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Armstrong E, Harvey LA, Payne NL, Zhang J, Ye P, Harris IA, Tian M, Ivers RQ. Do we understand each other when we develop and implement hip fracture models of care? A systematic review with narrative synthesis. BMJ Open Qual 2023; 12:e002273. [PMID: 37783525 PMCID: PMC10565304 DOI: 10.1136/bmjoq-2023-002273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/02/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND A hip fracture in an older person is a devastating injury. It impacts functional mobility, independence and survival. Models of care may provide a means for delivering integrated hip fracture care in less well-resourced settings. The aim of this review was to determine the elements of hip fracture models of care to inform the development of an adaptable model of care for low and middle-income countries (LMICs). METHODS Multiple databases were searched for papers reporting a hip fracture model of care for any part of the patient pathway from injury to rehabilitation. Results were limited to publications from 2000. Titles, abstracts and full texts were screened based on eligibility criteria. Papers were evaluated with an equity lens against eight conceptual criteria adapted from an existing description of a model of care. RESULTS 82 papers were included, half of which were published since 2015. Only two papers were from middle-income countries and only two papers were evaluated as reporting all conceptual criteria from the existing description. The most identified criterion was an evidence-informed intervention and the least identified was the inclusion of patient stakeholders. CONCLUSION Interventions described as models of care for hip fracture are unlikely to include previously described conceptual criteria. They are most likely to be orthogeriatric approaches to service delivery, which is a barrier to their implementation in resource-limited settings. In LMICs, the provision of orthogeriatric competencies by other team members is an area for further investigation.
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Affiliation(s)
- Elizabeth Armstrong
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Lara A Harvey
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Narelle L Payne
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Jing Zhang
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Pengpeng Ye
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Ian A Harris
- Orthopaedic Department, Liverpool Hospital, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Rebecca Q Ivers
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Tewari P, Sweeney BF, Lemos JL, Shapiro L, Gardner MJ, Morris AM, Baker LC, Harris AS, Kamal RN. Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review. JAMA Netw Open 2022; 5:e2231911. [PMID: 36112373 PMCID: PMC9482052 DOI: 10.1001/jamanetworkopen.2022.31911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors. OBJECTIVE To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS. EVIDENCE REVIEW A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components. FINDINGS Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements. CONCLUSIONS AND RELEVANCE In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.
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Affiliation(s)
- Pariswi Tewari
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Brian F. Sweeney
- Stanford University School of Medicine, Mountain View, California
| | - Jacie L. Lemos
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lauren Shapiro
- Department of Orthopaedic Surgery, University of California, San Francisco
| | - Michael J. Gardner
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Arden M. Morris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Laurence C. Baker
- Department of Health Research and Policy, Stanford University, Stanford, California
| | - Alex S. Harris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Robin N. Kamal
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- VOICES Health Policy Research Center, Stanford University, Stanford, California
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van der Vet PCR, Kusen JQ, Rohner-Spengler M, Link BC, Verleisdonk EJMM, Knobe M, Henzen C, Schmid L, Babst R, Beeres FJP. The Quality of Life, Patient Satisfaction and Rehabilitation in Patients With a Low Energy Fracture-Part III of an Observational Study. Geriatr Orthop Surg Rehabil 2021; 12:21514593211046407. [PMID: 34868722 PMCID: PMC8642119 DOI: 10.1177/21514593211046407] [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: 07/29/2021] [Revised: 07/29/2021] [Accepted: 08/17/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Due to the aging population the incidence of Low Energy Fractures (LEF) increases. LEF have high mortality and morbidity rates and often cause elderly to lose independence. Patient-reported outcomes, such as Quality of Life (QoL) and patient satisfaction (PS) are needed to evaluate treatment, estimate cost-benefit analyses, and to improve clinical decision-making and patient-centered care. Objective The primary goal was to evaluate QoL and PS in patients with LEF, and to compare QoL scores to the community dwelling population. Second, we observed the amount and type of physiotherapy (PT) sessions the patients conducted. Methods A single-center cohort study was conducted in Switzerland. Patients between 50 and 85 years, who were treated in the hospital for LEF, were followed 1 year after initial fracture. Data on QoL were obtained through the Euroqol-5-Dimension questionnaire-3-Level (EQ-5D-3L) and the EQ VAS (visual analog scale). PS was measured by a VAS on satisfaction with treatment outcome. Data on PT sessions, mobility and use of analgesics were collected by telephone interviews and written surveys. Results were compared between the different fracture locations and subgroup analyses were performed for age categories. Results 411 patients were included for analysis. The median scores of the EQ-5D-3L index-VAS and PS were 0.90 (0.75-1.0), 90 (71.3-95) and 100 (90-100). Significant differences in all scores were found between fracture location (P < .05), with hip fracture patients and patients with a malleolar fracture scoring lowest in all measures. QoL index in hip fracture patients was 0.76 (0.70-1.00), QoL VAS 80 (70-90), and PS 95 (80-100). Median amount of PT sessions in all patients was 18 (9-27) and a significant difference was found between fracture locations. Patients with a fracture of the humerus received the highest amount of PT sessions 27 (18-36), hip fracture patients had a median of 18 (9-27) sessions. Conclusion At follow-up, QoL throughout all patients with a LEF was comparable to a normal population. Remarkably, though hip fracture patients seem to suffer from a clinically relevant loss of QoL, they received fewer PT sessions and performed fewer long-lasting home training than patients with a humerus fracture. Intensive, progressive rehabilitation with a high frequency of supervised training is recommended after hip fracture. The low frequency of PT sessions found in this study is unsatisfying. In hip fracture patients and in patients with a malleolar fracture, especially when aged over 75 years, more efforts are required to improve rehabilitation and subsequently QoL.
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Affiliation(s)
- Puck C R van der Vet
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Jip Q Kusen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Bjoern-Christian Link
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Egbert-Jan M M Verleisdonk
- Department of Orthopaedic and Trauma Surgery, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, The Netherlands
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Christoph Henzen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Lukas Schmid
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Blauth M, Joeris A, Rometsch E, Espinoza-Rebmann K, Wattanapanom P, Jarayabhand R, Poeze M, Wong MK, Kwek EBK, Hegeman JH, Perez-Uribarri C, Guerado E, Revak TJ, Zohner S, Joseph D, Gosch M. Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study. BMJ Open 2021; 11:e039960. [PMID: 33972329 PMCID: PMC8112430 DOI: 10.1136/bmjopen-2020-039960] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 03/24/2021] [Accepted: 04/15/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes. DESIGN Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year. SETTING International (six countries, three continents) multicentre study. PARTICIPANTS 281 patients aged ≥70 with operatively treated proximal femur fractures. INTERVENTIONS Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy. OUTCOME MEASURES Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life. RESULTS Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002). CONCLUSIONS Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT02297581.
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Affiliation(s)
- Michael Blauth
- Formerly: Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Innsbruck, Austria
- Preclinical Clinical Medical, Depuy Synthes, Zuchwil, Switzerland
| | - Alexander Joeris
- AO Innovation Translation Center (AOITC), AO Foundation, Dübendorf, Switzerland
| | - Elke Rometsch
- AO Innovation Translation Center (AOITC), AO Foundation, Dübendorf, Switzerland
| | | | | | | | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Merng K Wong
- Orthopedic Surgery, Singapore General Hospital, Singapore
| | | | | | | | - Enrique Guerado
- Hospital Universitario Costa del Sol, Faculty of Medicine, University of Malaga, Marbella, Spain
| | - Thomas J Revak
- Department of Orthopaedic Surgery, Division of Orthopedic Trauma, Saint Louis University, Saint Louis, Missouri, USA
| | - Sebastian Zohner
- Klinik für Unfallchirurgie und Sporttraumatologie, Kepler Universitätsklinikum Med Campus III, Linz, Austria
| | - David Joseph
- Orthopedics, Elmhurst Hospital Center, Elmhurst, New York, USA
| | - Markus Gosch
- Paracelsus Medizinischen Privatuniversität für Geriatrie, Paracelsus Universitat Nurnberg, Nurnberg, Germany
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Efficacy of two integrated geriatric care pathways for the treatment of hip fractures: a cross-cultural comparison. Eur J Trauma Emerg Surg 2021; 48:2927-2936. [PMID: 33688974 DOI: 10.1007/s00068-021-01626-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Many studies have focussed on the implementation and outcomes of geriatric care pathways (GCPs); however, little is known about the possible impact of clinical practices on these pathways. A comparison was made between two traumageriatric care models, one Swiss (CH) and one Dutch (NL), to assess whether these models would perform similarly despite the possible differences in local clinical practices. MATERIALS AND METHODS This cohort study included all patients aged 70 years or older with a unilateral hip fracture who underwent surgery in 2014 and 2015. The primary outcomes were mortality and complications. Secondary outcomes were time to surgical intervention, hospital length of stay (HLOS), differences in surgical treatment and the number of patients who needed secondary surgical intervention. RESULTS A total of 752 patients were included. No differences were seen in mortality at 30 days, 90 days and 1 year post-operatively. In CH, fewer patients had a complicated course (43.5% vs. 51.3%; p = 0.048) and fewer patients were diagnosed with delirium (7.9% vs. 18.3%; p < 0.01). More myocardial infarctions (3.8% vs. 0.4%; p < 0.01) and red blood cell transfusions (27.2% vs. 13.3%; p < 0.01) were observed in CH and HLOS in CH was longer (Mdn difference: - 2; 95% CI - 3 to - 2). Furthermore, a difference in anaesthetic technique was found, CH performed more open reductions and augmentations than NL and surgeons in CH operated more often during out-of-office hours. Also, surgery time was significantly longer in CH (Mdn difference: - 62; 95% CI - 67 to - 58). No differences were seen in the number of patients who needed secondary surgical interventions. CONCLUSIONS This cross-cultural comparison of GCPs for geriatric hip fracture patients showed that quality of care in terms of mortality was equal. The difference in complicated course was mainly caused by a difference in delirium diagnosis. Differences were seen in surgical techniques, operation duration and timing. These clinical practices did not influence the outcome.
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Van Camp L, Dejaeger M, Tournoy J, Gielen E, Laurent MR. Association of orthogeriatric care models with evaluation and treatment of osteoporosis: a systematic review and meta-analysis. Osteoporos Int 2020; 31:2083-2092. [PMID: 32594206 DOI: 10.1007/s00198-020-05512-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/16/2020] [Indexed: 01/01/2023]
Abstract
UNLABELLED This systematic review and meta-analysis found low-quality evidence that orthogeriatric care is positively associated with diagnosis of osteoporosis, prescription of calcium and vitamin D supplements and bisphosphonates in older hip fracture patients. Evidence on fall and fracture prevention was scarce and inconclusive. Orthogeriatrics may reduce the treatment gap following hip fractures. INTRODUCTION Hip fracture patients are at imminent risk of additional fractures and falls. Orthogeriatric care might reduce the osteoporosis treatment gap and improve outcomes in these patients. However, the optimal orthogeriatric care model (geriatric liaison service, co-management, or geriatrician-led care) remains unclear. PURPOSE To summarize the association of different orthogeriatric care models for older hip fracture patients, compared to usual orthopaedic care, with fall prevention measures, diagnosis and treatment of osteoporosis and future falls and fractures. METHODS Two independent reviewers retrieved randomized controlled trials (RCTs) or controlled observational studies. Random effects meta-analysis was applied (PROSPERO ID: 165914). RESULTS One RCT and twelve controlled observational studies were included, encompassing 20,078 participants (68% women, median ages between 75 and 85 years). Orthogeriatric care was associated with higher odds of diagnosing osteoporosis (odds ratio [OR] 11.36; 95% confidence interval [CI] 7.26-17.77), initiation of calcium and vitamin D supplements (OR 41.44; 95% CI 7.07-242.91) and discharge on anti-osteoporosis medication (OR 7.06; 95% CI 2.87-17.34). However, there was substantial heterogeneity in these findings. Evidence on fall prevention and subsequent fractures was scarce and inconclusive. Almost all studies were at high risk of bias. Evidence was insufficient to compare different care models directly against each other. CONCLUSIONS Low-quality evidence suggests that orthogeriatric care is associated with higher rates of diagnosing osteoporosis, initiation of calcium and vitamin D supplements and anti-osteoporosis medication. Whether orthogeriatric care prevents subsequent falls and fractures in older hip fracture patients remains unclear.
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Affiliation(s)
- L Van Camp
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - M Dejaeger
- Gerontology and Geriatrics section, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - J Tournoy
- Gerontology and Geriatrics section, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - E Gielen
- Gerontology and Geriatrics section, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - M R Laurent
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Geriatrics Department, Imelda Hospital, Bonheiden, Belgium.
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Impact of geriatric co-management programmes on outcomes in older surgical patients: update of recent evidence. Curr Opin Anaesthesiol 2020; 33:114-121. [DOI: 10.1097/aco.0000000000000815] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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