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Schmalstieg-Bahr K, MacDonald S, Pohontsch N, Debus S, Scherer M. Asking the generalist - evaluation of a General Practice rounding and consult service. BMC PRIMARY CARE 2024; 25:113. [PMID: 38627632 PMCID: PMC11020190 DOI: 10.1186/s12875-024-02353-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/27/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Vascular surgery patients admitted to the hospital are often multimorbid. In case of questions regarding chronic medical problems different specialties are consulted, which leads to a high number of treating physicians and possibly contradicting recommendations. The General Practitioner´s (GP) view could minimize this problem. However, it is unknown for which medical problems a GP would be consulted and if regular GP-involvement during rounds would be considered helpful by the specialists. The aim of this study was to establish and describe a General Practice rounding service (GP-RS), to evaluate if the GP-RS is doable in a tertiary care hospital and beneficial to the specialists and to explore GP-consult indications. METHODS The GP-RS was established as a pilot project. Between June-December 2020, a board-certified GP from the Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf (UKE) joined the vascular surgery team (UKE) once-weekly on rounds. The project was evaluated using a multi-methods approach: semi-structured qualitative interviews were conducted with vascular surgery physicians that had either participated in the GP-RS (G1), had not participated (G2), other specialists usually conducting consults on the vascular surgery floor (G3) and with the involved GP (G4). Interviews were analyzed using Kuckartz' qualitative content analysis. In addition, two sets of quantitative data were descriptively analyzed focusing on the reasons for a GP-consult: one set from the GP-RS and one from an established, conventional "as needed" GP-consult service. RESULTS 15 interviews were conducted. Physicians perceived the GP-RS as beneficial, especially for surgical patients (G1-3). Optimizing medication, avoiding unnecessary consults and a learning effect for physicians in training (G1-4) were named as other benefits. Critical voices saw an increased workload through the GP-RS (G1, G3) and some consult requests as too specific for a GP (G1-3). Based on data from 367 vascular surgery patients and 80 conventional GP-consults, the most common reasons for a GP-consult were cardiovascular diseases including hypertension and diabetes. CONCLUSIONS A GP-RS is doable in a tertiary care hospital. Studies of GP co-management model with closer follow ups would be needed to objectively improve patient care and reduce the overall number of consults. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Katharina Schmalstieg-Bahr
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Building W37, 20246, Hamburg, Germany.
| | - Sophia MacDonald
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Building W37, 20246, Hamburg, Germany
| | - Nadine Pohontsch
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Building W37, 20246, Hamburg, Germany
| | - Sebastian Debus
- Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Building W37, 20246, Hamburg, Germany
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2
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Ackermann LL, Schwenk ES, Li CJ, Vaile JR, Weitz H. The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture. Hosp Pract (1995) 2023; 51:233-239. [PMID: 37927222 DOI: 10.1080/21548331.2023.2274307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes. METHODS An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use. RESULTS Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001). CONCLUSIONS A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.
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Affiliation(s)
- Lily L Ackermann
- Department of Medicine, Division of Hospital Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Chris J Li
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - John R Vaile
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Howard Weitz
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Meyer JR, Earnest RE, Johnson BM, Steffensmeier AM, Vyas DA, Laughlin RT. Implementation of a Multidisciplinary Preoperative Protocol for Geriatric Hip Fractures Improves Time to Surgery at a Level III Trauma Center. Geriatr Orthop Surg Rehabil 2023; 14:21514593231181991. [PMID: 37325698 PMCID: PMC10262602 DOI: 10.1177/21514593231181991] [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: 03/07/2023] [Revised: 05/29/2023] [Accepted: 05/29/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Hip fractures are common among the elderly, and delays in time to surgery (TTS) and length of stay (LOS) are known to increase mortality risk in these patients. Preoperative multidisciplinary protocols for hip fracture management are effective at larger trauma hospitals. The purpose of this study is to evaluate the effect of a similar multidisciplinary preoperative protocol for geriatric hip fracture patients at our Level III trauma center. Materials and Methods In this single-center retrospective study, patients aged 65 and older who were admitted from March 2016 to December 2018 (pre-protocol group, Cohort #1, n = 247) and from August 2021 to September 2022 (post-protocol group, Cohort #2, n = 169) were included. Demographic information, TTS, and LOS were obtained and compared using Student's t-test and Chi-square testing. Results There was a significant decrease in TTS in Cohort #2 compared to Cohort #1 (P < .001). There was a significant increase in LOS in Cohort #2 compared to Cohort #1 (P < .05), but when comparing a subset of Cohort #2 (Subgroup 2B, patients admitted from May to September 2022 when the effects of COVID-19 were likely dissipated) to Cohort #1, there was no significant difference in LOS (P = .13). For patients admitted to skilled nursing facilities (SNF), LOS in Cohort #2 was significantly longer than in Cohort #1 (P = .001). Discussion In general, Level III hospitals have fewer perioperative resources compared to larger Level I hospitals. Despite this fact, this multidisciplinary preoperative protocol effectively reduced TTS which improves mortality risk in elderly patients. LOS is a multifactorial variable, and we believe the COVID-19 pandemic was a significant confounder that reduced available SNF beds in our area which prolonged the average LOS in Cohort #2. Conclusion A multidisciplinary preoperative protocol for geriatric hip fracture management can improve efficiency of getting patients to surgery at Level III trauma centers.
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Affiliation(s)
- Jacob R. Meyer
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan E. Earnest
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian M. Johnson
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew M. Steffensmeier
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dheer A. Vyas
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard T. Laughlin
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Kern-Goldberger AS, Dalton EM, Rasooly IR, Congdon M, Gunturi D, Wu L, Li Y, Gerber JS, Bonafide CP. Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists. JAMA Netw Open 2023; 6:e232648. [PMID: 36912837 PMCID: PMC10011930 DOI: 10.1001/jamanetworkopen.2023.2648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
IMPORTANCE Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices. OBJECTIVES To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023. EXPOSURES Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics. MAIN OUTCOMES AND MEASURES The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians. RESULTS We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.
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Affiliation(s)
- Andrew S. Kern-Goldberger
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatric Hospital Medicine, Cleveland Clinic, Cleveland, Ohio
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Evan M. Dalton
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Irit R. Rasooly
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Morgan Congdon
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Deepthi Gunturi
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lezhou Wu
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yun Li
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeffrey S. Gerber
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Pérez Sánchez L, Vázquez Agra N, Rubal Bran D, Montero Ruiz E. [The internist as a hospital consultant by excellence]. J Healthc Qual Res 2023; 38:59-61. [PMID: 35676171 DOI: 10.1016/j.jhqr.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/11/2022] [Indexed: 01/25/2023]
Affiliation(s)
- L Pérez Sánchez
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, España
| | - N Vázquez Agra
- Departamento de Medicina Interna, Complejo Clínico Universitario, Santiago de Compostela, España
| | - D Rubal Bran
- Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, España
| | - E Montero Ruiz
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, España.
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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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Evaluation of a Novel Multidisciplinary Preoperative Workup Strategy for Geriatric Hip Fractures. J Orthop Trauma 2022; 36:413-419. [PMID: 34992191 DOI: 10.1097/bot.0000000000002342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the financial and clinical impact of a standardized, multidisciplinary team for surgical clearance and optimization in geriatric hip fracture patients. DESIGN Retrospective case series. SETTING Level-1 trauma center. PATIENTS One hundred twenty-four geriatric patients (age >65 years old) in the preprotocol group (cohort 1; January 2017-December 2018) and 98 geriatric patients in the postprotocol group (cohort 2; October 2019-January 2021) with operative hip fractures. INTERVENTION Implementation of a multidisciplinary team protocol consisting of Anesthesiology, Internal Medicine and Orthopedic Surgery departments for the assessment of medical readiness and optimization for surgical intervention in geriatric hip fractures. MAIN OUTCOME MEASURES Rate of cardiology consultation, need for cardiac workup (echocardiography stress testing, heath catheterization), time to medical readiness (TTMR), time to surgery, case-cancellation rate, length of stay (LOS), and total hospitalization charges. RESULTS Following implementation of the new protocol, there were significant ( P < 0.001) decreases in TTMR (19 vs. 11 hours), LOS (149 vs. 120 hours), case cancellation rate, and total hospital charges ($84,000 vs. $62,000). There were no significant differences with respect to in-hospital complications or readmission rates/mortality rates at 1 year. CONCLUSIONS Following implementation of a protocolized, multidisciplinary approach to optimizing geriatric fracture patients, we were able to demonstrate a reduction in unnecessary preoperative testing, TTMR for surgery, case cancellation rate, LOS, and total hospitalization charge-without a concomitant increase in complications or mortality. This study highlights that standardization of the perioperative care for geriatric hip fracture patients can provide effective patient care while also lowering financial and logistical burden in care for these injuries. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Roberts HJ, Rogers SE, Ward DT, Kandemir U. Protocol-based interdisciplinary co-management for hip fracture care: 3 years of experience at an academic medical center. Arch Orthop Trauma Surg 2022; 142:1491-1497. [PMID: 33651146 DOI: 10.1007/s00402-020-03699-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Interdisciplinary standardized protocols for the care of patients with hip fractures have been shown to improve outcomes. A hip fracture protocol was implemented at our institution to standardize care, focusing on emergency care, pre-operative medical management, operative timing, and geriatrics co-management. The aim of this study was to evaluate the efficacy of this protocol. METHODS We conducted a retrospective review of adult patients admitted to a single tertiary care institution who underwent operative management of a hip fracture between July 2012 and March 2020. Comparison of patient characteristics, hospitalization characteristics, and outcomes were performed between patients admitted before and after protocol implementation in 2017. RESULTS A total of 517 patients treated for hip fracture were identified: 313 before and 204 after protocol implementation. Average age, average Charlson Comorbidity Index, percent female gender, and distribution of hip fracture diagnosis did not vary significantly between groups. There was a significant reduction in time from admission to surgical management, from 37.0 ± 47.7 to 28.5 ± 27.1 h (p = 0.0016), and in the length of hospital stay, from 6.3 ± 6.5 to 5.4 ± 4.0 days (p = 0.0013). The percentage of patients whose surgeries were performed under spinal anesthesia increased from 12.5 to 26.5% (p = 0.016). There was no difference in 90-day readmission rate or mortality at 30 days, 90 days, or 1 year between groups. CONCLUSION With the implementation of an interdisciplinary hip fracture protocol, we observed significant and sustained reductions in time to surgery and hospital length of stay, important metrics in hip fracture management, without increased readmission or mortality. This has implications to minimize health care costs and improve outcomes for our aging population. LEVEL OF EVIDENCE III, therapeutic.
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Affiliation(s)
- Heather J Roberts
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave MU 320-W, San Francisco, CA, 94143, USA
| | - Stephanie E Rogers
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Derek T Ward
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave MU 320-W, San Francisco, CA, 94143, USA
| | - Utku Kandemir
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave MU 320-W, San Francisco, CA, 94143, USA.
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Amin RM, Raad M, Rao SS, Musharbash F, Best MJ, Amanatullah DF. Survival bias may explain the appearance of the obesity paradox in hip fracture patients. Osteoporos Int 2021; 32:2555-2562. [PMID: 34245343 PMCID: PMC8819709 DOI: 10.1007/s00198-021-06046-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 06/21/2021] [Indexed: 01/29/2023]
Abstract
UNLABELLED Patients with low-energy hip fractures do not follow the obesity paradox as previously reported. In datasets where injury mechanism is not available, the use of age >50 years (as opposed to commonly used >65 years) as a surrogate for a low-energy hip fracture patients may be a more robust inclusion criterion. PURPOSE: In elderly patients with a hip fracture, limited data suggests that obese patients counterintuitively have improved survival compared to normal-weight patients. This "obesity paradox" may be the byproduct of selection bias. We hypothesized that the obesity paradox would not apply to elderly hip fracture patients. METHODS The National Surgical Quality Improvement Project dataset identified 71,685 hip fracture patients ≥50 years-of-age with complete body mass index (BMI) data that underwent surgery. Patients were stratified into under and over 75-year-old cohorts (n=18,956 and 52,729, respectively). Within each age group, patients were stratified by BMI class and compared with respect to preoperative characteristics and 30-day mortality. Significant univariate characteristics (p<0.1) were included in multivariate analysis to determine the independent effect of obesity class on 30-day mortality (p<0.05). RESULTS Multivariate analysis of <75-year-old patients with class-III obesity were more likely to die within 30-days than similarly aged normal-weight patients (OR 1.91, CI 1.06-3.42, p=0.030). Multivariate analysis of ≥75-year-old overweight (OR 0.69, CI 0.62-0.77, p<0.001), class-I obese (OR 0.62, CI 0.51-0.74, p<0.001), or class-II obese (OR=0.69, CI 0.50-0.95, p=0.022) patients were less likely to die within 30-days when compared to similarly aged normal-weight patients. CONCLUSIONS Our data suggest that obesity is a risk factor for mortality in low-energy hip fracture patients, but the appearance of the "obesity paradox" in elderly hip fracture patients results from statistical bias that is only evident upon subgroup analysis.
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Affiliation(s)
- R M Amin
- Department of Orthopaedic Surgery, Stanford Medicine University, 450 Broadway Street, Redwood City, CA, 94063, USA
| | - M Raad
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - S S Rao
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - F Musharbash
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - M J Best
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - D F Amanatullah
- Department of Orthopaedic Surgery, Stanford Medicine University, 450 Broadway Street, Redwood City, CA, 94063, USA.
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10
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Kern-Goldberger AS, Money NM, Gerber JS, Bonafide CP. Inpatient Subspecialty Consultations: A New Target for High-Value Pediatric Hospital Care? Hosp Pediatr 2021:hpeds.2021-006165. [PMID: 34732510 DOI: 10.1542/hpeds.2021-006165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Nathan M Money
- Division of Pediatric Hospital Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jeffrey S Gerber
- Center for Pediatric Clinical Effectiveness
- Division of Infectious Diseases
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine
- Center for Pediatric Clinical Effectiveness
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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11
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Anstey J, Lucas BP. Worry Loves Company, but Unnecessary Consultations May Harm the Patients We Comanage. J Hosp Med 2020; 15:60-61. [PMID: 31869302 PMCID: PMC6932593 DOI: 10.12788/jhm.3304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 11/20/2022]
Affiliation(s)
- James Anstey
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
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