Orthogeriatric co-management for proximal femoral fractures. Can two additions make a big difference?

A systematic review of the association between early comprehensive geriatric assessment and outcomes in hip fracture care for older people

Aims

Performance indicators are increasingly used to improve the quality of healthcare provided to hip fracture patients. Joint care, under orthopaedic surgeons and physicians with an interest in older patients, is one of the more common indicators of high-quality care. In this systematic review, we investigated the association between 'comprehensive geriatric assessment' and patient outcomes following hip fracture injury.

Methods

In total, 12 electronic databases and other sources were searched for evidence, and the methodological quality of studies meeting the inclusion criteria was assessed. The protocol for this suite of related systematic reviews was registered with PROSPERO (ID: CRD42023417515).

Results

A total of 24,591 articles were reviewed, and 39 studies met the inclusion criteria for the review, involving a total of 25,363 patients aged over 60 years with a hip fracture. There were five randomized clinical trials, three quasi-experimental studies, two non-randomized parallel group control trials, 22 pre-/post-intervention studies, and seven retrospective cohort studies, conducted between January 1992 and December 2021. The timing and content of a comprehensive geriatric assessment was ill-defined in many studies and care pathways were heterogeneous, which precluded meta-analysis of the data. Early comprehensive geriatric assessment was associated with improved outcomes in 31 of the 36 (86%) patient-reported outcomes, including improved mobility (acute/long-term), functional status, and better quality of life. In total, 155 out of 219 (70.78%) clinical outcomes derived from hospital records showed a positive association with early comprehensive geriatric review, including reduced preoperative time and length of hospital stay, reduced incidence of postoperative complications, fewer hospital readmissions, and lower mortality.

Conclusion

Early comprehensive geriatric assessments after hip fracture in older people is associated with improved patient-reported outcomes and better clinical outcomes such as reduced incidence of complications, length of hospital stay, preoperative waiting time, and mortality. Standardization of the definitions of 'early' and 'comprehensive' geriatric assessments and consistent reporting of care pathway models would improve future evidence synthesis.

Time to surgery and 30-day mortality after hip fracture: An observational study of 29,695 patients reported to the Spanish National Hip Fracture Registry (SNHFR)

INTRODUCTION

The aim of this study was to investigate the effect of time to surgery (TTS) on 30-day mortality in a cohort of patients from the Spanish National Hip Fracture Registry (SNHFR).

METHODS

Retrospective study of a prospective database of hip fracture patients ≥ 75 years old between 2017 and 2019. Exclusion criterion was nonsurgical treatment. Association between TTS and 30-day mortality was assessed with a univariate analysis. Effect size was calculated using the probability of superiority. Regression analysis was performed to analyze the relationship between TTS and 30-day vital status. The ROC curve was used to evaluate the discrimination of mortality based on TTS.

RESULTS

A total of 29,695 patients met the inclusion criteria. The median TTS was 53.8 h. Surgery within 48 h was performed in 51.8 % of cases. Patients with delay of surgery more than 2 days rather than within 2 days were more likely to present an ASA score above 2 (58.9 % vs. 41.1 %, p < 0.001), less likely to achieve postoperative mobilization within 24 h (63 % vs. 67.4 %, p < 0.001), more likely to develop pressure ulcers (10.7 % vs. 6.9 %, p < 0.001), and had longer length of stay (10.7 days vs. 6.9 days, p < 0.001). The overall 30-day mortality rate was 7.8 %. Median TTS was significantly higher in decedents (66 h) than in survivors (56.5 h). There were higher statistically significant differences in 30-day mortality between patients who underwent surgery after 2 days (7.5 %) and those who underwent surgery within 2 days (5.4 %). The 30-day mortality was 5.2 % in patients operated within 24 h and 9.2 % in patients operated more than 120 h. Probability of superiority value was 0.44. Area under the curve reached a value of 0.55.

CONCLUSIONS

The associations between TTS and 30-day mortality were weak. Hip fracture surgery performed within 2 days was significantly associated with remobilization on the day after the hip fracture, with fewer postoperative pressure ulcers and shorter hospital stays. Despite the weakness of the TTS and 30-day mortality association, there are benefits to consider if surgery is performed within 2 days. Our results suggest that patients should be fit for surgery as soon as possible.

LEVEL OF EVIDENCE

IV.

GIFTS: Geriatric Intensive Functional Therapy Sessions-for the older trauma patient

BACKGROUND

Considering resources for comprehensive geriatric care, it would be beneficial for geriatric trauma patients (GTPs) and medical patients to be comanaged in one program focusing on ancillary therapeutics (AT): physical therapy, occupational therapy, speech language pathology, respiratory therapy, and sleep wake hygiene. This pilot study describes outcomes of GTPs in a hospital-wide program focused on geriatric-specific AT.

METHODS

Geriatric trauma patients and geriatric patients were screened by program coordinator for enrollment at one Level II trauma center from August 2021 to December 2022. Enrolled patients (EPs) were admitted to trauma or medicine floors and received repetitive AT with attention to sleep wake hygiene throughout hospitalization and compared with similar nonenrolled patients (NEPs). Excluded patients had any of the following: indication of geriatric syndrome with a fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) score of 5, no frailty with a FRAIL score of 0, comfort focused plans, or arrived from skilled care. Retrospective chart review of demographics and outcomes was completed for both EPs and NEPs.

RESULTS

A total of 224 EPs (28 trauma [TR]) were compared with 574 NEPs (148 TR). Enrolled patients showed shorter length of stay (mean, 3.8 vs. 6.1; p = 0.0001), less delirium (3.1% vs. 9.6%, p = 0.00222), less time to ambulation (13 hours vs. 39 hours, p = 0.0005), and higher likelihood to discharge home (56% vs. 27%, p < 0.0001) as compared with NEPs. The median FRAIL score was 3 for both groups. Enrolled medical patients ambulated the soonest at 11 average hours, compared with 23 hours for enrolled trauma patients and 39 hours for NEPs. There were zero delirium events among enrolled trauma patients; 25% was found among nonenrolled trauma patients ( p = 0.00288).

CONCLUSION

Despite a small trauma cohort, results support feasibility to include GTPs in hospital-wide programs with geriatric-specific AT. Mobility and cognitive strategies may improve opportunities to avoid delirium, decrease length of stay, and influence more frequent disposition to home.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Exploring geriatric trauma unit experiences through patients' eyes: a qualitative study

INTRODUCTION

The surgical management of older patients is complex due to age-related underlying comorbidities and decreased physiological reserves. Comanaged care models, such as the Geriatric Trauma Unit, are proven effective in treating the complex needs of patients with fall-related injuries. While patient-centered care is an important feature of these comanaged care models, there has been minimal research dedicated to investigating the patient experience within Geriatric Trauma Units. Therefore, it remains uncertain whether the Geriatric Trauma Unit's emphasis on a patient-centered approach truly manifests in these interactions. This study explores how patients with fall-related injuries admitted to a Geriatric Trauma Unit perceive and experience patient-centered care during hospitalization.

METHODS

This qualitative generic study was conducted in three teaching hospitals that integrated the principles of comanaged care in trauma care for older patients. Between January 2021 and May 2022, 21 patients were interviewed.

RESULTS

The findings highlight the formidable challenges that older patients encounter during their treatment for fall-related injuries, which often signify a loss of independence and personal autonomy. The findings revealed a gap in the consistent and continuous implementation of patient-centered care, with many healthcare professionals still viewing patients mainly through the lens of their injuries, rather than as individuals with distinct healthcare needs. Although focusing on fracture-specific care and physical rehabilitation aligns with some patient preferences, overlooking broader needs undermines the comprehensive approach to care in the Geriatric Trauma Unit.

CONCLUSION

Effective patient-centered care in Geriatric Trauma Units requires full adherence to its core elements: patient engagement, strong patient-provider relationships, and a patient-focused environment. This study shows that deviations from these principles can undermine care, emphasizing the need for a holistic approach that extends beyond treating immediate medical conditions.

Evaluation of Whether Emergency Physicians Should Join the Multidisciplinary Team for Older Hip Fracture Patients

Background

Geriatric hip fracture is one of the most common end-stage events in older patients with osteoporosis. We aimed to improve the original co-management process by engaging emergency physicians in the preoperative multidisciplinary management team (MDT). We evaluated this intervention in terms of reducing patient waiting time before surgery.

Methods

Emergency Department data and hospitalization data for patients diagnosed with geriatric hip fractures in Beijing Jishuitan Hospital (JSTH) were collected and sorted into the intervention group, for whom the MDT included emergency physicians (from January 2019 to December 2019), and the control group (from January 2017 to December 2017). The percentage of patients treated with surgery within 48 h of admission was used as the primary outcome. The secondary outcomes included the time from emergency visit to admission (hours), the time from admission to discharge (days), the percentage of patients receiving surgical treatment after admission, the rate of perioperative medical complications during hospitalization, postoperative admission to the Intensive Care Unit, and total deaths during hospitalization.

Results

A total of 2,152 patients were enrolled. The rate of hypertension (58.5% vs 52.1%), coronary heart disease (24.6% vs 19.9%), and cerebrovascular disease (19.4% vs 15.5%) was higher in the intervention group than in the control group. The percentage of patients receiving surgical treatment in the intervention group (98.3%) was significantly higher than in the control group (96.3%, p = 0.004). The proportion of patients receiving surgical treatment within 48 h of admission was significantly higher in the intervention group (82.4%) than in the control group (60.4%, p < 0.001). The hospital stay was significantly shorter in the intervention group compared with the control group (p < 0.001). The incidence of perioperative medical complications and mortality during hospitalization was similar in the two groups.

Conclusions

Involving emergency physicians in the MDT can reduce the waiting time before surgery and the hospital stay for older hip fracture patients.

Effects of Orthogeriatric Care Models on Outcomes of Hip Fracture Patients: A Systematic Review and Meta-Analysis

Orthogeriatrics is increasingly recommended in the care of hip fracture patients, although evidence for this model is conflicting or at least limited. Furthermore, there is no conclusive evidence on which model [geriatric medicine consultant service (GCS), geriatric medical ward with orthopedic surgeon consultant service (GW), integrated care model (ICM)] is superior. The review summarizes the effect of orthogeriatric care for hip fracture patients on length of stay (LOS), time to surgery (TTS), in-hospital mortality, 1-year mortality, 30-day readmission rate, functional outcome, complication rate, and cost. Two independent reviewers retrieved randomized controlled trials, controlled observational studies, and pre/post analyses. Random-effects meta-analysis was performed. Thirty-seven studies were included, totaling 37.294 patients. Orthogeriatric care significantly reduced LOS [mean difference (MD) - 1.55 days, 95% confidence interval (CI) (- 2.53; - 0.57)], but heterogeneity warrants caution in interpreting this finding. Orthogeriatrics also resulted in a 28% lower risk of in-hospital mortality [95%CI (0.56; 0.92)], a 14% lower risk of 1-year mortality [95%CI (0.76; 0.97)], and a 19% lower risk of delirium [95%CI (0.71; 0.92)]. No significant effect was observed on TTS and 30-day readmission rate. No consistent effect was found on functional outcome. Numerically lower numbers of complications were observed in orthogeriatric care, yet some complications occurred more frequently in GW and ICM. Limited data suggest orthogeriatrics is cost-effective. There is moderate quality evidence that orthogeriatrics reduces LOS, in-hospital mortality, 1-year mortality, and delirium of hip fracture patients and may reduce complications and cost, while the effect on functional outcome is inconsistent. There is currently insufficient evidence to recommend one or the other type of orthogeriatric care model.

Differences in hip fracture care in Europe: a systematic review of recent annual reports of hip fracture registries

PURPOSE

Hip fractures are of growing interest due to their increasing number, subsequent functional decline and high institutionalization rate of patients, mortality, and costs. Several process measurements are essential for hip fracture care. To compare and improve these, hip fracture registries in Europe became popular. This systematic review aims to describe the differences between hip fracture registries in Europe as well as the differences in hip fracture treatment between countries.

METHODS

A systematic search using the keywords "hip fracture" AND "national" AND "database OR audit OR registry OR register" was performed in PubMed, Embase and Cochrane Library according to PRISMA guidelines till 3rd December 2020. Recent annual reports of identified hip fracture registries in Europe were additionally identified in June 2021. Comparisons of most common case-mix, process and outcome measurements were performed.

RESULTS

11 registries in Europe were identified. Differences were observed regarding inclusion criteria of the different registries. Comparison of the different registries was difficult due to differences in the way to report measurements. While mortality rates differed substantially between countries, most of the process measurements met recommendations according to recent guidelines.

CONCLUSION

Hip fracture registries were a valid tool to compare hospitals within one country. However, a comparison between registries of different countries should have also been easily possible. For this, the registries need to make their data easily accessible and further unify their way of measuring and reporting.