[Geriatric trauma centers from the idea to implementation. What has been achieved?]

The Geriatrics at Risk Score (GeRi-Score) for mortality prediction in geriatric patients with proximal femur fracture - a development and validation study from the Registry for Geriatric Trauma (ATR-DGU)

This study developed an easy-to-use mortality prediction tool, which showed an acceptable discrimination and no significant lack of fit. The GeRi-Score was able to predict mortality and could distinguish between mild, moderate and high risk groups. Therefore, the GeRi-Score might have the potential to distribute the intensity of medical care.

PURPOSE

Several mortality-predicting tools for hip fracture patients are available, but all consist of a high number of variables, require a time-consuming evaluation and/or are difficult to calculate. The aim of this study was to develop and validate an easy-to-use score, which depends mostly on routine data.

METHODS

Patients from the Registry for Geriatric Trauma were divided into a development and a validation group. Logistic regression models were used to build a model for in-house mortality and to obtain a score. Candidate models were compared using Akaike information criteria (AIC) and likelihood ratio tests. The quality of the model was tested using the area under the curve (AUC) and the Hosmer-Lemeshow test.

RESULTS

38,570 patients were included, almost equal distributed to the development and to the validation dataset. The AUC was 0.727 (95% CI 0.711 - 0.742) for the final model, AIC resulted in a significant reduction in deviance compared to the basic model, and the Hosmer-Lemeshow test showed no significant lack of fit (p = 0.07). The GeRi-Score predicted an in-house mortality of 5.3% vs. 5.3% observed mortality in the development dataset and 5.4% vs. 5.7% in the validation dataset. The GeRi-Score was able to distinguish between mild, moderate and high risk groups.

CONCLUSIONS

The GeRi-Score is an easy-to-use mortality-predicting tool with an acceptable discrimination and no significant lack of fit. The GeRi-Score might have the potential to distribute the intensity of perioperative medical care in hip fracture surgery and can be used in quality management programs as benchmark tool.

Four-month outcome after proximal femur fractures and influence of early geriatric rehabilitation: data from the German Centres of Geriatric Trauma DGU

This study analyzed the outcome of orthogeriatric patients with hip fracture 4 months after surgery. The overall mortality rate was 12.2%. Sixty-five percent presented a degradation in walking ability, and 16% had to move to a nursing home. Early geriatric rehabilitation reduces the mortality rate and increases the rate of anti-osteoporotic treatment.

PURPOSE

Hip fractures are increasingly common with severe consequences. Therefore, the German Trauma Society (DGU) implemented an orthogeriatric co-management and developed the concept for certified Centre for Geriatric Trauma DGU. The patients' treatment data and the optional 120 days of follow-up were collected in the Registry for Geriatric Trauma DGU (ATR-DGU). This study analyzed these 4-month treatment results.

METHODS

A retrospective analysis of the ATR-DGU was conducted. Outcome parameters were the rate of readmission, rate of re-surgery, anti-osteoporotic therapy, housing, mortality, walking ability, and quality of life (QoL) 120 days post-surgery. The influence of the early geriatric rehabilitation (EGR) was evaluated using a regression analysis.

RESULTS

The follow-up data from 9780 patients were included. After 120 days, the mortality rate was 12.2%, the readmission rate 4%, and the re-surgery rate 3%. The anti-osteoporotic treatment increased from 20% at admission to 32%; 65% of the patients had a degradation in walking ability, and 16% of the patients who lived in their domestic environment pre-surgery had to move to a nursing home. QoL was distinctly reduced. The EGR showed a positive influence of anti-osteoporotic treatment (p<0.001) and mortality (p=0.011) but led to a slight reduction in QoL (p=0.026).

CONCLUSION

The 4-month treatment results of the ATR-DGU are comparable to international studies. The EGR led to a significant rise in anti-osteoporotic treatment and a reduction in mortality with a slight reduction in QoL.

Effect of time-to-surgery on in-house mortality during orthogeriatric treatment following hip fracture: A retrospective analysis of prospectively collected data from 16,236 patients of the AltersTraumaRegister DGU®

BACKGROUND

Time-to-surgery in geriatric hip fractures remains of interest. The majority of the literature reports a significantly decreased mortality rate after early surgery. Nevertheless, there are some studies presenting no effect of time-to-surgery on mortality. The body of literature addressing the effect of an orthogeriatric co-management is growing. Here we investigate the effect of time-to-surgery on in-house mortality in a group of patients treated under the best possible conditions in certified orthogeriatric treatment units.

METHODS

We conducted a retrospective cohort registry analysis from prospectively collected data of the AltersTraumaRegister DGU®. Data were analyzed univariably, and the association of early surgery with in-house mortality was assessed with multivariable logistic regression while controlling for specified patient characteristics. Additionally, propensity score matching for time-to-surgery was applied to examine its effect on the in-house mortality rate.

FINDINGS

A total of 15,099 patients met the inclusion criteria. The median age was 85 years (IQR 80-89), and 72.1% were female. The overall in-house mortality rate was 5.5%. Most (71.2%) of the patients were treated within 24 h, and 91.6% within 48 h. Neither the multivariable logistic regression model nor the propensity score matching indicated that early surgery was associated with a decreased mortality rate. The most important indicators for mortality were ASA ≥ 3 [Odds ratio (OR) 3.4, 95% confidence interval (CI) 2.35-5.11], fracture event during inpatient stay (OR 2.6, 95% CI 1.48-4.3), ISAR ≥ 2 (OR 1.88, 95% CI 1.33-2.76), and male gender (OR 1.71, 95% CI 1.39-2.09).

INTERPRETATION

Our results suggest that for those patients, who were treated in an orthogeriatric co-management under the best possible conditions, there are no significant differences regarding in-house mortality rate between the time-to-surgery intervals of 24 and 48 h or slightly above. This and the comparatively small number of patients who underwent surgery after 24 h show that an extension of the pre-surgery interval, justified by an orthogeriatric treatment team, will not be detrimental to the affected patients.

Differences of hemiarthroplasty and total hip replacement in orthogeriatric treated elderly patients: a retrospective analysis of the Registry for Geriatric Trauma DGU®

PURPOSE

Medial femoral neck fractures are typically managed with hemiarthroplasty (HA) or total hip arthroplasty (THA) in elderly patients. There is a debate as to which treatment predominates. The literatures have reported better outcomes for those patients with proximal femur fracture who were treated in an orthogeriatric centres compared to standard orthopaedic hospitals. Therefore, we have analysed the differences of outcome between HA and THA on patients, exclusively treated in orthogeriatric co-management and compared the results with the available literature.

METHODS

We conducted a retrospective registry analysis of the Registry for Geriatric Trauma DGU^®. Between 2016 and 2018, data for 16,236 patients from 78 different hospitals were available: they were analysed univariably, and differences between HA and THA were examined using propensity score matching, according to the American Society of Anesthesiologists (ASA) grade, Identification-of-Seniors-At-Risk (ISAR) Score, anticoagulation level, sex, age, and walking ability prefracture.

RESULTS

There were 4,662 patients treated with HA and 892 with THA, meeting inclusion criteria. Patients in the HA group were older (84 years (IQR 80-89) vs. 79 years (IQR 75-83); p < 0.001), with more severe preexisting conditions, with an ASA grade ≥ 3 in 79% vs. 57% in the THA group (p < 0.001). After matching, the mortality rate, in-house revision rate, and quality of life (QoL) 7 days postoperatively were not significantly different by group. After 120 days, the HA group presented a lower rate of surgical complications (4% vs. 10%; p = 0.006), while the THA group had a higher rate of independent walking (18% vs. 28%; p = 0.001) and a higher QoL, measured by the EQ-5D-3L (0.81 (IQR 0.7-1.0) vs. 0.9 (IQR 0.72-1.0); p = 0.01).

CONCLUSIONS

Due to better walking ability and QoL, THA might be the better choice in healthier and more mobile patients, while HA would be better for multimorbid patients to avoid additional complication-associated treatments. Not the age of the patient but the preoperative condition might be important for the choice between THA and HA.

The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients

Purpose

The study aimed to examine the changing incidence of geriatric trauma and evaluate the predictive ability of different scoring tools for in-hospital mortality in geriatric trauma patients.

Methods

Annual reports released by the National Trauma Database (NTDB) in the USA from 2005 to 2015 and the Trauma Register DGU® in Germany from 1994 to 2012 were analyzed to examine the changing incidence of geriatric trauma. Secondary analysis of a single-center cohort study conducted among 311 severely injured geriatric trauma patients in a level I trauma center in Switzerland was completed. According to the in-hospital survival status, patients were divided into the survival and non-survival group. The differences of the ISS (injury severity score), NISS (new injury severity score), TRISS (Trauma and Injury Severity Score), APACHE II (Acute Physiology and Chronic Health Evaluation II), and SPAS II (simplified acute physiology score II) between two groups were evaluated. Then, the areas under the receiver-operating characteristic curve (AUC-ROC) of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients were calculated.

Results

The analysis of the NTDB showed that the increase in the number of geriatric trauma ranged from 18 to 30% between 2005 and 2015. The analysis of the DGU® showed that the mean age of trauma patients rose from 39.11 in 1993 to 51.10 in 2013, and the proportion of patients aged ≥ 60 years rose from 16.5 to 37.5%. The findings from the secondary analysis showed that 164 (52.73%) patients died in the hospital. The ISS, NISS, APACHE II, and SAPS II in the death group were significantly higher than those in the survival group, and the TRISS in the death group was significantly lower than those in the survival group. The AUCs of the ISS, NISS, TRISS, APACHE II, and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients were 0.807, 0.850, 0.828, 0.715, and 0.725, respectively.

Conclusion

The total number of geriatric trauma is increasing as the population ages. The accuracy of ISS, NISS and TRISS was higher than the APACHE II and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients.

[120-day follow-up after proximal femoral fractures-first results from the Geriatric Trauma Registry DGU®]

BACKGROUND

Geriatric trauma centers which are certified to the status of a Geriatic Trauma Center DGU® based on the criteria catalogue as outlined by the German Trauma Society (DGU), are required to participate in the Geriatric Trauma Register (ATR-DGU) for quality management and outcome analyses. The evaluation is pseudoanonymous and includes data on all treated hip fracture patients over 70 years old. This has been in regular use since 2016. This study analyzed the postoperative evaluation of gait, mortality, quality of life, hospital readmission and treatment of osteoporosis after 120 days.

METHODS

A voluntary retrospective data evaluation of the ATR-DGU 120-day follow-up from 2017 was carried out. Written consent for the analysis and publication of the data was obtained from six clinics that already participated in the follow-up. The primary target parameters were mortality rate, readmission and revision rates, gait quality, osteoporosis treatment and quality of life according to EQ-5D-3L. The patient data were completely pseudonymized and a descriptive analysis was carried out.

RESULTS

In this study 957 patients from the 6 hospitals were included. The average age was 84.5 years (±6.8 years). The mortality rate during the acute treatment phase was 5%. The 120-day follow-up could be evaluated in 412 patients, 10% of these required hospital readmission due to complications oft he same fracture and of these 6% required revision surgery. The mortality rate at 120 days was 12%. In 54% of the patients the fracture led to deterioration of mobility and 49% of patients received osteoporosis treatment after 120 days. The results of the EQ-5D-3L at 120 days revealed improvement as compared to the values on postoperative day 7; however, the preoperative status with respect to mobility and quality of life could not be regained.

CONCLUSION

Despite the clear advantages of interdisciplinary treatment, the results are still limited concerning mobilization and quality of life. Further analysis of causative and influencing factors is necessary.

Identifying Disparities in the Management of Hip Fractures Within Europe: A Comparison of 3 Health-Care Systems

Introduction:

This study investigates the management of hip fractures in a German maximum care hospital and compares these data to evidence-based standard and practice in 180 hospitals participating in the UK National Hip Fracture Database (NHFD) and 16 hospitals participating in the Irish Hip Fracture Database (IHFD). This is the first study directly comparing the management of hip fractures between 3 separate health-care systems within Europe.

Methods:

Electronic medical data were collected retrospectively describing the care pathway of elderly patients with a hip fracture admitted to a large trauma unit in the south of Germany “University Hospital Freiburg” (UHF). The audit evaluated demographics, postoperative outcome, and the adherence to the 6 “Blue Book” standards of care. These data were directly compared with the data from the UK NHFD and the IHFD acquired from 180 and 16 hospitals, respectively.

Results:

At 36 hours, 95.8% of patients had received surgery in UHF, compared to 71.5% in the NHFD and 58% of patients in the IHFD. The rate of in-hospital mortality was 4.7% compared to 7.1% in the NHFD and 5% in the IHFD. The mean average acute length of stay was 13.4 days compared to 16.4 days in the NHFD and 20 days in the IHFD. Reoperation rates are 3.3% compared to 1% in the NHFD and 1.1% in the IHFD; 50.5% of patients were discharged on bone protection medication, compared to 47% in the IHFD and 79.3% in the UK NHFD.

Discussion:

Despite uniformly acknowledged evidence-based treatment guidelines, the management of hip fractures remains heterogeneous within Europe.

Conclusion:

These data show that different areas of the hip fracture care pathway in Germany, England, and Ireland, respectively, show room for improvement in light of the growing socioeconomic burden these countries are expected to face.

[Online survey for assessment of geriatric early rehabilitation complex treatment in geriatric trauma centers of the DGU by the medical services of the health funds]

BACKGROUND

Orthogeriatric co-management of proximal femoral fractures has been proven to effectively reduce mortality rates. This involves extending resources in hospitals treating these patients as well as dealing with the possibility of prolonged periods of hospitalization. The increase in costs of orthogeriatric co-management are best illustrated by the implementation of geriatric early rehabilitation complex treatment. In view of the problems concerning billing this complex treatment, an online survey was carried among certified geriatric trauma centers of the German Trauma Society (DGU®).

METHODS

Based on a trauma-geriatric consensus 20 questions were formulated by the Academy of Trauma Surgery (AUC) as an online questionnaire and sent to all 75 certified geriatric trauma centers. Apart from a description of the results, a subanalysis based on the figures presented by the case closing departments (geriatrics or trauma surgery) was included. The questions covered a 2-year period of experiences from 2016 to 2018.

RESULTS

A total of 26 of the 75 certified geriatric trauma centers participated (35%). A continuous increase in cost analysis evaluations by the medical services of the health funds was observed. A rise from 38% in 2016 to 45% in 2018 was seen. An analogous rejection trend from 16% to 24% during this period was evident as well. Subanalysis revealed significantly higher cost evaluation by the medical services of the health funds and cost rejection rates if trauma departments were the case closing disciplines.

CONCLUSION

The online survey revealed significantly higher assessment and rejection rates when compared to other hospital services. This could prove potentially detrimental to the future of orthogeriatric co-management.

[Challenges of implementing a geriatric trauma network : A regional structure]

BACKGROUND

At present, there is a high percentage and increasing tendency of patients presenting with orthogeriatric injuries. Moreover, significant comorbidities often exist, requiring increased interdisciplinary treatment. These developments have led the German Society of Trauma Surgery, in cooperation with the German Society of Geriatrics, to establish geriatric trauma centers.

METHODS

As a conglomerate hospital at two locations, we are cooperating with two external geriatric clinics. In 2015, a geriatric trauma center certification in the form of a conglomerate network structure was agreed upon for the first time in Germany. For this purpose, the requirements for certification were observed. Both structure and organization were defined in a manual according to DIN EN ISO 9001:2015.

RESULTS

Between 2008 and 2016, an increase of 70% was seen in geriatric trauma cases in our hospital, with a rise of up to 360% in specific diagnoses. The necessary standards and regulations were compiled and evaluated from our hospitals. After successful certification, improvements were necessary, followed by a planned re-audit. These were prepared by multiprofessional interdisciplinary teams and implemented at all locations.

CONCLUSIONS

A network structure can be an alternative to classical cooperation between trauma and geriatric units in one clinic and help reduce possible staffing shortage. Due to the lack of scientific evidence, future evaluations of the geriatric trauma register should reveal whether network structures in geriatric trauma surgery lead to a valid improvement in medical care.

Geriatric Fracture Centre (German Trauma Society): guidelines and certification to improve geriatric trauma care

Because of demographic changes and the increasing proportion of orthogeriatric patients, the German Trauma Society (DGU) established a certification process for geriatric fracture centres (AltersTraumaZentrum DGU®). This article is a detailed illustration of the certification process and the related Registry. The main goal of the certification is to support orthogeriatric comanagement and to improve the quality of care for geriatric patients. The requirements of the Criteria Catalogue force participating centres to continuously survey and improve their standards and structures. As a result, the requirements should lead to a high quality of care. To prove that the certification leads to higher quality of care, the DGU started a Geriatric Fracture Registry (AltersTraumaRegister DGU®) in 2016, which is obligatory for all certified centres. Studies on comanaged care and the improvement of quality by certified geriatric fracture centres are planned. Further health-care research will also be possible with the collected data.