Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis

Improving hip fracture outcomes with integrated orthogeriatric care: a comparison between two accepted orthogeriatric models

Background

our orthopaedic trauma unit serves a large elderly population, admitting 400-500 hip fractures annually. A higher than expected mortality was detected amongst these patients, prompting a change in the hip fracture pathway. The aim of this study was to assess the impact of a change in orthogeriatric provision on hip fracture outcomes and care quality indicators.

Patients and Methods

the hip fracture pathway was changed from a geriatric consultation service to a completely integrated service on a dedicated orthogeriatric ward. A total of 1,894 consecutive patients with hip fractures treated in the 2 years before and after this intervention were analysed.

Results

despite an increase in case complexity, the intervention resulted in a significant reduction in mean length of stay from 27.5 to 21 days (P < 0.001), a significant reduction in mean time to surgery from 41.8 to 27.2 h (P < 0.001) and a significant 22% reduction in 30-day mortality (13.2-10.3%, P = 0.04). After controlling for the effects of age, gender, American Society of Anesthesiology (ASA) Grade and abbreviated mental test score (AMTS), the effect of integrating orthogeriatric services into the hip fracture pathway significantly reduced the risk of mortality (odds ratio 0.68, P = 0.03).

Conclusions

changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly improved mortality and performance indicators. This is the first study to directly compare two accepted models of orthogeriatric care in the same hospital.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Comprehensive Geriatric Assessment for Prevention of Delirium After Hip Fracture: A Systematic Review of Randomized Controlled Trials

OBJECTIVES

To assess the efficacy of comprehensive geriatric assessment (CGA) in prevention of delirium after hip fracture.

DESIGN

Systematic review and metaanalysis.

SETTING

Ward based models on geriatrics wards and visiting team based models on orthopaedics wards were included.

PARTICIPANTS

Four trials (three European, one U.S.; 973 participants) were identified. Two assessed ward-based, and two assessed team-based interventions.

MEASUREMENTS

MEDLINE, EMBASE, CINAHL and PsycINFO databases; Clinicaltrials.gov; and the Central Register of Controlled Trials were searched. Reference lists from full-text articles were reviewed. Incidence of delirium was the primary outcome. Length of stay, delirium severity, institutionalization, long-term cognition and mortality were predefined secondary outcomes. Duration of delirium was included as a post hoc outcome.

RESULTS

There was a significant reduction in delirium overall (relative risk (RR) = 0.81, 95% confidence interval (CI) = 0.69-0.94) in the intervention group. Post hoc subgroup analysis found this effect to be preserved in the team-based intervention group (RR = 0.77, 95% CI = 0.61-0.98) but not the ward-based group. No significant effect was observed on any secondary outcome.

CONCLUSION

There was a reduction in the incidence of delirium after hip fracture with CGA. This is in keeping with results of non-randomized controlled trials and trials in other populations. Team-based interventions appeared superior in contrast to the Ellis CGA paper, but it is likely that heterogeneity in interventions and population studied affected this.

Osteoporosis: a discussion on the past 5 years

PURPOSE OF THE REVIEW

The purposes of this study are to examine the literature within the past 5 years regarding osteoporosis and offer a discussion on new topics and controversies.

RECENT FINDINGS

Patient compliance with therapy remains an issue. The effectiveness of Vitamin D and calcium are being called into question Atypical femur fractures have been associated with bisphosphonate and denosumab use. Treatment is both surgical and pharmaceutical. A multidisciplinary approach to osteoporotic fractures is important and having some form of fracture liaison service (FLS) improves the efficacy of osteoporotic care and decreases secondary fractures. Screening for osteoporosis remains low. Ultrasound may be cost-effective for diagnosis. Understanding of osteoporosis has come a long way in the medical community, but the translation to the lay community has lagged behind. Patients often take a laissez-faire attitude toward osteoporosis that can affect compliance. Information read by patients often focuses on complications, such as atypical femur fractures and myocardial infarctions. It is essential for providers to be able to discuss these issues with patients. Newer medications and more cost-effective diagnostic tests exist, but availability may be limited. FLS are effective, but the most cost-effective model for therapy still eludes us. Areas for further investigation include FLS models, the effectiveness of vitamin supplementation, and more ubiquitous and cost-effective diagnostic tools.

Prolonged suppressive antibiotic therapy for prosthetic joint infection in the elderly: a national multicentre cohort study

During prosthetic joint infection (PJI), optimal surgical management with exchange of the device is sometimes impossible, especially in the elderly population. Thus, prolonged suppressive antibiotic therapy (PSAT) is the only option to prevent acute sepsis, but little is known about this strategy. We aimed to describe the characteristics, outcome and tolerance of PSAT in elderly patients with PJI. We performed a national cross-sectional cohort study of patients >75 years old and treated with PSAT for PJI. We evaluated the occurrence of events, which were defined as: (i) local or systemic progression of the infection (failure), (ii) death and (iii) discontinuation or switch of PSAT. A total of 136 patients were included, with a median age of 83 years [interquartile range (IQR) 81-88]. The predominant pathogen involved was Staphylococcus (62.1%) (Staphylococcus aureus in 41.7%). A single antimicrobial drug was prescribed in 96 cases (70.6%). There were 46 (33.8%) patients with an event: 25 (18%) with an adverse drug reaction leading to definitive discontinuation or switch of PSAT, 8 (5.9%) with progression of sepsis and 13 died (9.6%). Among patients under follow-up, the survival rate without an event at 2 years was 61% [95% confidence interval (CI): 51;74]. In the multivariate Cox analysis, patients with higher World Health Organization (WHO) score had an increased risk of an event [hazard ratio (HR) = 1.5, p = 0.014], whereas patients treated with beta-lactams are associated with less risk of events occurring (HR = 0.5, p = 0.048). In our cohort, PSAT could be an effective and safe option for PJI in the elderly.

Complications during hospitalization and risk factors in elderly patients with hip fracture following integrated orthogeriatric treatment

INTRODUCTION

This study aimed to evaluate the incidence of complications in elderly patients with a hip fracture following integrated orthogeriatric treatment. To discover factors that might be adjusted, in order to improve outcome in those patients, we examined the association between baseline patient characteristics and a complicated course.

METHODS

We included patients aged 70 years and older with a hip fracture, who were treated at the Centre for Geriatric Traumatology (CvGT) at Ziekenhuisgroep Twente (ZGT) Almelo, the Netherlands between April 2011 and October 2013. Data registration was carried out using the clinical pathways of the CvGT database. Based on the American Society of Anesthesiologists (ASA) score, patients were divided into high-risk (HR, ASA 3 ≥, n = 341) and low-risk (LR, ASA 1-2, n = 111) groups and compared on their recovery. Multivariate logistic regression was used to identify risk factors for a complicated course.

RESULTS

The analysis demonstrated that 49.6% (n = 224) of the patients experienced a complicated course with an in-hospital mortality rate of 3.8% (n = 17). In 57.5% (n = 196) of the HR patients, a complicated course was seen compared to 25.2% (n = 28) of the LR patients. The most common complications in both groups were the occurrence of delirium (HR 25.8% vs. LR 8.1%, p ≤ 0.001), anemia (HR 19.4% vs. LR 6.3%, p = 0.001), catheter-associated urinary tract infections (CAUTIs) (HR 10.6% vs. LR 7.2%, p = 0.301) and pneumonia (HR 10.9% vs. LR 5.4%, p = 0.089). Independent risk factors for a complicated course were increasing age (OR 1.04, 95% CI 1.01-1.07, p = 0.023), delirium risk VMS Frailty score (OR 1.57, 95% CI 1.04-2.37, p = 0.031) and ASA score ≥3 (OR 3.62, 95% CI 2.22-5.91, p ≤ 0.001).

CONCLUSIONS

After integrated orthogeriatric treatment, a complicated course was seen in 49.6% of the patients with a hip fracture. The in-hospital mortality rate was 3.8%. Important risk factors for a complicated course were increasing age, poor medical condition and delirium risk VMS Frailty score. Awareness of risk factors that affect the course during admission can be useful in optimizing care and outcomes. In the search for possible areas for improvement in care, targeted preventive measures to mitigate delirium, and healthcare-associated infections (HAIs), such as CAUTIs and pneumonia are important.

Surgical Guidelines for Perioperative Management of Older Adults: What Geriatricians Need to Know

A multidisciplinary panel of experts representing surgery, anesthesia, and geriatrics recently published guidelines for surgeons on the optimal perioperative management of older adults, including recommendations on postoperative recovery and posthospital transitions of care. Geriatricians have an important role in the care for older adults in the preoperative period as older adults consider surgical options and prepare for surgical procedures, during the perioperative period as inpatient consultants, and in the postoperative period as older adults transition to rehabilitation facilities or to home. This article outlines the perioperative surgical guidelines and describes how they apply to the role of the geriatrician in the care of older adults during the perioperative period.

Increased orthogeriatrician involvement in hip fracture care and its impact on mortality in England

Objectives

to describe the increase in orthogeriatrician involvement in hip fracture care in England and its association with improvements in time to surgery and mortality.

Study design

analysis of Hospital Episode Statistics for 196,401 patients presenting with hip fracture to 150 hospitals in England between 1 April 2010 and 28 February 2014, combined with data on orthogeriatrician hours from a national organisational survey.

Methods

we examined changes in the average number of hours worked by orthogeriatricians in orthopaedic departments per patient with hip fracture, and their potential effect on mortality within 30 days of presentation. The role of prompt surgery (on day of or day after presentation) was explored as a potential confounding factor. Associations were assessed using conditional Poisson regression models with adjustment for patients' sex, age and comorbidity and year, with hospitals treated as fixed effects.

Results

between 2010 and 2013, there was an increase of 2.5 hours per patient in the median number of hours worked by orthogeriatricians-from 1.5 to 4.0 hours. An increase of 2.5 hours per patient was associated with a relative reduction in mortality of 3.4% (95% confidence interval 0.9% to 5.9%, P = 0.01). This corresponds to an absolute reduction of approximately 0.3%. Higher numbers of orthogeriatrician hours were associated with higher rates of prompt surgery, but were independently associated with lower mortality.

Conclusion

in the context of initiatives to improve hip fracture care, we identified statistically significant and robust associations between increased orthogeriatrician hours per patient and reduced 30-day mortality.

Leveraging the Preoperative Clinic to Engage Older Patients in Shared Decision Making About Complex Surgery: An Illustrative Case

The decision to pursue surgery is often complicated in older adults. A multidisciplinary, shared approach to decision-making may improve communication between patients and their providers and facilitate complex risk assessment. We describe a case of an older adult presenting for complex surgery in which the preoperative anesthesia clinic visit was used to facilitate involvement of the geriatrics service. This multidisciplinary approach allowed for re-evaluation and reiteration of risks and benefits, in-depth discussion of the patient's values and goals, and recommendations for care teams downstream in the patient's surgical pathway to ensure treatment consistent with patient goals and clinical recommendations.

The effects of habitual functional training on physical functioning in patients after hip fracture: the protocol of the HIPFRAC study

Background

The survivors after hip fracture often report severe pain and loss of physical functioning. The poor outcomes cause negative impact on the person’s physical functioning and quality of life and put a financial burden on society. Rehabilitation is important to improve physical functioning after hip fracture. To maintain the continuity in rehabilitation we have an assumption that it is of utmost importance to continue and progress the functional training that already started at the hospital, while the patients are transferred to short-term stays in a nursing home before they are returning to home. The aim presently is to examine the effects of a functional training program, initiated by the physiotherapist and performed by the nurses, on physical functioning while the patients are at short term stays in primary health care.

Methods/design

Inclusion and randomization will take place during hospital stay. All patients 65 years or above who have sustained a hip fracture are eligible, except if they have a score on Mini Mental State (MMS-E) of less than 15, could walk less than 10 m prior to the fracture, or are terminally ill. The intervention consists of additional functional training as part of the habitual daily routine during short term stays at nursing homes after discharge from hospital. The primary outcome is physical functioning measured by the Short Physical Performance Battery (SPPB). Secondary outcomes are Timed “Up & Go” (TUG), hand grip strength, activPAL accelerometer, and self-reported measures like new Mobility Score (NMS), Walking Habits, University of California Los Angeles (UCLA) activity scale, Fall efficacy scale (FES), EuroQol health status measure (EQ-5D-5 L), and pain.

Discussion

Issues related to internal and external validity in the study are discussed. The outline for the arguments in this protocol is organized according to the guidelines of the Medical Research Council (MRC) guidance on how to develop and evaluate complex interventions.

Trial registration

ClinicalTrials.gov NCT02780076.

The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care

The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.

Comparison of 3 Different Perioperative Care Models for Patients With Hip Fractures Within 1 Health Service

INTRODUCTION

Orthogeriatric care models have been introduced within many health-care facilities to improve outcomes for hip fracture patients. This study aims to evaluate differences in care between 3 models, an orthopedic model, a geriatric model, and a comanaged model.

MATERIALS AND METHODS

A retrospective analysis was conducted for hip fracture patients treated at Western Health between November 2012 and March 2014. All patients aged 65 years or older were included in the analysis.

RESULTS

There were 183 patients in the orthopedic model, 137 in the geriatric model, and 126 in the comanaged model. Demographics and clinical characteristics were similar across the 3 models. Length of stay, mortality, and discharge destination were also consistent across the 3 groups. However, groups involving geriatricians were more likely to receive preoperative medical assessments, have greater recognition of postoperative medical problems, and have implementation of long-term osteoporosis management.

CONCLUSION

The involvement of geriatricians in perioperative care models resulted in more comprehensive medical care without impacting length of stay, mortality, or discharge destination.

[Geriatric intervention in elderly hip fracture patients admitted to University Hospital of Guadalajara: Clincal, healthcare and economical repercussions]

OBJECTIVE

To evaluate the healthcare outcomes and economic impact of geriatric intervention in patients over 75 years old with hip fracture in acute phase.

MATERIAL AND METHODS

Retrospective study of patients admitted to the University Hospital of Guadalajara (HUGU) due to hip fracture. An analysis was made of the number of cases per year, preoperative period, hospital stay, and mortality of all the patients over 75 years admitted to the HUGU due to hip fracture between 2002 and 2013.

RESULTS

A total of 2942 patients were included. Comparing the activity of 2013 to that of 2006, the mean hospital stay fell from 18.5 to 11.2 days (-39.2%), and mortality from 8.9% to 6.8% (-23%). In contrast, the mean preoperative stay remained at a mean of 2.7 days versus 2.4 in previous years in the early post-intervention period. Hospital stay decreased, despite a progressive annual increase in the daily cost of hospitalisation due to hip fracture surgery, the reduced stay led to a reduction of the total cost by more than 900,000 euros each year. Geriatric intervention has gradually reduced mean hospital stay and mortality, although with a tendency to increase mean preoperative stay.

CONCLUSIONS

Geriatric intervention in patients with hip fracture reduces mortality and length of hospital stay, and decreasing costs.

Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment

To improve the quality of care and reduce the healthcare costs of elderly patients with a hip fracture, surgeons and geriatricians collaborated intensively due to the special needs of these patients. After treatment at the Centre for Geriatric Traumatology (CvGT), we found a significant decrease in the 1-year mortality rate in frail elderly patients compared to the historical control patients who were treated with standard care.

INTRODUCTION

The study aimed to evaluate the effect of an orthogeriatric treatment model on elderly patients with a hip fracture on the 1-year mortality rate and identify associated risk factors.

METHODS

This study included patients, aged 70 years and older, who were admitted with a hip fracture and treated in accordance with the integrated orthogeriatric treatment model of the CvGT at the Hospital Group Twente (ZGT) between April 2008 and October 2013. Data registration was carried out by several disciplines using the clinical pathways of the CvGT database. A multivariate logistic regression analysis was used to identify independent risk factors for 1-year mortality. The outcome measures for the 850 patients were compared with those of 535 historical control patients who were managed under standard care between October 2002 and March 2008.

RESULTS

The analysis demonstrated that the 1-year mortality rate was 23.2 % (n = 197) in the CvGT group compared to 35.1 % (n = 188) in the historical control group (p < 0.001). Independent risk factors for 1-year mortality were male gender (odds ratio (OR) 1.68), increasing age (OR 1.06), higher American Society of Anesthesiologists (ASA) score (ASA 3 OR 2.43, ASA 4-5 OR 7.05), higher Charlson Comorbidity Index (CCI) (CCI 1-2 OR 1.46, CCI 3-4 OR 1.59, CCI 5 OR 2.71), malnutrition (OR 2.01), physical limitations in activities of daily living (OR 2.35), and decreasing Barthel Index (BI) (OR 0.96).

CONCLUSION

After integrated orthogeriatric treatment, a significant decrease was seen in the 1-year mortality rate in the frail elderly patients with a hip fracture compared to the historical control patients who were treated with standard care. The most important risk factors for 1-year mortality were male gender, increasing age, malnutrition, physical limitations, increasing BI, and medical conditions. Awareness of risk factors that affect the 1-year mortality can be useful in optimizing care and outcomes. Orthogeriatric treatment should be standard for elderly patients with hip fractures due to the multidimensional needs of these patients.

Shoulder Arthroscopy in Adults 60 or Older: Risk Factors That Correlate With Postoperative Complications in the First 30 Days

PURPOSE

To investigate the 30-day postoperative adverse event (AE) rates of adults 60 years or older after shoulder arthroscopy and identify risk factors for complications in this patient population.

METHODS

Patients aged 60 or more who underwent shoulder arthroscopy were identified in the American College of Surgeons National Surgery Quality Improvement Program database from 2006 to 2013 using 12 Current Procedural Terminology codes related to shoulder arthroscopy. Complications were categorized as severe AEs, minor AEs, and infectious AEs for separate analyses. Pearson's χ² tests were used to identify associations between patient characteristics and AE occurrence and binary logistic regression for multivariate analysis of independent risk factors.

RESULTS

In total, 7,867 patients were included for analysis. Overall, 1.6% (n = 127) of the older adults experienced at least one AE with 1.1% (n = 90) severe AEs, 0.6% (n = 46) minor AEs, and 0.4% (n = 28) infectious complications. Multivariate analysis revealed that age 80 years or older (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2-2.7, P = .01), body mass index greater than 35 (OR = 1.8, 95% CI = 1.1-2.7, P = .01), functionally dependent status (OR = 2.9, 95% CI = 1.3-6.8, P = .01), American Society of Anesthesiologists class greater than 2 (OR = 1.5, 95% CI = 1.0-2.2, P = .04), congestive heart failure (OR = 6.1, 95% CI = 1.8-21.2, P = .03), disseminated cancer (OR = 7.9, 95% CI = 1.4-43.9, P = .02), and existence of an open wound at the time of surgery (OR = 4.0, 95% CI = 1.1-14.6, P = .03) were independently associated with the occurrence of an AE. Nineteen of the patients included in the study required readmission to the hospital within the 30-day period for an overall readmission rate of 0.2%.

CONCLUSIONS

Patients 60 years or older who underwent shoulder arthroscopy for a variety of indications have a low overall 30-day postoperative complication rate of 1.6%. Although low, this is a higher rate than previously reported for the overall shoulder arthroscopy population. Independent patient characteristics associated with increased risk of AE occurrence included age 80 years or older, body mass index greater than 35, functional dependent status, American Society of Anesthesiologists score of 3 or 4, congestive heart failure, disseminated cancer, and existence of an open wound.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Geriatric Hip Fracture Care: Fixing a Fragmented System

CONTEXT

Fragmentation in geriatric hip fracture care is a growing concern because of the aging population. Patients with hip fractures at our institution historically were admitted to multiple different services and units, leading to unnecessary variation in inpatient care. Such inconsistency contributed to delays in surgery, discharge, and functional recovery; hospital-acquired complications; failure to adhere to best practices in osteoporosis management; and poor coordination with outpatient practitioners.

OBJECTIVE

To describe a stepwise approach to systems redesign for this patient population.

DESIGN

We designed and implemented a comprehensive geriatric hip fracture program for patients aged 65 years and older at our academic Medical Center in October 2014. Key interventions included admission of all ward-status patients to the Orthopedics Service with hospitalist comanagement; geographic placement on the Orthopedics Unit; and standardized, evidence-based electronic order sets bundling geriatric best practices and a streamlined workflow for discharge planning.

MAIN OUTCOME MEASURES

Hospital length of stay.

RESULTS

We identified 271 admissions among 267 patients between January 1, 2012, and March 31, 2016; of those, 154 were before and 117 were after program implementation. Mean hospital length of stay significantly improved from 6.4 to 5.5 days (p = 0.004). The 30-day all-cause readmission rate and discharge disposition remained stable. The percentage of patients receiving osteoporosis evaluation and treatment increased significantly. The rate of completed 30-day outpatient follow-up also improved.

CONCLUSION

Our comprehensive geriatric hip fracture program achieved and sustained gains in the quality and efficiency of care by improving fragmentation in the health care system.

Interdisciplinary management of hip fracture

Hip fracture is a prevalent age-associated occurrence incorporating both medical and surgical need and a major challenge to public health and NHS resources. Effective management requires coordinated collaboration across specialties, professions and services. This concise guideline focuses on interdisciplinary aspects of hip fracture management abstracted from National Institute for Health and Care Excellence (NICE) clinical guideline (CG124), including the concept and implementation of the Hip Fracture Programme, detection and management of comorbidity and delirium, optimal analgesia, timing of surgery, multidisciplinary mobilisation, rehabilitation and hospital discharge. The recently updated National Hip Fracture Database report and NICE quality standard are potential drivers for progress.

Outcome parameters in orthogeriatric co‑management - a mini-review

Recognizing hip and other fragility fractures as an adverse event of chronic geriatric conditions led to the concept of orthogeriatric co-management (OGC). OGC today represents various forms of structural cooperation between orthopedic trauma surgeons and multiprofessional geriatric teams taking care of frail elderly patients. The models are country specific. Despite several published models there are still no clear recommendations on how this service should be best organized. The 12 outcome parameters published by the Experts' Roundtable in 2013 were recommended to be used for the further assessment of different OCG models. This literature review was prepared accordingly and showed the need for further studies to determine the best OGC model and to define a uniform set of outcome parameters for use in future clinical studies.

Frailty and sarcopenia: From theory to clinical implementation and public health relevance

The sustainability of healthcare systems is threatened by the increasing (absolute and relative) number of older persons referring to clinical services. Such global phenomenon is questioning the traditional paradigms of medicine, pushing towards the need of new criteria at the basis of clinical decision algorithms. In this context, frailty has been advocated as a geriatric condition potentially capable of overcoming the weakness of chronological age in the identification of individuals requiring adapted care due to their increased vulnerability to stressors. Interestingly, frailty poses itself beyond the concept of nosological conditions due to the difficulties at correctly framing traditional diseases in the complex and heterogeneous scenario of elders. Thus, frailty may play a key role in public health policies for promoting integrated care towards biologically aged individuals, currently presenting multiple unmet clinical needs. At the same time, the term frailty has also been frequently used in the literature for framing a physical condition of risk for (mainly functional) negative endpoints. The combination of such physical impairment with an organ-specific phenotype (e.g., the age-related skeletal muscle decline or sarcopenia) may determine the assumptions for the development of a clinical condition to be used as potential target for ad hoc interventions against physical disability. In the present article, we present the background of frailty and sarcopenia, and discuss their potentialities for reshaping current clinical and research practice in order to promote holistic approach to older patients, solicit personalization of care, and develop new targets for innovative interventions.

Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery

The Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α₂ agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery.

Geriatric trauma

PURPOSE OF REVIEW

The landscape of trauma is changing due to an aging population. Geriatric patients represent an increasing number and proportion of trauma admissions and deaths. This review explores recent literature on geriatric trauma, including triage criteria, assessment of frailty, fall-related injury, treatment of head injury complicated by coagulopathy, goals of care, and the need for ongoing education of all surgeons in the care of the elderly.

RECENT FINDINGS

Early identification of high-risk geriatric patients is imperative to initiate early resuscitative efforts. Geriatric patients are typically undertriaged because of their baseline frailty being underappreciated; however, centers that see more geriatric patients do better. Rapid reversal of anticoagulation is important in preventing progression of brain injury. Anticipation of difficult disposition necessitates early involvement of physical therapy for rehabilitation and case management for appropriate placement.

SUMMARY

Optimal care of geriatric trauma patients will be based on the well established tenets of trauma resuscitation and injury repair, but with distinct elements that address the physiological and anatomical challenges presented by geriatric patients.

Geriatric syndromes: How to treat

The survival of HIV-infected persons has been increasing over the last years, thanks to the implementation of more effective pharmacological and non-pharmacological interventions. Nevertheless, HIV-infected persons are often "biologically" older than their "chronological" age due to multiple clinical, social, and behavioral conditions of risk. The detection in this population of specific biological features and syndromic conditions typical of advanced age has made the HIV infection an interesting research model of accelerated and accentuated aging. Given such commonalities, it is possible that "biologically aged" HIV-positive persons might benefit from models of adapted and integrated care developed over the years by geriatricians for the management of their frail and complex patients. In this article, possible strategies to face the increasingly prevalent geriatric syndromes in HIV-infected persons are discussed. In particular, it is explained the importance of shifting from the traditional disease-oriented approach into models of care facilitating a multidisciplinary management of frailty.

Measurement of Function Post Hip Fracture: Testing a Comprehensive Measurement Model of Physical Function

BACKGROUND

Measurement of physical function post hip fracture has been conceptualized using multiple different measures.

PURPOSE

This study tested a comprehensive measurement model of physical function.

DESIGN

This was a descriptive secondary data analysis including 168 men and 171 women post hip fracture.

METHODS

Using structural equation modeling, a measurement model of physical function which included grip strength, activities of daily living, instrumental activities of daily living, and performance was tested for fit at 2 and 12 months post hip fracture, and among male and female participants. Validity of the measurement model of physical function was evaluated based on how well the model explained physical activity, exercise, and social activities post hip fracture.

FINDINGS

The measurement model of physical function fit the data. The amount of variance the model or individual factors of the model explained varied depending on the activity.

CONCLUSION

Decisions about the ideal way in which to measure physical function should be based on outcomes considered and participants.

CLINICAL RELEVANCE

The measurement model of physical function is a reliable and valid method to comprehensively measure physical function across the hip fracture recovery trajectory.

Orthogeriatric care: improving patient outcomes

Hip fractures are a very serious socio-economic problem in western countries. Since the 1950s, orthogeriatric units have introduced improvements in the care of geriatric patients admitted to hospital because of hip fractures. During this period, these units have reduced mean hospital stays, number of complications, and both in-hospital mortality and mortality over the middle term after hospital discharge, along with improvements in the quality of care and a reduction in costs. Likewise, a recent clinical trial has reported greater functional gains among the affected patients. Studies in this field have identified the prognostic factors present upon admission or manifesting themselves during admission and that increase the risk of patient mortality or disability. In addition, improved care afforded by orthogeriatric units has proved to reduce costs. Nevertheless, a number of management issues remain to be clarified, such as the optimum anesthetic, analgesic, and thromboprophylactic protocols; the type of diagnostic and therapeutic approach best suited to patients with cognitive problems; or the efficiency of the programs used in convalescence units or in home rehabilitation care. Randomized clinical trials are needed to consolidate the evidence in this regard.

Racial and Socioeconomic Disparities in Hip Fracture Care

BACKGROUND

Despite declines in both the incidence of and mortality following hip fracture, there are racial and socioeconomic disparities in treatment access and outcomes. We evaluated the presence and implications of disparities in delivery of care, hypothesizing that race and community socioeconomic characteristics would influence quality of care for patients with a hip fracture.

METHODS

We collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS), which prospectively captures information on all discharges from nonfederal acute-care hospitals in New York State. Records for 197,290 New York State residents who underwent surgery for a hip fracture between 1998 and 2010 in New York State were identified from SPARCS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multivariable regression models were used to evaluate the association of patient characteristics, social deprivation, and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission, and 1-year mortality.

RESULTS

After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation, and other variables, black patients were at greater risk for delayed surgery (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.57), a reoperation (hazard ratio [HR] = 1.21; CI = 1.11, 1.32), readmission (OR = 1.17; CI = 1.11, 1.22), and 1-year mortality (HR = 1.13; CI = 1.07, 1.21) than white patients. Subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. Additionally, there was a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. Compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery (OR = 1.17; CI = 1.10, 1.24) whereas privately insured patients were at decreased risk for delayed surgery (OR = 0.77; CI = 0.74, 0.81), readmission (OR = 0.77; CI = 0.74, 0.81), complications (OR = 0.80; CI = 0.77, 0.84), and 1-year mortality (HR = 0.80; CI = 0.75, 0.85).

CONCLUSIONS

There are race and insurance-based disparities in delivery of care for patients with hip fracture, some of which persist after adjusting for social deprivation. In addition to investigation into reasons contributing to disparities, targeted interventions should be developed to mitigate effects of disparities on patients at greatest risk.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty after hip fracture

Practice is inconsistent and inequitable

Hospital case volume and outcomes for proximal femoral fractures in the USA: an observational study

OBJECTIVE

To explore whether older adults with isolated hip fractures benefit from treatment in high-volume hospitals.

DESIGN

Population-based observational study.

SETTING

All acute hospitals in California, USA.

PARTICIPANTS

All individuals aged ≥65 that underwent an operation for an isolated hip fracture in California between 2007 and 2011. Patients transferred between hospitals were excluded.

PRIMARY AND SECONDARY OUTCOMES

Quality indicators (time to surgery) and patient outcomes (length of stay, in-hospital mortality, unplanned 30-day readmission, and selected complications).

RESULTS

91,401 individuals satisfied the inclusion criteria. Time to operation and length of stay were significantly prolonged in low-volume hospitals, by 1.96 (95% CI 1.20 to 2.73) and 0.70 (0.38 to 1.03) days, respectively. However, there were no differences in clinical outcomes, including in-hospital mortality, 30-day re-admission, and rates of pneumonia, pressure ulcers, and venous thromboembolism.

CONCLUSIONS

These data suggest that there is no patient safety imperative to limit hip fracture care to high-volume hospitals.

Integrating Geriatric Consults into Routine Care of Older Trauma Patients: One-Year Experience of a Level I Trauma Center

BACKGROUND

Although involvement of geriatricians in the care of older trauma patients is associated with changes in processes of care and improved outcomes, few geriatrician consultations were ordered on our service.

STUDY DESIGN

Mandatory geriatric consults were initiated in September 2013 for all trauma patients 70 years and older admitted to our hospital. We prospectively collected data on patients admitted from October 2013 through September 2014 (postintervention) and compared their data with those of patients admitted from June 2011 through June 2012 (preintervention). We collected data on processes of care (DNR and do not intubate status, delirium, and referral for cognitive evaluation) and patient outcomes (mortality, readmission, and length of stay). Descriptive statistics and post-hoc power analyses were performed.

RESULTS

There were 215 and 191 patients included in the preintervention and postintervention cohorts, respectively. After the intervention, geriatric consults increased from 3.26% to 100%. Patients with DNR and do not intubate status increased from 10.23% to 38.22% (p < 0.01). Referral for formal cognitive evaluation increased from 2.33% to 14.21% (p < 0.01) and delirium documentation increased from 31.16% to 38.22% (p = 0.14). In-hospital mortality and 30-day mortality in the pre- and postintervention periods were 9.30% vs 5.24% (p = 0.12) and 11.63% vs 6.81% (p = 0.10), respectively. Intensive care unit readmission rate was 8.26% preintervention and 1.96% postintervention (p = 0.06). There were no changes in 30-day hospital readmission and length of stay. Power analyses showed more patients were needed to show statistically significant outcomes.

CONCLUSIONS

The initiation of mandatory geriatric consults on our trauma service was associated with improved advance care planning and increased multidisciplinary care. Ensuring involvement of geriatricians can aid in reducing adverse outcomes among geriatric trauma patients.

Quality of care for patients with a fracture of the hip in major trauma centres

Aims

In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip.

Patients and Methods

All patients in the United Kingdom National Hip Fracture Database, between April 2010 and December 2013, were included. The indicators of quality that were recorded included the time to arrival on an orthopaedic ward, to review by a geriatrician, and to operation. The clinical outcomes were the development of a pressure sore, discharge home, length of stay, in-hospital mortality, and re-operation within 30 days.

Results

There were 289 466 patients, 49 350 (17%) of whom were treated in hospitals that are now MTCs. Using multivariable logistic and generalised linear regression models, there were no significant differences in any of the indicators of the quality of care or clinical outcomes between MTCs, hospitals awaiting MTC designation and non-MTC hospitals.

Conclusion

These findings suggest that the regionalisation of major trauma in England did not improve or compromise the overall care of elderly patients with a fracture of the hip. Take home message: There is no evidence that reconfiguring major trauma services in England disrupted the treatment of older adults with a fracture of the hip. Cite this article: Bone Joint J 2016;98-B:414–19.

Perioperative medicine for older patients: how do we deliver quality care?

The demand for surgical intervention in older people is rising due to the growing older population with multimorbidity. Yet older people continue to have reduced access to surgery and have more adverse postoperative outcomes than younger people. Current models of preoperative risk assessment and optimisation are poorly suited to this complex surgical population. Furthermore, there has been little emphasis on perioperative management of older people in national anaesthetic and surgical curriculums. New models of care and training in perioperative medicine for older people are evolving, with national reports calling for collaboration between geriatricians, general physicians, anaesthetists and surgeons. Such collaboration is necessary to impact clinical service development, research agendas and education and training. In this article, we discuss the challenges and potential solutions in the establishment of quality surgical care for older people.

State of origin: Australian states use widely different resources for hospital management of hip fracture, but achieve similar outcomes

Objective Hospital management of hip fracture varies widely with regard to length of stay, delivery of post-surgical care and costs. The present study compares the association between hospital utilisation and costs and patient outcomes in the six Australian states. Methods The present study was a retrospective cohort study of linked administrative databases for 2530 Australian veterans and war widows aged ≥65 years, hospitalised for hip fracture in 2008–09. Department of Veterans’ Affairs datasets for hospital episodes, residential aged care admissions and date of death were linked. Patient characteristics, hospital utilisation and process data, rates of mortality and residential care placement and delivery of community services were compared for patients from each of the states. Results There were no significant differences in fracture incidence, patient demographics or fracture type among the states. Adjusted total mean length of hospital stay ranged from 24.7 days (95% confidence interval (CI) 22.3–27.5 days) to 35.0 days (95% CI 32.6–37.6 days; P < 0.001) and adjusted total hospital cost ranged between A$24 792 (95% CI A$22 191–A$27 700) and A$35 494 (95% CI A$32 853–A$38 343; P < 0.001). Rates of referral to rehabilitation ranged from 31.7% to 50.4% (P = 0.003). At 1 year, there were no significant differences between states for key outcome determinants of mortality (P = 0.71) or for the proportion of patients who retained their independent living status (P = 0.66). Conclusion Hospital resources for management of hip fracture differ substantially among the Australian states. Key medium-term patient outcomes do not show significant differences. A potential for substantial cost-efficiencies without increased risk to patient welfare is suggested. What is known about this topic? Hospital resources deployed in the initial management of hip fracture differ widely between countries, regions and individual hospitals. Patient outcomes also vary widely, but are inconsistently associated with resource outlays. What does this paper add? The paper describes the different resource outlays for management of hip fracture in six Australian jurisdictions and the absence of equivalent differences in medium-term patient outcomes. What are the implications for practitioners? Efficiencies in hospital management of hip fracture may be achievable without negative consequences for patients. The elements of models of care should be examined for their contribution to early and later patient outcomes.

Hip fracture programs: are they effective?

This manuscript will evaluate the published evidence on efficacy of organized hip fracture programs to determine if they improve patient outcomes. A detailed literature search was conducted to find manuscripts published in the past 20 years about organized hip fracture care programs. Seventeen programs with published results were identified from this detailed search and these were evaluated and synthesized in the following manuscript. Organized hip fracture programs offer significant benefits to patients, care providers and health systems. The more complex program designs have a more profound effect on improvement in outcomes for hip fracture patients. Most programs have reported reduced length of stay, reduced in-hospital mortality rates, and reduced complications. Some programs have reported reduced costs and reduced readmission rates after implementing an organized hip fracture program.

Can improved quality of care explain the success of orthogeriatric units? A population-based cohort study

BACKGROUND

admission to orthogeriatric units improves clinical outcomes for patients with hip fracture; however, little is known about the underlying mechanisms.

OBJECTIVE

to compare quality of in-hospital care, 30-day mortality, time to surgery (TTS) and length of hospital stay (LOS) among patients with hip fracture admitted to orthogeriatric and ordinary orthopaedic units, respectively.

DESIGN

population-based cohort study.

MEASURES

using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry, we identified 11,461 patients aged ≥65 years admitted with a hip fracture between 1 March 2010 and 30 November 2011. The patients were divided into two groups: (i) those treated at an orthogeriatric unit, where the geriatrician is an integrated part of the multidisciplinary team, and (ii) those treated at an ordinary orthopaedic unit, where geriatric or medical consultant service are available on request. Outcome measures were the quality of care as reflected by six process performance measures, 30-day mortality, the TTS and the LOS. Data were analysed using log-binomial, linear and logistic regression controlling for potential confounders.

RESULTS

admittance to orthogeriatric units was associated with a higher chance for fulfilling five out of six process performance measures. Patients who were admitted to an orthogeriatric unit experienced a lower 30-day mortality (adjusted odds ratio (aOR) 0.69; 95% CI 0.54-0.88), whereas the LOS (adjusted relative time (aRT) of 1.18; 95% CI 0.92-1.52) and the TTS (aRT 1.06; 95% CI 0.89-1.26) were similar.

CONCLUSIONS

admittance to an orthogeriatric unit was associated with improved quality of care and lower 30-day mortality among patients with hip fracture.

Rehabilitation – a new approach. Part four: a new paradigm, and its implications

This editorial proposes changes in healthcare services that should greatly improve the health status of all patients with disability. The main premises are that: rehabilitation usually involves many actions delivered by many people from different organisations over a prolonged period; specific rehabilitation actions cover a wide range of professional activities, with face to face therapy only being one; and the primary patient activity that improves function is practice of personally relevant activities in a safe environment. This editorial argues that: rehabilitation should occur at all times and in all settings, in parallel with medical care in order to maximise recovery and to avoid loss of fitness, skills and confidence associated with rest and being cared for; hospitals and other healthcare settings should adapt the environment to encourage practice of activities at all times; and that measuring rehabilitation, whether in research or for re-imbursement, should not simply consider face-to-face ‘therapy time’ but must include: all the other important activities undertaken by the team; ‘structures’ such as the appropriateness of the environment; and a process measure of the time spent by patients undertaking activities.

[Geriatric fracture centers. Improved patient care and economic benefits]

The world's population is aging resulting in changes in the way we manage geriatric care. Furthermore, this population has a considerable risk of fragility fractures, most notably hip fractures. Hip fractures are associated with significant morbidity and mortality and have large economic consequences. It is due to these factors that the concept of an elderly trauma center was developed. These trauma centers utilize the expertise in orthopedic and geriatric disciplines to provide coordinated care to the elderly hip fracture patient. As a result, studies have demonstrated improvements in clinical outcomes within the hospital stay, a reduction in iatrogenic complications, and improvements in 1-year mortality rates compared to the usual care given at a similar facility. Furthermore, economic models have demonstrated that there is a role for regionalized hip fracture centers that can be both profitable and provide more efficient care to these patients.

Emergency Major Abdominal Surgical Procedures in Older Adults: A Systematic Review of Mortality and Functional Outcomes

OBJECTIVES

To systematically review the current literature on mortality and functional outcomes after emergency major abdominal surgery in older adults.

DESIGN

Systematic literature search and standardized data collection of primary research publications from January 1994 through December 2013 on mortality or functional outcome in adults aged 65 and older after emergency major abdominal surgery using PubMed, EMBASE, Web of Science, Cochrane, and CINAHL. Bibliographies of relevant reports were also hand-searched to identify all potentially eligible studies.

SETTING

Systematic review of retrospective and cohort studies using Preferred Reporting Items for Systematic reviews and Meta-Analyses, Meta-analysis Of Observational Studies in Epidemiology, Strengthening the Reporting of Observational Studies in Epidemiology, and A Measurement Tool to Assess Systematic Reviews guidelines.

PARTICIPANTS

Older adults.

MEASUREMENTS

Articles were assessed using a standardized quality scoring system based on study design, measurement of exposures, measurement of outcomes, and control for confounding.

RESULTS

Of 1,459 articles screened, 93 underwent full-text review, and 20 were systematically reviewed. In-hospital and 30-day mortality of all older adults exceeded 15% in 14 of 16 studies, where reported. Older adults undergoing emergency major abdominal surgery consistently had higher mortality across study settings and procedure types than younger individuals undergoing emergency procedures and older adults undergoing elective procedures. In studies that stratified older adults, odds of death increased with age. None of these studies examined postoperative functional status, which precluded including functional outcomes in this review. Differences in exposures, outcomes, and data presented in the studies did not allow for quantification of association using metaanalysis.

CONCLUSION

Age independently predicts mortality after emergency major abdominal surgery. Data on changes in functional status of older adults who undergo these procedures are lacking.

The influence of inpatient comprehensive geriatric care on elderly patients with hip fractures: a meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy of in-patient comprehensive geriatric care for elderly patients with hip fracture.

METHODS

Relevant literatures were searched using the following databases including PubMed, OVID, Web of science, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trails until August 1, 2015. Eligible studies were restricted to randomized controlled trials (RCTs). The available data was extracted by two independent authors and pooled through using Review manager version 5.2. For data deemed not appropriate for synthesis, a narrative overview was conducted.

RESULTS

15 trials evaluating 3458 participants were identified in our meta-analysis. Our findings indicated patients who underwent comprehensive geriatric cares showed no significant greater improvement than control in in-patient mortality (Odds risk (OR) 0.73, 95% confidence interval (CI) 0.51 to 1.05, P=0.09), 3-(OR 0.96, 95% CI 0.51 to 1.81, P=0.90), 6-(OR 1.03, 95% CI 0.73 to 1.45, P=0.86) and 12-months mortality (OR 0.93, 95% CI 0.77 to 1.12, P=0.30). The proportion of patients who were discharged from hospital to the same place of residence as before the fracture was higher in intervention group than control (OR 1.67, 95% CI 0.80 to 3.37, P=0.0003). In addition, the pooled results showed that the number of patients in intervention group who had regained the same level of activities of daily living (ADL) (43.9% vs 30.2%, 46.0% vs 29.1%) and walking ability (71.3% vs 53.2%, 68.9% vs 56.3%) as before the fracture was higher than control at 3 and 12 months after discharge, respectively.

CONCLUSION

Comprehensive geriatric care promoted the functional improvement for elderly patients with hip fracture. Meanwhile, the proportion of patients who were discharged from hospital to the same place as before fracture in intervention group was higher as compared to control. However, our finding showed no significant difference on in-patients mortality, follow-up mortality and length of stay between both groups.

Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study

Background

Delay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients.

Methods

This study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data.

Results

The improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47 % to 83 %, with performance predictably ranging between 67 % and 98 % if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation.

Conclusions

Timeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures.

Geriatric orthopedic co-management of older adults with hip fracture: an emerging standard

Hip fracture, a common complication of fall injuries in older adults, often results in high rate of mortality, increased debility, functional loss, and worse quality of life. The value of geriatric teams and model of care for the hip fracture patients have been examined in a number of studies, and even though most studies have demonstrated potential impact in improving outcomes for the hip fracture patients, they are often observational or quasi-experimental designs that are prone to bias. In this editorial, we review the Lancet article by Prestmo and colleagues, a randomized controlled trial that demonstrated improved outcomes for hip fracture patients managed in a geriatric unit.