outcomes in geriatric hip fracture patients. The secondary aim was to evaluate if the SHFP treatment effect varies by baseline mortality risk. An observational cohort study was conducted using data from the National Surgical Quality Improvement Program (NSQIP) for the years of 2016 and 2017. The study included 17,395 geriatric hip fracture patients over the age of 65. Over half (54%) of patients were enrolled in a SHFP on admission to hospital. The primary outcome was 30-day mortality. Secondary outcomes included 30-day reoperation and readmission. Multivariable logistic regression was used to estimate treatment effects, adjusting for race, anesthesia technique, and baseline mortality risk. The heterogeneity of treatment effect was determined by stratifying patients into quartiles based on their baseline mortality risk. The overall 30-day mortality risk was 6.6%. Enrollment in a SHFP did not reduce the 30-day risk of mortality (risk difference (RD): -0.2; 95% CI: -0.7, 0.3; p = 0.48), reoperation (RD: -0.2%; 95% CI: -0.6, 0.3; p = 0.36) or readmission (RD: -0.4%; 95% CI: -0.1, 0.4%; p = 0.20) when analyzed as a single sample. However, there were greater differences in the SHFP treatment effects when stratified by their preoperative mortality risk. Specifically, a 2.0% (95% CI: 4.2, 0.0%; p = 0.06) reduction in mortality was observed in the patients in the highest risk quartile for mortality and a 1.7% (95% CI: -3.2, -0.2%; p = 0.02) reduction in the medium-high risk quartile. The NSQIP data suggest that SHFPs do not significantly improve the short-term outcomes for the average geriatric hip fracture patient. However, a SHFP may significantly reduce the risk of 30-day mortality in higher risk patients. Therefore, the efficiency of SHFPs could potentially be improved with targeted deployment to high risk geriatric hip fracture patients.
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Affiliation(s)
- Aresh Sepehri
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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10
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Golinelli D, Boetto E, Mazzotti A, Rosa S, Rucci P, Berti E, Ugolini C, Fantini MP. Cost Determinants of Continuum-Care Episodes for Hip Fracture. Health Serv Insights 2021; 14:1178632921991122. [PMID: 33642863 PMCID: PMC7894600 DOI: 10.1177/1178632921991122] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/08/2021] [Indexed: 11/17/2022] Open
Abstract
Many factors affect the healthcare costs and outcomes in patients with hip fracture (HF). Through the construction of a Continuum-Care Episode (CCE), we investigated the costs of CCEs for HF and their determinants. We used data extracted from administrative databases of 5094 consecutive elderly patients hospitalized in 2017 in Emilia Romagna, Italy, to evaluate the overall costs of the CCE. We calculated the acute and post-acute costs from the date of the hospital admission to the end of the CCE. The determinants of costs by type of surgical intervention (total hip replacement, partial hip replacement, open reduction, and internal fixation) were investigated using generalized linear regression models. Regardless of the type of surgical intervention, hospital bed-based rehabilitation in public or private healthcare facilities either followed by rehabilitation in a community hospital/temporary nursing home beds or not were the strongest determinants of costs, while rehabilitation in intermediate care facilities alone was associated with lower costs. CCE's cost and its variability is mainly related to the rehabilitation setting. Cost-wise, intermediate care resulted to be an appropriate setting for providing post-acute rehabilitation for HF, representing the one associated with lower overall costs. Intermediate care organizational setting should be privileged when planning integrated care HF pathways.
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Affiliation(s)
- Davide Golinelli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum–University of Bologna, Italy
| | - Erik Boetto
- School of Hygiene and Preventive Medicine, Alma Mater Studiorum–University of Bologna, Italy
| | - Antonio Mazzotti
- 1st Orthopedic and Traumatologic Clinic, IRCCS–Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Simona Rosa
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum–University of Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum–University of Bologna, Italy
| | - Elena Berti
- Regional Agency for Health and Social Care, Emilia-Romagna Region - ASSR, Bologna, Italy
| | - Cristina Ugolini
- Department of Economics and CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum–University of Bologna, Italy
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11
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Li J, Shen K, Hu J, Li X, Liu J, Du Y, Huang K. The Clinicians' Satisfaction with Clinical Pathway Implementation: Preliminary Development of an Assessment Scale in China. Risk Manag Healthc Policy 2021; 14:303-313. [PMID: 33531848 PMCID: PMC7847415 DOI: 10.2147/rmhp.s290565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/18/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose To develop a satisfaction scale of Chinese clinicians with Clinical Pathway (CP) implementation and evaluate its validity, reliability and item discrimination. Materials and Methods Literature review, in-person interviews, and Delphi were used to design the scale. Data were collected in two phases using random sampling on the spot and an online survey. In the first phase, data from 239 clinicians were investigated in exploratory factor analysis. In the second phase, 513 valid questionnaires were collected and used for confirmatory factor analysis. Results The scale developed in this study has three dimensions (organization support, process identity, and effect perception) and a total of 21 items. Cronbach’s alpha of each dimension was higher than 0.9. The 3-factor model had enough fitness (χ2/df = 5.602, NFI = 0.926, IFI = 0.938, CFI = 0.938, RFI = 0.914, TLI = 0.929, RMSEA = 0.095, RMR = 0.045). The standardized factor loadings of 21 variables were between 0.742 and 0.949. The average variance extracted (AVE) of each dimension was higher than 0.7, and the construct reliability (CR) of the dimensions was higher than 0.9. The Chi-square difference test results showed that the difference value between the unlimited and limited model of each two potential constructs was higher than 3.84 (P < 0.001). Conclusion The clinicians’ satisfaction scale developed in this study has good construct validity, convergent validity, discriminant validity, internal consistency, and item discrimination. This suggests its usefulness as a tool to assess the satisfaction of clinicians in the implementation of CP in China.
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Affiliation(s)
- Junlong Li
- Sichuan Vocational College of Health and Rehabilitation, Zigong, Sichuan, People's Republic of China
| | - Kui Shen
- Sichuan Vocational College of Health and Rehabilitation, Zigong, Sichuan, People's Republic of China
| | - Jun Hu
- Health Information Center of Zigong, Sichuan, People's Republic of China
| | - Xinyue Li
- Finance Department, Zigong Fourth People's Hospital, Zigong, Sichuan, People's Republic of China
| | - Jie Liu
- Sichuan Vocational College of Health and Rehabilitation, Zigong, Sichuan, People's Republic of China
| | - Yonghong Du
- Sichuan Vocational College of Health and Rehabilitation, Zigong, Sichuan, People's Republic of China
| | - Kang Huang
- Health Commission of Zigong, Zigong, Sichuan, People's Republic of China
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Shi BY, Hannan CV, Jang JM, Ali I, Srikumaran U. Association Between Delays in Radiography and Surgery With Hip Fracture Outcomes in Elderly Patients. Orthopedics 2020; 43:e609-e615. [PMID: 32841359 DOI: 10.3928/01477447-20200812-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 08/05/2019] [Indexed: 02/03/2023]
Abstract
Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is "surgery delay" (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P=.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [Orthopedics. 2020;43(6):e609-e615.].
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Aletto C, Aicale R, Pezzuti G, Bruno F, Maffulli N. Impact of an orthogeriatrician on length of stay of elderly patient with hip fracture. Osteoporos Int 2020; 31:2161-2166. [PMID: 32572520 DOI: 10.1007/s00198-020-05510-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/16/2020] [Indexed: 12/16/2022]
Abstract
UNLABELLED Hip fracture patients are complex, and orthopaedic management is limited to the surgery phase. To provide better evaluation pre-operatively and an optimal level of post-operative care, an orthogeriatrician was introduced in the orthopaedic team. This ensured that time to surgery from admission consistently was below 48 h, decreasing hospitalization time after surgery and total length of stay. INTRODUCTION Hip fractures are a major health issue in elderly and frail patient. The integration of orthogeriatric care within the orthopaedic team could be useful to optimize the clinical conditions of these patients in perioperative phases and stabilize them after surgery, reducing hospital length of stay. The present study evaluates the role of an orthogeriatrician in the management of patients with a hip fracture. MATERIALS AND METHODS Data about patients admitted and operated from February to September 2018 and from February to September 2019 were collected from the San Giovanni di Dio e Ruggi d'Aragona Hospital of Salerno database. A total of 352 patients were identified and divided in two groups according to the year in which the orthogeriatrician was working in Orthopaedic Department. Records regarding age, sex, side and type of fracture, time of admission, day of surgery and discharge were collected and length of stay, days from the admission to surgery and days from surgery to discharge were calculated. RESULTS There were no statistically significant differences in the pre-surgery phases of both groups, and all patients were operated at a mean of 2.1 days ± 1.8 SD from admission (p > 0.05). No statistically significant difference between demographic data in both groups (p > 0.01) was observed. There was, however, statistically significant reduction of hospitalization time after surgery and total LOS from 2018 to 2019 (p < 0.01). CONCLUSION An Orthogeriatric doctor in an Orthopaedic and Traumatology Department may lead a multidisciplinary approach to manage elderly patients with hip fractures, ensuring that the time to surgery from admission is less than 48 h, and reducing hospitalization time after surgery and total length of stay.
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Affiliation(s)
- C Aletto
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - R Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - G Pezzuti
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - F Bruno
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - N Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy.
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England.
- Faculty of Medicine, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, England.
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de Jong L, van Rijckevorsel V, Klem TMAL, Kuijper M, Roukema GR. Prospective cohort protocol examining the perioperative indicators for complications and early mortality following hip fracture surgery in the frail patient. BMJ Open 2020; 10:e038988. [PMID: 32994255 PMCID: PMC7526269 DOI: 10.1136/bmjopen-2020-038988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The primary aim is to validate earlier suggested risk factors and to find new associated risk factors for (30-day) mortality after a hip fracture in the frail population. The secondary aim is to determine the factors associated with perioperative complications. At last we want to develop and validate a more specific 30-day mortality prediction tool compared with the Nottingham Hip Fracture Score. The 30-day mortality prediction can help inform surgical risk and guide shared decision-making among patients, family and physicians. METHODS AND ANALYSIS The study is designed as a prospective multicentre cohort study within the area of Rotterdam, the Netherlands starting from January 2018. All patients over 65 years of age, with an acute proximal hip fracture, are included. Treatment of patients will be by standard practice of care using the latest national and international guidelines. Inclusion will be continued at least until January 2021 and including at least 2500 patients. In this large cohort we hope to have sufficient strength and quality to identify risk factors of 30-day mortality and to compare them to known risk factors in literature. Moreover, we plan to develop and validate a 30-day mortality prediction tool, which identifies patients with a high probability of 30-day mortality. ETHICS AND DISSEMINATION Ethical approval for this protocol was given by the Ethics Committee of the Maasstad Hospital (TWOR). Patient data are stored anonymously using the Castor data management system. No external funding is used for this study. Results will be published in peer-reviewed publications and at international conferences. TRIAL REGISTRATION NUMBER NL8313.
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Affiliation(s)
- Louis de Jong
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Taco M A L Klem
- Department of Surgery, Franciscus Gasthuis en Vlietland Hospital, Rotterdam, The Netherlands
| | - Martijn Kuijper
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Gert R Roukema
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
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Schuijt HJ, Kusen J, van Hernen JJ, van der Vet P, Geraghty O, Smeeing DPJ, van der Velde D. Orthogeriatric Trauma Unit Improves Patient Outcomes in Geriatric Hip Fracture Patients. Geriatr Orthop Surg Rehabil 2020; 11:2151459320949476. [PMID: 32864179 PMCID: PMC7430081 DOI: 10.1177/2151459320949476] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Introduction: An aging population in developed countries has increased the number of
osteoporotic hip fractures and will continue to grow over the next decades.
Previous studies have investigated the effect of integrated orthogeriatric
trauma units and care model on outcomes of hip fracture patients. Although
all of the models perform better than usual care, there is no conclusive
evidence which care model is superior. More confirmative studies reporting
the efficacy of orthogeriatric trauma units are needed. The objective of
this study was to evaluate outcomes of hip fracture patients admitted to the
hospital before and after implementation of an orthogeriatric trauma
unit. Materials and methods: This retrospective cohort study was conducted at a level 2 trauma center
between 2016 and 2018. Patients aged 70 years or older with a hip fracture
undergoing surgery were included to evaluate the implementation of an
orthogeriatric trauma unit. The main outcomes were postoperative
complications, patient mortality, time spent at the emergency department,
time to surgery, and hospital length of stay. Results: A total of 806 patients were included. After implementation of the
orthogeriatric trauma unit, there was a significant decrease in
postoperative complications (42% vs. 49% in the historical cohort,
p = 0.034), and turnaround time at the emergency
department was reduced by 38 minutes. Additionally, there was significantly
less missing data after implementation of the orthogeriatric trauma unit.
After correcting for covariates, patients in the orthogeriatric trauma unit
cohort had a lower chance of complications (OR 0.654, 95% CI 0.471-0.908,
p = 0.011) and a lower chance of 1-year mortality (OR
0.656, 95% CI 0.450-0.957, p = 0.029). Conclusions: This study showed that implementation of an orthogeriatric trauma unit leads
to a decrease in postoperative complications, 1-year mortality, and time
spent at the emergency department, while also improving the quality of data
registration for clinical studies. Level of Evidence: Level III.
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Affiliation(s)
- Henk Jan Schuijt
- Department of Surgery, Sint Antonius Hospital, Utrecht, the Netherlands.,Department of Surgery, University Medical Center Utrecht, the Netherlands
| | - Jip Kusen
- Department of Surgery, Sint Antonius Hospital, Utrecht, the Netherlands.,Department of Surgery, University Medical Center Utrecht, the Netherlands
| | | | - Puck van der Vet
- Department of Surgery, Sint Antonius Hospital, Utrecht, the Netherlands.,Department of Surgery, University Medical Center Utrecht, the Netherlands
| | - Olivia Geraghty
- Department of Internal Medicine and Geriatrics, Sint Antonius Hospital, Utrecht, the Netherlands
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Peng K, Yang M, Tian M, Chen M, Zhang J, Wu X, Ivers R, Si L. Cost-effectiveness of a multidisciplinary co-management program for the older hip fracture patients in Beijing. Osteoporos Int 2020; 31:1545-1553. [PMID: 32219498 DOI: 10.1007/s00198-020-05393-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
UNLABELLED The multidisciplinary co-management program for geriatric patients with hip fracture is cost-effective in the Chinese population and it has the potential to be scaled up in China. INTRODUCTION The study aimed to investigate the cost-effectiveness of a multidisciplinary co-management program for patients with hip fracture in China. METHODS Hip fracture patients who were admitted to an orthopedic hospital in Beijing were included in the multidisciplinary co-management program. The cost-effectiveness of intervention was evaluated compared to the conventional management. A Markov microsimulation model was developed to simulate lifetime costs and effectiveness. Costs including intervention, hospitalization, medications, and long-term care costs were expressed using 2019 US dollars and the healthcare perspective was adopted. Effectiveness was evaluated using both 1-year mortality-averted and quality-adjusted life years (QALYs). Costs and effectiveness were discounted at 5% per annum. The willingness-to-pay (WTP) threshold was set at $26,481 per QALY gained which was three times gross domestic product (GDP) per capita in China. One-way and probabilistic sensitivity analyses were conducted. RESULTS The lifetime cost for the conventional management (n = 1839) and intervention group (n = 1192) was $11,975 and $13,309 respectively. The lifetime QALYs were 2.38 and 2.45 years and the first-year mortality was 17.8% and 16.1%. The incremental cost-effectiveness ratio was $19,437 per QALY gained or $78,412 per 1-year mortality-averted. Given the Chinese WTP threshold, the intervention had a 78% chance being cost-effective. The cost-effectiveness of the intervention was sensitive to cost of intervention and the proportion of patients who underwent surgery within 48 h. CONCLUSIONS The multidisciplinary co-management program for patients with hip fracture is cost-effective and it has the potential to be scaled up in the Chinese population.
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Affiliation(s)
- K Peng
- School of Public Health, The University of Sydney, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, NSW, 2042, Australia
| | - M Yang
- Department of Orthopedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - M Tian
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, NSW, 2042, Australia
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - M Chen
- School of Health Policy & Management, Nanjing Medical University, Nanjing, China
| | - J Zhang
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
- School of Public Health and Community Medicine, UNSW, Kensington, Australia
| | - X Wu
- Department of Orthopedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - R Ivers
- School of Public Health, The University of Sydney, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, NSW, 2042, Australia
- School of Public Health and Community Medicine, UNSW, Kensington, Australia
| | - L Si
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, NSW, 2042, Australia.
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Tittel S, Burkhardt J, Roll C, Kinner B. Clinical pathways for geriatric patients with proximal femoral fracture improve process and outcome. Orthop Traumatol Surg Res 2020; 106:141-147. [PMID: 31870558 DOI: 10.1016/j.otsr.2019.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 05/04/2019] [Accepted: 07/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the current study was to evaluate the implementation of clinical pathways (CPs) in hip fracture management. METHODS Six hundred and five proximal femoral fractures were prospectively included into a hospital data-base. The effects of CPs were evaluated using a pre-during-post design. Different procedural (time to surgery, length of stay, discharge, etc.) and patient outcome parameters (mortality, complications, etc.) were evaluated. RESULTS In both categories significant changes could be detected during the three-year period. E.g. significant reduction of time to surgery, improvement of discharge management, reduction of internal complications. However, no significant changes could be demonstrated for mortality or revision rate. CONCLUSION We could show a relevant improvement with the implementation of clinical pathways for the treatment of proximal femoral fractures in elderly patients. LEVEL OF EVIDENCE III, prospective non-randomised cohort study.
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Affiliation(s)
- Sandra Tittel
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Janosch Burkhardt
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Christina Roll
- Zentrum für Ambulante Rehabilitation, Regensburg, Germany
| | - Bernd Kinner
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
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Štrbac S, Rakić S, Vujić-Aleksić V, Škrbić R. The role of clinical pathways on healthcare quality improvement in hospitals for patient undergoing total hip replacement. SCRIPTA MEDICA 2020. [DOI: 10.5937/scriptamed51-26870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Effectiveness of regional clinical pathways on postoperative length of stay for hip fracture patients: A retrospective observational study using the Japanese Diagnosis Procedure Combination database. J Orthop Sci 2020; 25:127-131. [PMID: 30799165 DOI: 10.1016/j.jos.2019.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/29/2019] [Accepted: 02/04/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Regional clinical pathways, a new type of clinical pathway, are practiced with the aim of standardizing and optimizing medical care by cooperation among multiple medical institutions in a region. However, current evaluation of the effectiveness of regional clinical pathways for hip fracture, a major health problem requiring hospitalization for orthopedic surgery, is insufficient. This study aimed to determine the association between regional clinical pathways and postoperative hospital length of stay (LOS) among hip fracture patients. In particular, we focused on the variation in postoperative LOS of hip fracture patients among hospitals and the contribution of regional clinical pathways to this variation. METHODS Using data from the Diagnosis Procedure Combination (DPC) database in Japan from April 2011 to March 2013, patients who were diagnosed with "fracture of head and neck of femur" (ICD10 code S72.0) or "pertrochanteric fracture" (S72.1) and received "bipolar hip arthroplasty" or "open reduction and internal fixation" were extracted. A total of 110,133 patients were included. Associations between regional clinical pathways and postoperative LOS were analyzed using cross-sectional analysis with multilevel regression models. RESULTS Hospitals that implemented a regional clinical pathway showed a significant reduction (13 days) in the postoperative LOS of hip fracture patients. We found a 16% inter-hospital variation in postoperative LOS, which might be explained by hospital-level implementation of regional clinical pathways. Application of regional clinical pathways at the patient level resulted in a 4-day decrease in postoperative LOS. CONCLUSIONS Implementation of regional clinical pathways for hip fracture patients at the hospital level was associated with reduced postoperative LOS, regardless of whether or not pathways were implemented at the patient level. This suggests that regional clinical pathways are effective for patient care management in hospitals.
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The implementation of a Geriatric Fracture Centre for hip fractures to reduce mortality and morbidity: an observational study. Arch Orthop Trauma Surg 2019; 139:1705-1712. [PMID: 31309288 DOI: 10.1007/s00402-019-03229-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the effect of an orthogeriatric treatment model on elderly patients with traumatic hip fractures (THF). The Geriatric Fracture Centre (GFC) is a multidisciplinary care pathway with attention for possible age-related diseases, discharge management and out-of-hospital treatment. MATERIALS AND METHODS A prospective cohort study with a historical cohort group was conducted at a level I trauma centre in Switzerland. Patients over the age of 70 years with THFs who underwent surgical treatment at GFC in 2013 and 2016 were included. Primary outcomes were mortality and complications. Secondary outcomes were hospital length of stay (HLOS), time to surgery and place of discharge. RESULTS A total of 322 patients were included in this study. In 2016, mortality showed a reduction of 2.9% at 30 days (p = 0.42) and 3.4% at 90 days (p = 0.42) and 0.1% at 1 year (p = 0.98). The number of patients with a complicated course showed a decrease of 2.2% in 2016 (p = 0.69). A significant increase in the diagnosis of delirium by 11.2% was seen in 2016 (p < 0.001). The median HLOS was significantly reduced by 2 days (p < 0.001). An increase of 21.1% was seen in patients who were sent to rehabilitation in 2016 (p < 0.001). Day-time surgery increased by 10.2% (p = 0.04). CONCLUSION The implementation of the GFC leads to improved processes and outcomes for geriatric patients with THFs. Increased awareness and recognition led to an increase in the diagnosis of complications that would otherwise remain untreated. Expanding these efforts might lead to more significant effects and an increase in the reduction of morbidity and mortality in the future.
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Gioffrè-Florio M, Murabito LM, Visalli C, Pergolizzi FP, Famà F. Trauma in elderly patients: a study of prevalence, comorbidities and gender differences. G Chir 2019; 39:35-40. [PMID: 29549679 DOI: 10.11138/gchir/2018.39.1.035] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Trauma, in geriatric patients, increases with age, and is a leading cause of disability and institutionalization, resulting in morbidity and mortality. The aim of our study was to analyse the prevalence of trauma, the related risk factors, mortality and sex differences in the prevalence in a geriatric population. PATIENTS AND METHOD We observed 4,554 patients (≥65 years) with home injuries or car accidents. Patients were evaluated with ISS (Injury Severity Score) and major trauma with ATLS (Advanced Trauma Life Support). The instrumental investigation was in the first instance, targeted X-Ray or whole-body CT. RESULTS In over four years of study we treated 4,554 geriatric: 2,809 females and 1,745 Males. When the type of trauma was analysed the most common was head injury, followed by fractures of lower and upper limbs. In our experience hospitalization mainly involved patients over 80. In all patients mortality during assessment was 0.06%. DISCUSSION The geriatric patient is often defined as a "frail elderly", for the presence of a greater "injury sensitivity". This is due to the simultaneous presence of comorbidity, progressive loss of full autonomy and exposure to a high risk of traumatic events. Optimal management of the trauma patient can considerable reduce mortality and morbidity. CONCLUSIONS Falls and injuries in geriatric age are more frequent in women than in men. Among typical elder comorbidities, osteoporosis certainly causes a female preponderance in the prevalence of fractures. Our discharge data demonstrate that disability, which requires transfer to health care institutions, has a greater effect on women than men.
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Asplin G, Carlsson G, Fagevik Olsén M, Zidén L. See me, teach me, guide me, but it’s up to me! Patients’ experiences of recovery during the acute phase after hip fracture. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2019.1650394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Gillian Asplin
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Physiotherapy and Occupational Therapy, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Gunnel Carlsson
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Physiotherapy and Occupational Therapy, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Monika Fagevik Olsén
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Physiotherapy and Occupational Therapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lena Zidén
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Physiotherapy and Occupational Therapy, Sahlgrenska University Hospital, Mölndal, Sweden
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Sheehan KJ, Guerrero EM, Tainter D, Dial B, Milton-Cole R, Blair JA, Alexander J, Swamy P, Kuramoto L, Guy P, Bettger JP, Sobolev B. Prognostic factors of in-hospital complications after hip fracture surgery: a scoping review. Osteoporos Int 2019; 30:1339-1351. [PMID: 31037362 DOI: 10.1007/s00198-019-04976-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/14/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION To examine prognostic factors that influence complications after hip fracture surgery. To summarize proposed underlying mechanisms for their influence. METHODS We reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Scoping Review extension. We searched MEDLINE, Embase, CINAHL, AgeLine, Cochrane Library, and reference lists of retrieved studies for studies of prognostic factor/s of postoperative in-hospital medical complication/s among patients 50 years and older treated surgically for non-pathological closed hip fracture, published in English on January 2008-January 2018. We excluded studies of surgery type or in-hospital medications. Screening was duplicated by two independent reviewers. One reviewer completed the extraction with accuracy checks by the second reviewer. We summarized the extent, nature, and proposed underlying mechanisms for the prognostic factors of complications narratively and in a dependency graph. RESULTS We identified 44 prognostic factors of in-hospital complications after hip fracture surgery from 56 studies. Of these, we identified 7 patient factors-dehydration, anemia, hypotension, heart rate variability, pressure risk, nutrition, and indwelling catheter use; and 7 process factors-time to surgery, anesthetic type, transfusion strategy, orthopedic versus geriatric/co-managed care, multidisciplinary care pathway, and potentially modifiable during index hospitalization. We identified underlying mechanisms for 15 of 44 factors. The reported association between 12 prognostic factors and complications was inconsistent across studies. CONCLUSIONS Most factors were reported by one study with no proposed underlying mechanism for their influence. Where reported by more than one study, there was inconsistency in reported associations and the conceptualization of complications differed, limiting comparison across studies. It is therefore not possible to be certain whether intervening on these factors would reduce the rate of complications after hip fracture surgery.
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Affiliation(s)
- K J Sheehan
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK.
| | - E M Guerrero
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - D Tainter
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - B Dial
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - R Milton-Cole
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - J A Blair
- Department of Orthopaedics and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, USA
| | - J Alexander
- Department of Rehabilitation Sciences, Kingston & St George's University of London, London, UK
| | - P Swamy
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - L Kuramoto
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
| | - P Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
| | - J P Bettger
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - B Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Kalmet PHS, de Joode SGCJ, Fiddelers AAA, Ten Broeke RHM, Poeze M, Blokhuis T. Long-term Patient-reported Quality of Life and Pain After a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Retrospective Comparative Cohort Study. Geriatr Orthop Surg Rehabil 2019; 10:2151459319841743. [PMID: 31218092 PMCID: PMC6557012 DOI: 10.1177/2151459319841743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 03/01/2019] [Accepted: 03/13/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction There is an increase in incidence of hip fractures in the ageing population. The implementation of multidisciplinary clinical pathways (MCP) has proven to be effective in improving the care for these frail patients, and MCP tends to be more effective than usual care (UC). The aim of this study was to analyze potential differences in patient-reported outcome among elderly patients with hip fractures who followed MCP versus those who followed UC. Materials and Methods This retrospective cohort study included patients aged 65 years or older with a low-energy hip fracture, who underwent surgery in the Maastricht University Medical Center, Maastricht, the Netherlands. Two cohorts were analyzed; the first one had patients who underwent UC in 2012 and the second one contained patients who followed MCP in 2015. Collected data regarded demographics, patient-reported outcomes (Short Form 12 [SF-12] and the Numeric Rating Scale [NRS] to measure pain), and patient outcome. Results This cohort study included 398 patients, 182 of them were included in the MCP group and 216 were in the UC group. No differences in gender, age, or American Society of Anesthesiologists classification were found between the groups. No significant differences were found in SF-12 and the NRS data between the MCP group and UC group. In the MCP group, significantly lower rates of postoperative complications were found than in the UC group, but mortality within 30 days and one year after the hip fracture was similar in both groups. Discussion Although the effects of hip fractures in the elderly on patient-reported outcome, pain and quality of life have been addressed in several recent studies, the effects of MCP on long-term outcome was unclear. Conclusion A multidisciplinary clinical pathway approach for elderly patients with a hip fracture is associated with a reduced time to surgery and reduced postoperative complications, while no differences were found in quality of life, pain, or mortality.
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Affiliation(s)
- Pishtiwan H S Kalmet
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stijn G C J de Joode
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Audrey A A Fiddelers
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rene H M Ten Broeke
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martijn Poeze
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Taco Blokhuis
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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25
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Kusen J, van der Vet P, Wijdicks FJ, Houwert M, Dijkgraaf M, Hamaker M, Geraghty O, Verleisdonk EJ, van der Velde D. Different approaches towards geriatric trauma care for hip fracture patients: an inter-hospital comparison. Eur J Trauma Emerg Surg 2019; 47:557-564. [PMID: 31020360 DOI: 10.1007/s00068-019-01129-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 04/01/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Hip fractures in geriatric patients have high morbidity and mortality rates. The implementation of a multidisciplinary geriatric care pathway (GCP) may improve treatment for this patient population. This study focusses on two level II hospitals with a different treatment protocols. A comparison was made between a multidisciplinary GCP and extensive standard care with a focus on geriatric hip fracture patients to assess if a multidisciplinary GCP leads to lower mortality and morbidity. METHODS This retrospective cohort study included patients aged 70 years or older with a unilateral proximal hip fracture who underwent surgery between January 2014 and December 2015. The primary outcome measures complications and 30-day mortality. Secondary outcome measures were time to surgery, hospital length of stay (HLOS) and secondary surgical interventions. RESULTS This study included a total of 898 patients. No differences were found between major postoperative complications, 30-day mortality, HLOS or the amount of secondary surgical interventions. CONCLUSIONS Mortality, major complications, HLOS and the amount of secondary surgical interventions showed no differences between both hospitals. This inter-hospital comparison of two types of geriatric care models showed no outcome that favours one specific geriatric care model over another. This provides opportunities for future studies to get a better understanding of what specific factors of geriatric care models contribute most to an improvement in the treatment of this patient population and decide which approach is most cost effective.
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Affiliation(s)
- Jip Kusen
- Department of Surgery, Diakonessenhuis Utrecht, Bosboomstraat Utrecht 1, 3582 KE, Utrecht, The Netherlands
| | - Puck van der Vet
- Department of Surgery, Diakonessenhuis Utrecht, Bosboomstraat Utrecht 1, 3582 KE, Utrecht, The Netherlands
| | - Frans-Jasper Wijdicks
- Department of Surgery, Diakonessenhuis Utrecht, Bosboomstraat Utrecht 1, 3582 KE, Utrecht, The Netherlands.
| | - Marijn Houwert
- Department of Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Marcel Dijkgraaf
- Department of Clinical Epidemiology, AMC Amsterdam, Amsterdam, The Netherlands
| | - Marije Hamaker
- Department of Geriatrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Olivia Geraghty
- Department of Geriatrics, Antoniusziekenhuis Nieuwegein, Nieuwegein, The Netherlands
| | - Egbert-Jan Verleisdonk
- Department of Surgery, Diakonessenhuis Utrecht, Bosboomstraat Utrecht 1, 3582 KE, Utrecht, The Netherlands
| | - Detlef van der Velde
- Department of Surgery, Antoniusziekenhuis Nieuwegein, Nieuwegein, The Netherlands
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26
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de Joode SGCJ, Kalmet PHS, Fiddelers AAA, Poeze M, Blokhuis TJ. Long-term functional outcome after a low-energy hip fracture in elderly patients. J Orthop Traumatol 2019; 20:20. [PMID: 30976999 PMCID: PMC6459450 DOI: 10.1186/s10195-019-0529-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The incidence of hip fractures is increasing. Elderly patients with a hip fracture frequently present with comorbidities, which are associated with higher mortality rates. Clinical studies regarding long-term functional outcome and mortality in hip fractures are rare. The aim of this study was to analyse the functional outcome and the mortality rate after a follow-up of 5 years in elderly patients with a hip fracture. MATERIALS AND METHODS This combined retrospective and cross-sectional study included patients aged 65 years or older with a low energy hip fracture who underwent surgery in the Maastricht University Medical Center+, the Netherlands. Data such as demographics and mortality rates were retrospectively collected and functional outcome (i.e. mobility, pain, housing conditions and quality of life) was assessed by a questionnaire. RESULTS Two hundred and sixteen patients were included in this study (mean age 82.2, SD ± 7.5). No significant differences were found in pain before hip fracture and after 1-year and 5-year follow-ups. Long-term functional outcome deteriorated after a hip fracture, with a significant increase in the use of walking aids (p < 0.001), a significant decrease of patients living in a private home (p < 0.001), and a low physical quality of life (SF-12 PCS = 27.1). The mortality incidences after 30-day, 1-year and 5-year follow-ups were 7.9%, 37.0% and 69.4%, respectively. CONCLUSION Long-term functional outcome in elderly patients with hip fractures significantly deteriorated, with an increased dependency for mobility and housing conditions and a decreased physical quality of life. In addition, hip fractures are associated with high mortality rates at the 5-year follow-up. LEVEL OF EVIDENCE Level III, a retrospective cohort study.
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Affiliation(s)
- Stijn G C J de Joode
- Department of Trauma Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Pishtiwan H S Kalmet
- Department of Trauma Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | | | - Martijn Poeze
- Department of Trauma Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.,Network Acute Care Limburg, Maastricht, The Netherlands.,Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Taco J Blokhuis
- Department of Trauma Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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27
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Wu X, Tian M, Zhang J, Yang M, Gong X, Liu Y, Li X, Lindley RI, Anderson M, Peng K, Jagnoor J, Ji J, Wang M, Ivers R, Tian W. The effect of a multidisciplinary co-management program for the older hip fracture patients in Beijing: a "pre- and post-" retrospective study. Arch Osteoporos 2019; 14:43. [PMID: 30903390 DOI: 10.1007/s11657-019-0594-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/12/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hip fracture becomes a major public health issue with the growing aging population. This study evaluated a multidisciplinary co-management program for older hip fracture patients and found it significantly improved the best practice indicators. It provided preliminary evidence to support the use of such intervention in hip fracture management. PURPOSE/INTRODUCTION Hip fracture leads to high morbidity and mortality in older people. A previous study found a significant disparity in hip fracture management in Beijing Jishuitan Hospital (JSTH) compared to best practice care in the United Kingdom (UK). Following this audit, JSTH launched a multidisciplinary co-management care plan for older hip fracture patients. This study aims to evaluate the effect of this program on the six standards recommended in the UK hip fracture best practice guidelines. METHODS In this retrospective study, electronic medical record data were collected before and after the intervention. Eligible patients were aged ≥ 65 years, had X-ray confirmed hip fracture, and were admitted to JSTH within 30 days of injury. Patient demographic information, time from emergency department presentation to admission, time from admission to surgery, pressure ulcers, osteoporosis assessment, and falls prevention were collected. Multivariable logistic and median regression models were used for binary and continuous outcomes respectively. Segment regression was also performed for time-related outcomes. RESULTS A total of 3540 eligible patients were identified. After the intervention, half of the patients who received co-management received surgery within 48 h of ward admission compared to 6.4% previously, 0.3% (vs 1.4%) developed pressure ulcers, and 76% (vs 19%) received osteoporosis assessment. No significant differences were observed in fall assessment rates. However, there was a higher rate of ward admission within 4 h of arrival in emergency for patients admitted pre-intervention (61% vs 34%). CONCLUSIONS The introduction of the co-management model significantly reduced the time from admission to surgery and improved other practice outcomes. A multicenter randomized controlled trial is needed to evaluate the impact of this model on patient health outcomes.
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Affiliation(s)
- Xinbao Wu
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Maoyi Tian
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China.,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Jing Zhang
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - Minghui Yang
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Xiaofeng Gong
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Yishu Liu
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China.,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Xian Li
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China.,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Richard I Lindley
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Melanie Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Kensington, NSW, 2052, Australia
| | - Ke Peng
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Jagnoor Jagnoor
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Jiachao Ji
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - Manyi Wang
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Rebecca Ivers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia. .,School of Public Health and Community Medicine, University of New South Wales, Sydney, Kensington, NSW, 2052, Australia.
| | - Wei Tian
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China.
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Continuous improvement process: ortho-geriatric co-management of proximal femoral fractures. Arch Orthop Trauma Surg 2019; 139:347-354. [PMID: 30519735 DOI: 10.1007/s00402-018-3086-7] [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: 07/01/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The objective of the current study was to evaluate the effect of a quality management system on treatment and care delivery of proximal femoral fractures. Specifically, our hypothesis was that the "plan-do-check-act (PDCA)" philosophy of the ISO 9001 quality management system results in a continuous improvement process. METHODS 1015 proximal femoral fractures were prospectively included into a hip fracture database over a 5-year period, after a restructuring process with implementation of clinical pathways and standard operation procedures. A close and structured ortho-geriatric co-management (certified ortho-geriatric center) was the basis for treatment. ISO 9001 certification was granted for the first time in 2012. Procedural and patient outcome parameters were analyzed by year and evaluated statistically using SPSS 25.0. RESULTS In both categories (procedural and outcome) significant changes could be detected during the 5-year period, e.g., significant reduction of time to surgery for the first 2 years, improvement in discharge management, and reduction of surgical complications. However, no significant changes could be demonstrated for mortality or internal complications such as pneumonia, urinary tract infections, or postoperative delirium. However, the incidence of the latter was already on a very low level at the onset of the quality improvement process. CONCLUSION We could show a relevant and continuous improvement of several quality indicators during a 5-year period after implementation of a quality management system based on the PDCA philosophy for the treatment of proximal femoral fractures in elderly patients. However, other parameters (internal complications, cost-effectiveness, etc.) need our close attention in the future.
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29
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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: 1.6] [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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30
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Mahran DG, Farouk O, Ismail MA, Alaa MM, Eisa A, Ragab II. Effectiveness of home based intervention program in reducing mortality of hip fracture patients: A non-randomized controlled trial. Arch Gerontol Geriatr 2018; 81:8-17. [PMID: 30471472 DOI: 10.1016/j.archger.2018.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE The study was done to investigate whether a postoperative intervention program is effective in reducing mortality and improving mobility in two comparative hip fracture patients over one year postoperatively. METHODS A non-randomized controlled trial study with an intervention group of hip fracture patients and historical control group with 12 months follow up. One hundred twenty four admitted hip fracture patients to the Trauma Unit of Assiut University Hospitals, aged 50 years and older were included from 1st July to 31st December 2014. They were divided into 64 and 60 patients as intervention and control groups respectively. Weight, height and bone mineral density were measured and baseline characteristics were taken. The intervention was a postoperative care program in the form of education sessions with an explanatory leaflet on discharge for nutrition and physical exercise program at home. Follow up phone calls were done at 3 months, 6 months and one year postoperatively by one assessor. Physical mobility was assessed by 24 items Western Ontario And McMaster Universities Osteoarthritis Index (WOMAC). RESULTS Mortality was significantly higher in the control group, WOMAC score was significantly better among intervention group through follow up. By multivariate Cox survival analysis, advancing age, no intervention, osteoporosis, postoperative complications, chest infections and heart attacks were significant predictors for mortality. CONCLUSION A significant improvement in mobility and reduction of mortality was achieved by application of a postoperative care program that could be incorporated into the hip fracture patients' care pathway.
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Affiliation(s)
- Dalia G Mahran
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Osama Farouk
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Mervat A Ismail
- Adult Nursing Department, Faculty of Nursing, Assiut University, Assiut, Egypt
| | - Mohamed M Alaa
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Amr Eisa
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Islam I Ragab
- Adult Medical Surgical Nursing Department, Faculty of Nursing, South Valley University, Qena, Egypt
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Reguant F, Arnau A, Lorente JV, Maestro L, Bosch J. Efficacy of a multidisciplinary approach on postoperative morbidity and mortality of elderly patients with hip fracture. J Clin Anesth 2018; 53:11-19. [PMID: 30286380 DOI: 10.1016/j.jclinane.2018.09.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/16/2018] [Accepted: 09/26/2018] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVE We evaluated the efficacy of a multidisciplinary approach to reduce postoperative complications and 1-year mortality in patients, undergoing hip fracture surgery and the impact of surgical delay on mortality. DESIGN A non-randomized intervention study with a historical control group (CG). SETTING During the hospital stay of patients undergoing hip fracture surgery and subsequent follow-up during 12 months post-discharge. PATIENTS 240 patients undergoing hip fracture surgery were included in the CG. 272 patients were included in the intervention group (IG). INTERVENTIONS CG patients received the standard care given at our hospital. Patients in the IG received a new model of multidisciplinary approach to care. MEASUREMENTS The following variables were collected: study group, age, gender, ASA physical status, comorbidity, type of fracture, type of anaesthesia, surgical delay, postoperative complications, hospital stay, destination after discharge and postoperative mortality. MAIN RESULTS 512 patients (CG = 240; IG = 272). Mean age was 83.8 years in CG and 84.9 years in IG. Patients in the IG had a worse health status according to ASA (III-IV: 68.8% vs 51.7%; p < 0.001) and took more drugs (p < 0.001). Surgery was performed within 48 h of admission in 55.1% of patients of the IG (38.3% CG; p < 0.001). Incidence of postoperative complications (67.3% IG vs 76.2% CG p = 0.025) and hospital stay was shorter in the IG (p < 0.001). A surgical delay of >48 h (HR = 0.61; CI95%: 0.42-0.88) and allocation to the IG (HR = 0.64; CI95%: 0.44-0.93) were the protective factors for mortality. CONCLUSIONS The multidisciplinary approach could be associated with a decrease in postoperative complications, hospital stay and mortality. Surgical delay may not increase the risk of mortality. The main objective in the management of these patients should be the optimization of their general health status before surgery rather than surgical delay.
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Affiliation(s)
- F Reguant
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària de Manresa, C/ Dr. Joan Soler, 1-3, 08243 Manresa, Barcelona, Spain; School of Medicine and Health Sciences, International University of Catalonia (UIC), C/Josep Trueta, s/n., 08195 Sant Cugat del Vallès, Barcelona, Spain.
| | - A Arnau
- School of Medicine and Health Sciences, International University of Catalonia (UIC), C/Josep Trueta, s/n., 08195 Sant Cugat del Vallès, Barcelona, Spain; Clinical Research Unit, Althaia Xarxa Assistencial Universitària de Manresa, C/ Dr, Joan Soler, 1-3, 08243 Manresa, Barcelona, Spain
| | - J V Lorente
- Department of Anaesthesiology, Althaia Xarxa Assistencial Universitària de Manresa, C/ Dr. Joan Soler, 1-3, 08243 Manresa, Barcelona, Spain; School of Medicine and Health Sciences, International University of Catalonia (UIC), C/Josep Trueta, s/n., 08195 Sant Cugat del Vallès, Barcelona, Spain
| | - L Maestro
- Specialized Nursing in Anaesthesia, Althaia Xarxa Assistencial Universitària de Manresa, C/ Dr. Joan Soler, 1-3, 08243 Manresa, Barcelona, Spain
| | - J Bosch
- School of Medicine and Health Sciences, International University of Catalonia (UIC), C/Josep Trueta, s/n., 08195 Sant Cugat del Vallès, Barcelona, Spain
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Early coordinated rehabilitation in acute phase after hip fracture - a model for increased patient participation. BMC Geriatr 2017; 17:240. [PMID: 29041916 PMCID: PMC5646112 DOI: 10.1186/s12877-017-0640-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/08/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Studies have shown that patients with hip fracture treated in a Comprehensive Geriatric Care (CGC) unit report better results in comparison to orthopaedic care. Furthermore, involving patients in their healthcare by encouraging patient participation can result in better quality of care and improved outcomes. To our knowledge no study has been performed comparing rehabilitation programmes within a CGC unit during the acute phase after hip fracture with focus on improving patients' perceived participation and subsequent effect on patients' function. METHODS A prospective, controlled, intervention performed in a CGC unit and compared with standard care. A total of 126 patients with hip fracture were recruited who were prior to fracture; community dwelling, mobile indoors and independent in personal care. Intervention Group (IG): 63 patients, mean age 82.0 years and Control Group (CG): 63 patients mean age 80.5 years. INTERVENTION coordinated rehabilitation programme with early onset of patient participation and intensified occupational therapy and physiotherapy after hip fracture surgery. The primary outcome measure was self-reported patient participation at discharge. Secondary outcome measures were: TLS-BasicADL; Bergs Balance Scale (BBS); Falls Efficacy Scale FES(S); Short Physical Performance Battery (SPPB) and Timed Up and Go (TUG) at discharge and 1 month and ADL staircase for instrumental ADL at 1 month. RESULTS At discharge a statistically significant greater number of patients in the IG reported higher levels of participation (p < 0.05) and independence in lower body hygiene (p < 0.05) and dressing (p < 0.001). There were however no statistically significant differences at discharge and 1 month between groups in functional balance and confidence, performance measures or risk for falls. CONCLUSION This model of OT and PT coordinated inpatient rehabilitation had a positive effect on patients' perceived participation in their rehabilitation and ADL at discharge but did not appear to affect level of recovery or risk for future falls at 1 month. A large proportion of patients remained at risk for future falls at 1 month in both groups highlighting the need for continued rehabilitation after discharge. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03301584 (Retrospectively registered: 4th October 2017).
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Seys D, Bruyneel L, Deneckere S, Kul S, Van der Veken L, van Zelm R, Sermeus W, Panella M, Vanhaecht K. Better organized care via care pathways: A multicenter study. PLoS One 2017; 12:e0180398. [PMID: 28672030 PMCID: PMC5495424 DOI: 10.1371/journal.pone.0180398] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 06/15/2017] [Indexed: 11/18/2022] Open
Abstract
An increased need for efficiency and effectiveness in today’s healthcare system urges professionals to improve the organization of care. Care pathways are an important tool to achieve this. The overall aim of this study was to analyze if care pathways lead to better organization of care processes. For this, the Care Process Self-Evaluation tool (CPSET) was used to evaluate how healthcare professionals perceive the organization of care processes. Based on information from 2692 health care professionals gathered between November 2007 and October 2011 we audited 261 care processes in 108 organizations. Multilevel analysis was used to compare care processes without and with care pathways and analyze if care pathways led to better organization of care processes. A significant difference between care processes with and without care pathways was found. A care pathway in use led to significant better scores on the overall CPSET scale (p<0.001) and its subscales, “coordination of care” (p<0.001) and “follow-up of care” (p<0.001). Physicians had the highest score on the overall CPSET scale and the five subscales. Care processes organized by care pathways had a 2.6 times higher probability that the care process was well-organized. In around 75% of the cases a care pathway led to better organized care processes. Care processes supported by care pathways were better organized, but not all care pathways were well-organized. Managers can use care pathways to make healthcare professionals more aware of their role in the organization of the care process.
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Affiliation(s)
- Deborah Seys
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, UZ Leuven, Leuven, Belgium
| | - Svin Deneckere
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Medical Department, Delta Hospitals Roeselare, Roeselare, Belgium
| | - Seval Kul
- Department of Biostatistics, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Liz Van der Veken
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ruben van Zelm
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Q Consult, Utrecht, The Netherlands
| | - Walter Sermeus
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Massimiliano Panella
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont 'A. Avogadro', Novara, Italy
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, UZ Leuven, Leuven, Belgium
- * E-mail:
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Kelly-Pettersson P, Samuelsson B, Muren O, Unbeck M, Gordon M, Stark A, Sköldenberg O. Waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: A cohort study. Int J Nurs Stud 2017; 69:91-97. [PMID: 28189926 DOI: 10.1016/j.ijnurstu.2017.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hip fractures are common in the elderly and are associated with a high adverse event and mortality rate. Time to surgery is one of the major modifiable risk factors influencing adverse outcomes in hip-fracture patients. National guidelines and recommendations have been introduced which advocate specific time frames in which surgery should be performed i.e. within 24-48h. These time constraints have been arbitrarily set without being modelled on the linear assumption i.e. that risk increases continually over time and not within specific cut-off times. OBJECTIVES To investigate how waiting time to surgery influenced the risk of serious adverse events in hip-fracture patients during the hospital stay and to examine how the risk increased over time. DESIGN An observational single cohort study Participants 576 patients (72.4% females, mean [SD] age 82 [10]) years, with a hip fracture were included in the cohort study. METHODS The outcomes of the study were the occurrence of serious adverse events during hospital stay, length of stay and one-year mortality. A structured medical record review was carried out to identify outcomes and mortality data was obtained from the Swedish National Death Registry. Waiting time to surgery was used as the exposure variable and age, sex, type of fracture, comorbidities using the American Society of Anaesthesiologists classification score and the presence of cognitive dysfunction were identified as confounders. A logistic regression analysis was performed to identify risk factors influencing outcomes. RESULTS A total of 119 patients (20.6%) suffered 397 (range 1-5) serious adverse events during hospital stay. Every 10h of waiting time to surgery increased the risk of serious adverse events by 12% (odds ratio 1.12 [95% confidence interval 1.02-1.23]). We found no optimal cut-off times for waiting time to surgery. For every 24h of waiting time, the length of stay from surgery was increased by 0.6days (95% CI 0.1-1.1). We found no correlation between waiting time to surgery and one-year mortality. CONCLUSIONS A large proportion of patients suffered from at least one serious adverse event after hip-fracture surgery and there are no safe limits for waiting time to surgery for hip-fracture patients. As the risk increases with every hour of waiting time, patients with higher American Society of Anesthesiologists classification scores, males and those with subtrochanteric fractures should be prioritized for surgery.
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Affiliation(s)
- Paula Kelly-Pettersson
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden
| | - Bodil Samuelsson
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden
| | - Olle Muren
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden
| | - Maria Unbeck
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden
| | - Max Gordon
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden
| | - André Stark
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden
| | - Olof Sköldenberg
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden.
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