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Boulet J, Belzile EL, Dion N, Morency C, Bérubé M, Tremblay A, Pelet S. Palliative care is a viable option for frail elderly patients with neurocognitive disorders admitted for hip fractures. BMC Musculoskelet Disord 2024; 25:635. [PMID: 39127682 DOI: 10.1186/s12891-024-07739-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
IMPORTANCE Most patients presenting with a hip fracture regardless of their comorbidities are surgically treated. A growing body of research states that a certain type of elderly patient could benefit more from a palliative approach. OBJECTIVE Identify the patient who would benefit most from a palliative care approach instead of a surgery. DESIGN Exploratory-matched retrospective cohort study between 2015 and 2021. SETTING Single Level 1 Trauma Center. PARTICIPANTS There were 2240 hip fracture patients admitted to our institution between 2015 and 2021. Patients over 65 years old with intertrochanteric or femoral neck fractures could be included. A total of 129 patients opted for palliative care (Palliative Group = PG). This cohort was compared to a matched cohort (for age, sex and fracture type) who underwent surgery but died within three months of the procedure (Surgery Deceased Group = SDG) and another matched cohort who survived more than three months (Surgery Alive Group = SAG) following surgery. MAIN OUTCOMES AND MEASURES Medical charts were reviewed for patient demographics, autonomy level, level of care, neurocognitive disorders (NCD), fracture type, in-hospital data and outpatient death within three months of admission. Analysis was performed through univariate and multivariate models with SAS OnDemand for Academics (alpha 0.05). RESULTS Patients in the PG (n = 129) were 88.2 ± 7.2 years old, 71.3% were females, and 61.2% had a femoral neck fracture. Patients in the SDG (n = 95) and SAG (n = 107) were well matched. The PG differed from the SDG (n = 95) and SAG (n = 107) regarding NCD (85.3% vs. 57.9% vs. 36.4%, p < 0.01) and the presence of Behavioral and psychological symptoms of dementia (BPSD) (19.4% vs. 5.3% vs. 3.7%, p < 0.01). There were more known heart failure (24.2% vs. 16.3%, p < 0.01) and Chronic Obstructive Pulmonary Disease (COPD) in the SDG group than in the PG group (26.6 vs. 14.7%, p = 0.02). Patients in the SAG have a significant lower rate of NCD (OR 2,7 (95%CI 1,5-5,0)), heart failure (OR 5,7 (95%CI 1,9-16,4)) and COPD (OR 2,8 (95%CI 1,2-6,3)) than other groups. Prefracture mobility, autonomy and living situation significantly differed between the groups. Median survival was six days in PG and 17 days in SDG. All groups lost autonomy and mobility. There were more complications in the SDG group than in the PG group. The end-of-care trajectory was death or hospice for most patients in the PG and SDG groups. More than 30% of the SAG group could not return home at discharge. CONCLUSION The presence of an NCD and diminished prefracture autonomy strongly support counseling for palliative care. The high rate of complications when surgery is proposed for frail patients with multiple comorbidities suggests that the concept of palliative surgery needs to be revisited.
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Affiliation(s)
- Justine Boulet
- Department of Surgery, Division of Orthopedic Surgery, CHU de Quebec-Universite Laval, Quebec City, QC, Canada.
- Department of Surgery, Faculty of Medicine, Laval University, Quebec City, QC, Canada.
| | - Etienne L Belzile
- Department of Surgery, Division of Orthopedic Surgery, CHU de Quebec-Universite Laval, Quebec City, QC, Canada
- Department of Surgery, Faculty of Medicine, Laval University, Quebec City, QC, Canada
| | - Norbert Dion
- Department of Surgery, Division of Orthopedic Surgery, CHU de Quebec-Universite Laval, Quebec City, QC, Canada
- Department of Surgery, Faculty of Medicine, Laval University, Quebec City, QC, Canada
| | - Chantal Morency
- Palliative Care Unit, Department of Medicine, CHU de Quebec-Universite Laval, Quebec City, QC, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Practices Research Unit, CHU de Quebec-Universite Laval Research Centre, Quebec City, QC, Canada
- Faculty of Nursing, Laval University, Quebec City, QC, Canada
| | | | - Stéphane Pelet
- Department of Surgery, Division of Orthopedic Surgery, CHU de Quebec-Universite Laval, Quebec City, QC, Canada.
- Department of Surgery, Faculty of Medicine, Laval University, Quebec City, QC, Canada.
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Laane D, Kroes T, van den Berg A, de Jongh M, The R, Van der Velde D, Nijdam T. Patient and proxy perspectives in decision-making for geriatric hip fracture management in the Netherlands: a qualitative study. BMJ Open 2024; 14:e082093. [PMID: 38858152 PMCID: PMC11168140 DOI: 10.1136/bmjopen-2023-082093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/09/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE The objective of this study was to explore the perspectives with the decision-making process between surgery and palliative, non-operative management of geriatric hip fracture patients and their proxies. DESIGN A qualitative interview study was performed. Patients and proxies were asked to participate in semi-structured interviews. Data were analysed using reflexive thematic analysis according to Braun and Clarke's six-step guide. SETTING AND PARTICIPANTS Hip fracture patients in the Netherlands were eligible for inclusion. For hip fracture patients with a pre-existing diagnosis of dementia and for patients who opted for palliative, non-operative management, proxies were included. RESULTS A total of 16 interviews were conducted, consisting of 4 patient interviews and 12 proxy interviews. Five themes were identified during thematic analysis: (1) underlying patient values, (2) the provision of information, (3) reasons to consider either palliative, non-operative management or surgery, (4) involvement in decision and (5) realisation of expectations. Information provided by the physician varied in terms of desired level of detail but involved discussing the advantages and disadvantages of surgery and palliative, non-operative management. Patients and proxies underscored the importance of achieving optimal quality of life, and the disparity between expected and actual treatment outcomes was unpleasant and negatively influenced the overall experience. CONCLUSIONS In-depth analysis provided a unique insight into the patient and proxy perspectives in shared decision-making for geriatric hip fracture management in the acute setting. Overall, there were differences between reported experiences and preferences of participants. This heterogeneity stresses the importance of keeping a person-centred approach during shared decision-making. Other key considerations during shared decision-making include physicians informing patients from professional experience and communicating sensitively about both treatment options and prognosis. Physicians should aim to provide realistic, sensitive and timely information to both patients and proxies during the choice between curation and palliation for their hip fracture.
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Affiliation(s)
- Duco Laane
- Department of Trauma Surgery, St Antonius Hospital Location Utrecht, Utrecht, Netherlands
| | - Thamar Kroes
- Department of Trauma Surgery, St Antonius Hospital Location Utrecht, Utrecht, Netherlands
| | - Arda van den Berg
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, Netherlands
| | - Mariska de Jongh
- Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, Netherlands
| | - Regina The
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, Netherlands
| | - Detlef Van der Velde
- Department of Trauma Surgery, St Antonius Hospital Location Utrecht, Utrecht, Netherlands
| | - Thomas Nijdam
- Department of Trauma Surgery, St Antonius Hospital Location Utrecht, Utrecht, Netherlands
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Vleeshouwers K, Faut C, van Leendert J, Sipers W, Vandenberghe F, van der Hooft B, Pijls N, Göbbels S, Saadan H, Brüggemann R, Brouns S, Spaetgens B. Exploring multidisciplinary decision-making factors for geriatric trauma patients: An observational real-life clinical study. J Am Geriatr Soc 2024; 72:1543-1547. [PMID: 38217354 DOI: 10.1111/jgs.18750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 01/15/2024]
Affiliation(s)
- Karin Vleeshouwers
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Carline Faut
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jannic van Leendert
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Walther Sipers
- Department of Geriatric Medicine, Zuyderland Medical Centre, Heerlen-Sittard-Geleen, The Netherlands
| | - Florence Vandenberghe
- Department of Orthopedic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bram van der Hooft
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Noor Pijls
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sanne Göbbels
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hamza Saadan
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Renée Brüggemann
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Steffie Brouns
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bart Spaetgens
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Testa L, Richardson L, Cheek C, Hensel T, Austin E, Safi M, Ransolin N, Carrigan A, Long J, Hutchinson K, Goirand M, Bierbaum M, Bleckly F, Hibbert P, Churruca K, Clay-Williams R. Strategies to improve care for older adults who present to the emergency department: a systematic review. BMC Health Serv Res 2024; 24:178. [PMID: 38331778 PMCID: PMC10851482 DOI: 10.1186/s12913-024-10576-1] [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: 10/30/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance. METHODS A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach. RESULTS Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience. CONCLUSION It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.
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Affiliation(s)
- Luke Testa
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Lieke Richardson
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Colleen Cheek
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia.
| | - Theresa Hensel
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Cologne, Germany
| | - Elizabeth Austin
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Mariam Safi
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Internal Medicine Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Natália Ransolin
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brasil
| | - Ann Carrigan
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Janet Long
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Magali Goirand
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Mia Bierbaum
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Allied Health and Human Performance, IIMPACT in Health, University of South Australia, Adelaide, 5001, Australia
| | - Felicity Bleckly
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Allied Health and Human Performance, IIMPACT in Health, University of South Australia, Adelaide, 5001, Australia
| | - Kate Churruca
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
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Bellova P, Linne M, Postler AE, Günther KP, Stiehler M, Goronzy J. Girdlestone resection arthroplasty for femoral neck fractures has poorer outcomes than hemiarthroplasty in frail patients with increased risk for arthroplasty-related complications: a retrospective case study of 21 patients. Acta Orthop 2024; 95:61-66. [PMID: 38288960 PMCID: PMC10826842 DOI: 10.2340/17453674.2024.34901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 11/23/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND AND PURPOSE Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes. PATIENTS AND METHODS 21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015-2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan-Meier analysis. The mean follow-up (FU) was 1.5 (0-4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score. RESULTS The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0-50] vs. 46 [11-80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group. CONCLUSION Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.
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Affiliation(s)
- Petri Bellova
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany.
| | - Marcus Linne
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
| | - Anne Elisabeth Postler
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
| | - Klaus-Peter Günther
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
| | - Maik Stiehler
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
| | - Jens Goronzy
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
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Sioutis S, Zikopoulos A, Karampikas V, Mitsiokapa E, Tsatsaragkou A, Katsanos S, Mastrokalos D, Koulalis D, Mavrogenis AF. Hip Fractures in Patients with Dementia: An Emerging Orthopedic Concern. J Long Term Eff Med Implants 2024; 34:85-93. [PMID: 37938210 DOI: 10.1615/jlongtermeffmedimplants.2023046658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Hip fractures are a very common injury in the elderly population associated with an increased mortality rate. Currently, more and more elderly patients are diagnosed with dementia. Demented patients are more prone to falls and hip fractures compared to the general population because of conditions related to their disease such as instability, osteoporosis, poor muscle control and weakness. The coexistence of dementia and hip fractures is a difficult situation for both the patients and the treating physicians because of postoperative complications in this frail subgroup of patients and their inability to stand up and walk. To enhance the literature, we reviewed published studies of hip fracture patients suffering from dementia to discuss why they have more frequent hip fractures, to review their associated in-hospital complications, and to emphasize on their postoperative management to be able to reach the pre-injury activity level and optimal quality of life.
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Affiliation(s)
- Spyridon Sioutis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, University Medical School, Athens, Greece
| | - Alexandros Zikopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasileios Karampikas
- First Department of Orthopedics, National and Kapodistrian University of Athens, ATTIKON University General Hospital, Athens, Greece
| | - Evanthia Mitsiokapa
- Department of Physical and Rehabilitation Medicine, Thoracic Diseases General Hospital Sotiria, Athens, Greece
| | | | - Spyridon Katsanos
- Department of Emergency Medicine and Cardiology, National and Kapodistrian University of Athens
| | - Dimitrios Mastrokalos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios Koulalis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
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Rougereau G, Naline C, Boisrenoult P, Langlais T, Pujol N. Proximal femoral fracture and female gender are risk factors for recurrent fracture: Cohort study of 292 patients over 75 years-old with iterative osteoporotic fractures. Injury 2023:S0020-1383(23)00187-0. [PMID: 36931968 DOI: 10.1016/j.injury.2023.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 02/19/2023] [Accepted: 02/25/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE The purpose of this study was to: 1/ describe the characteristics of a cohort of patients over 75 years of age hospitalized in perioperative geriatric units (UPOG) for iterative fractures; 2/ investigate the risks of institutionalization related to the first fracture; and 3/ search for potential risk factors for iterative fracture. METHODS This is a retrospective single-center study analyzing patients over 75 years old, hospitalized in UPOG. RESULTS Of the 3207 patients hospitalized, 292 patients had a refracture (9.1%), with a mean age of 85.4+/-5.8 years. Initial fractures were mainly intertrochanteric (43.2%) and the femoral neck (32.9%). Refractures occurred mainly in the first year (55.5%), with a median delay of 9.6 months. Refractures were mainly intertrochanteric (29.5%), peri‑implant (prosthesis, osteosynthesis) (28.8%), and femoral neck (26.7%). Dementia was the only factor for institutionalization after the first fracture episode (p = 0.0002). Proximal femoral fracture (PFF) and female gender were risk factors for iterative fracture (10.2% vs. 6.8%, p = 0.003; 10.7% vs. 6.8%, p = 0.005 respectively), but not age (85.4 vs. 85.8 years, p = 0.24). PFF were more likely to result in the same fracture type in the second episode (58.1% vs 7.1%, p<0.0001). The time to refracture was shorter in case of peri‑implant fracture (p = 0.0002), or discharge directly to home (p = 0.04). CONCLUSION PFF and female gender are risk factors for recurrent fracture, which is even more likely to occur early in case of home discharge or peri‑implant fracture.
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Affiliation(s)
- Grégoire Rougereau
- Department of Orthopaedic and Trauma Surgery, Hôpital André Mignot, Université Île-de-France Ouest, 177 Rue de Versailles, 78150 Le Chesnay, France.
| | - Charlotte Naline
- Department of Orthopaedic and Trauma Surgery, Hôpital André Mignot, Université Île-de-France Ouest, 177 Rue de Versailles, 78150 Le Chesnay, France; Department of Geriatrics, Hôpital André Mignot, Université Île-de-France Ouest, 177 Rue de Versailles, 78150 Le Chesnay, France
| | - Philippe Boisrenoult
- Department of Orthopaedic and Trauma Surgery, Hôpital André Mignot, Université Île-de-France Ouest, 177 Rue de Versailles, 78150 Le Chesnay, France
| | - Tristan Langlais
- Department of Orthopaedic paediatric Surgery, Hôpital des enfants, Purpan, Université de Toulouse, Toulouse, France; Department of Orthopaedic paediatric Surgery, Sorbonne Université, A. Trousseau, APHP, Paris, France
| | - Nicolas Pujol
- Department of Orthopaedic and Trauma Surgery, Hôpital André Mignot, Université Île-de-France Ouest, 177 Rue de Versailles, 78150 Le Chesnay, France
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8
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Crijns TJ, Segina P, Kortlever JTP, Thomas JE, Ring D, Reichel L, Vagner G, Ramtin S. Moderators and Mediators of the Relationship of Shared Decision-Making and Satisfaction. J Patient Exp 2023; 10:23743735231171563. [PMID: 37138951 PMCID: PMC10150427 DOI: 10.1177/23743735231171563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Background:Evidence suggests that health literacy, perceived availability of information and guidance to adapt to challenges (informational support), and symptoms of depression all have the potential to mediate or moderate the relationship between patient-rated involvement in decisions and satisfaction with care. If so these could be useful targets for improving patient experience. Methods: We prospectively enrolled 130 new adult patients visiting an orthopedic surgeon over a 4-month period. All patients were asked to complete measures of satisfaction with care (21-item Medical Interview Satisfaction Scale), perceived involvement in decisions (9-item Shared Decision-Making Questionnaire), symptoms of depression (the Patient-Reported Outcomes Measurement Information Scale [PROMIS] Depression Computerized Adaptive Test [CAT]), perceived availability of information and guidance to adapt to challenges (PROMIS Informational Support CAT), and the Newest Vital Sign test of health literacy. Results: The strong correlation between satisfaction with care (ρ = 0.60, P < .001) and perceived involvement in decisions was neither mediated nor moderated by health literacy, perceived availability of information and guidance, and symptoms of depression. Conclusions: The observation that patient-rated shared decision-making is strongly related to satisfaction with an office visit, independent of health literacy, perceived support, and symptoms of depression, is consistent with evidence that various measures of patient experience tend to correlate and emphasizes the importance of the patient-clinician relationship. Level of Evidence: Level II, prospective study.
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Affiliation(s)
- Tom J Crijns
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Paxton Segina
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Joost T P Kortlever
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Jacob E Thomas
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - David Ring
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
- David Ring, Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Health Discovery Building 6.706; 1701 Trinity St., Austin, TX 78712, USA.
| | - Lee Reichel
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Gregg Vagner
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Sina Ramtin
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
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9
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Yan B, Sun W, Wang W, Wu J, Wang G, Dou Q. Prognostic significance of frailty in older patients with hip fracture: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2022; 46:2939-2952. [PMID: 36227383 DOI: 10.1007/s00264-022-05605-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Hip fracture (HF) has become a major healthcare concern associated with higher mortality in older patients. Frailty is one of the most important problems in aging population but its prognostic value in HF remains susceptible. This systematic review and meta-analysis aimed to evaluate the association between frailty and adverse outcomes in older patients with HF. METHODS We systematically searched electrical databases including PubMed and Embase to find eligible literature with end-search restriction of February 20, 2021. The main endpoints were all-cause mortality, peri-operative complications, abnormal discharge, and length of stay (LOS). Pooled effect size was calculated by random-effects or fixed-effect model according to study heterogeneity. Three subgroup analyses based on follow-up times, study design, and frailty criteria were conducted. RESULTS We screened 22 studies out of 1599 identified studies in our analysis. Compared with normal patients, frail ones had a higher risk of mortality both before (OR = 3.48, 95% CI: 2.50-4.85, I2 = 87.2%, P < 0.001) and after (OR = 1.87, 95% CI: 1.44-2.44, I2 = 85.5%, P < 0.001) adjustment. The incidence of peri-operative complications, abnormal discharge, and prolonged LOS also significantly increased in frail subjects. There was no publication bias observed and the pooled results were stable based on sensitivity analysis. CONCLUSION Overall, more attention needs to be paid to the prognostic effects caused by frailty in seniors with HF. Better understanding of the association between frailty and adverse outcomes in HF could help doctors perform co-management across orthopaedic and geriatric departments.
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Affiliation(s)
- Bingzi Yan
- West China School of Medicine, Sichuan University, Renmin South Road, No. 17, Wuhou District, Chengdu, 610041, China
| | - Wanting Sun
- West China School of Medicine, Sichuan University, Renmin South Road, No. 17, Wuhou District, Chengdu, 610041, China
| | - Wen Wang
- Chinese Evidence-Based Medicine Center and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, Sichuan, China
| | - Jinhui Wu
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Guanglin Wang
- Department of Orthopedics, West China School of Medicine, West China Hospital, Sichuan University, No. 37, Wuhou Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Qingyu Dou
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 37, Guoxue Rd, Wuhou District, Chengdu, 610041, China.
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10
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Nijdam TMP, Laane DWPM, Spierings JF, Schuijt HJ, Smeeing DPJ, van der Velde D. Proxy-reported experiences of palliative, non-operative management of geriatric patients after a hip fracture: a qualitative study. BMJ Open 2022; 12:e063007. [PMID: 35948383 PMCID: PMC9379475 DOI: 10.1136/bmjopen-2022-063007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The objective of this study was to explore the experiences from the period after the choice was made for palliative, non-operative management for geriatric patients with a hip fracture, to the most important factors in the process, as reported by a proxy. DESIGN Semistructured interviews were conducted between 1 August 2020 and 1 April 2021 to investigate by-proxy reported patient experiences of non-operative management after hip fracture. Interviews followed a topic guide, recorded and transcribed per word. Thematic analysis was used to identify themes in the data. SETTING AND PARTICIPANTS Patients were retrospectively identified from the electronic patient record. Relatives (proxies) of the patients who underwent palliative, non-operative management were contacted and were asked to participate in a semistructured interview and were named participants. The participants were proxies of the patients since patients were expected to be deceased during the timing of the interview. RESULTS A total of 26 patients were considered eligible for inclusion in this study. The median age of the patients was 88 years (IQR 83-94). The 90-day mortality rate was 92.3%, with a median palliative care period of 11 days (IQR 4-26). A total of 19 participants were subjected to the interview. After thematic analysis, four recurring themes were identified: (1) the decision-making process, (2) pain experience, (3) patient-relative interaction and (4) the active dying. CONCLUSIONS With the introduction of shared decision-making in an acute setting for geriatric patients with hip fracture, proxies reported palliative, non-operative management as an acceptable and adequate option for patients with high risk of adverse outcomes after surgery. The emerged themes in palliative care for patients with hip fracture show great similarity with severe end-stage disease palliative care, with pain identified as the most important factor influencing comfort of the patient and their environment after hip fracture. Future research should focus on further improving targeted analgesia for these patients focusing on acute pain caused by the fracture.
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Affiliation(s)
| | | | - Jelle Friso Spierings
- Department of Surgery, St Antonius Ziekenhuis Locatie Utrecht, Utrecht, The Netherlands
| | - Henk Jan Schuijt
- Department of Surgery, St Antonius Ziekenhuis Locatie Utrecht, Utrecht, The Netherlands
| | | | - Detlef van der Velde
- Department of Surgery, St Antonius Ziekenhuis Locatie Utrecht, Utrecht, The Netherlands
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11
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Kong C, Zhang Y, Wang C, Wang P, Li X, Wang W, Wang Y, Shen J, Ren X, Wang T, Zhao G, Lu S. Comprehensive geriatric assessment for older orthopedic patients and analysis of risk factors for postoperative complications. BMC Geriatr 2022; 22:644. [PMID: 35927629 PMCID: PMC9354431 DOI: 10.1186/s12877-022-03328-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/20/2022] [Indexed: 11/12/2022] Open
Abstract
Background The comprehensive geriatric assessment (CGA) has been proposed as a supplementary tool to reduce perioperative complications of geriatric patients, however there is no universally accepted standardization of CGA for orthopedic surgery. In this study, a novel CGA strategy was applied to evaluate the conditions of older patients undergoing orthopedic surgery from a broad view and to identify potential risk factors for postoperative complications. Methods A prospective cohort study was conducted from March 2019 to December 2020.The study enrolled patients (age > 75 years) for elective or confined orthopedic surgery. All patients were treated by a multidisciplinary team. A structured CGA was conducted to identify high-risk older patients and to facilitate coordinated multidisciplinary team care by a geriatric team. The basic patient characteristics, CGA results, postoperative complication and mortality rates were collected. Multivariate logistic regression analysis was used to identify risk factors for postoperative complications. Results A total of 214 patients with an age of 81.07 ± 4.78 (range, 75–100) years were prospectively enrolled in this study. In total, 66 (30.8%) complications were registered, including one death from myocardial infarction (mortality rate, 0.5%). Poor Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) were accompanied by frailty, worse perioperative risk, pain, and nutritional status. Poor ADL was also associated with higher risks of falling, polypharmacy, and cardiac and respiration complications. Poor IADL was associated with a higher risk of cardiac and respiration complications. Higher stroke risk was accompanied by higher risks of cardiac complications, delirium, and hemorrhage. Worse American Society of Anesthesiologists (ASA) score was associated with worse ADL, IADL, frailty, and higher delirium risk. Multivariate logistic regression analysis showed that spinal fusion (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.65 to 0.83; p = 0.0214), blood loss(OR, 1.68; 95% CI, 1.31 to 2.01; p = 0.0168), ADL (severe dysfunction or worse) (OR, 1.45; 95% CI, 1.16 to 1.81; p = 0.0413), IADL (serious dependence) (OR, 1.08; 95% CI, 1.33 to 1.63; p = 0.0436), renal function (chronic kidney disease (CKD) ≥ stage 3a) (OR, 2.01; 95% CI, 1.54 to 2.55; p = 0.0133), and malnutrition(OR, 2.11; 95% CI, 1.74 to 2.56; p = 0.0101) were independent risk factors for postoperative complications. Conclusion The CGA process reduces patient mortality and increases safety in older orthopedic surgery patients. Spinal fusion, blood loss, ADL (severe dysfunction or worse), IADL (serious dependence), renal function (CKD ≥ stage 3a) and nutrition mini nutritional assessment (MNA) (malnourished) were independent risk factors of postoperative complications following orthopaedic surgery in older patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03328-5.
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Affiliation(s)
- Chao Kong
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Yanhong Zhang
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Chaodong Wang
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Peng Wang
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Xiangyu Li
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Wei Wang
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Yu Wang
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Jianghua Shen
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Xiaoyi Ren
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China
| | - Tianlong Wang
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China. .,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China. .,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.
| | - Guoguang Zhao
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China. .,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China. .,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.
| | - Shibao Lu
- Department of Orthopedics, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China. .,National Geriatric Disease Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China. .,Beijing Municipal Geriatric Medical Research Center, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Xicheng, Beijing, 100053, People's Republic of China.
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12
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Spronk I, Loggers SAI, Joosse P, Willems HC, Van Balen R, Gosens T, Ponsen KJ, Steens J, van de Ree CLP(M, Zuurmond RG, Verhofstad MHJ, Van Lieshout EMM, Polinder S. Shared decision-making for the treatment of proximal femoral fractures in frail institutionalised older patients: healthcare providers' perceived barriers and facilitators. Age Ageing 2022; 51:6653485. [PMID: 35930725 PMCID: PMC9355456 DOI: 10.1093/ageing/afac174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Proximal femoral fractures are common in frail institutionalised older patients. No convincing evidence exists regarding the optimal treatment strategy for those with a limited pre-fracture life expectancy, underpinning the importance of shared decision-making (SDM). This study investigated healthcare providers' barriers to and facilitators of the implementation of SDM. METHODS Dutch healthcare providers completed an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators. If ≥20% of participants responded with 'totally disagree/disagree', items were considered barriers and, if ≥80% responded with 'agree/totally agree', items were considered facilitators. RESULTS A total of 271 healthcare providers participated. Five barriers and 23 facilitators were identified. Barriers included the time required to both prepare for and hold SDM conversations, in addition to the reflective period required to allow patients/relatives to make their final decision, and the number of parties required to ensure optimal SDM. Facilitators were related to patients' values, wishes and satisfaction, the importance of SDM for patients/relatives and the fact that SDM is not considered complex by healthcare providers, is considered to be part of routine care and is believed to be associated with positive patient outcomes. CONCLUSION Awareness of identified facilitators and barriers is an important step in expanding the use of SDM. Implementation strategies should be aimed at managing time constraints. High-quality evidence on outcomes of non-operative and operative management can enhance implementation of SDM to address current concerns around the outcomes.
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Affiliation(s)
- Inge Spronk
- Address correspondence to: Inge Spronk. Tel: +31 107038460.
| | - Sverre A I Loggers
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM Alkmaar, The Netherlands
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Pieter Joosse
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM Alkmaar, The Netherlands
| | - Hanna C Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam UMC location AMC, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Romke Van Balen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Taco Gosens
- Department of Orthopaedic Surgery, Elisabeth-TweeSteden Ziekenhuis, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - Kornelis J Ponsen
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM Alkmaar, The Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, PO Box 1074, 1940 EB Beverwijk, The Netherlands
| | - Jeroen Steens
- Department of Orthopaedic Surgery, Dijklander Ziekenhuis, PO Box 600, 1620 AR Hoorn, The Netherlands
| | - C L P (Marc) van de Ree
- Department Trauma TopCare, Elisabeth-TweeSteden Ziekenhuis, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - Rutger G Zuurmond
- Department of Orthopaedic Surgery, Isala, PO Box 10400, 8000 GK Zwolle, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Suzanne Polinder
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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13
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Guan L, Wang C, Zhao B, Yang M, Zhu S, Wu X. Evaluation of Whether Emergency Physicians Should Join the Multidisciplinary Team for Older Hip Fracture Patients. Front Surg 2022; 9:842978. [PMID: 35662825 PMCID: PMC9157767 DOI: 10.3389/fsurg.2022.842978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 04/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background Geriatric hip fracture is one of the most common end-stage events in older patients with osteoporosis. We aimed to improve the original co-management process by engaging emergency physicians in the preoperative multidisciplinary management team (MDT). We evaluated this intervention in terms of reducing patient waiting time before surgery. Methods Emergency Department data and hospitalization data for patients diagnosed with geriatric hip fractures in Beijing Jishuitan Hospital (JSTH) were collected and sorted into the intervention group, for whom the MDT included emergency physicians (from January 2019 to December 2019), and the control group (from January 2017 to December 2017). The percentage of patients treated with surgery within 48 h of admission was used as the primary outcome. The secondary outcomes included the time from emergency visit to admission (hours), the time from admission to discharge (days), the percentage of patients receiving surgical treatment after admission, the rate of perioperative medical complications during hospitalization, postoperative admission to the Intensive Care Unit, and total deaths during hospitalization. Results A total of 2,152 patients were enrolled. The rate of hypertension (58.5% vs 52.1%), coronary heart disease (24.6% vs 19.9%), and cerebrovascular disease (19.4% vs 15.5%) was higher in the intervention group than in the control group. The percentage of patients receiving surgical treatment in the intervention group (98.3%) was significantly higher than in the control group (96.3%, p = 0.004). The proportion of patients receiving surgical treatment within 48 h of admission was significantly higher in the intervention group (82.4%) than in the control group (60.4%, p < 0.001). The hospital stay was significantly shorter in the intervention group compared with the control group (p < 0.001). The incidence of perioperative medical complications and mortality during hospitalization was similar in the two groups. Conclusions Involving emergency physicians in the MDT can reduce the waiting time before surgery and the hospital stay for older hip fracture patients.
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Affiliation(s)
- Lan Guan
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, China
| | - Cong Wang
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, China
| | - Bin Zhao
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, China
| | - Minghui Yang
- Department of Orthopedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
- Correspondence: Minghui Yang
| | - Shiwen Zhu
- Department of Orthopedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Xinbao Wu
- Department of Orthopedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
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14
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Loggers SAI, Willems HC, Van Balen R, Gosens T, Polinder S, Ponsen KJ, Van de Ree CLP, Steens J, Verhofstad MHJ, Zuurmond RG, Van Lieshout EMM, Joosse P. Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study. JAMA Surg 2022; 157:424-434. [PMID: 35234817 PMCID: PMC8892372 DOI: 10.1001/jamasurg.2022.0089] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population. Objective To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy. Design, Setting, and Participants This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category ≤2). Exposures Shared decision-making (SDM) followed by nonoperative or operative fracture management. Main Outcomes and Measures The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire). Results Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8. Conclusions and Relevance Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.
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Affiliation(s)
- Sverre A. I. Loggers
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Hanna C. Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam University Medical Center location AMC, Amsterdam, the Netherlands
| | - Romke Van Balen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Taco Gosens
- Department of Orthopaedic Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Kornelis J. Ponsen
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands,Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | | | - Jeroen Steens
- Department of Orthopaedic Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
| | - Michael H. J. Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Esther M. M. Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Pieter Joosse
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands,Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
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15
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Wijnen HH, Schmitz PP, Es-Safraouy H, Roovers LA, Taekema DG, Van Susante JLC. Nonoperative management of hip fractures in very frail elderly patients may lead to a predictable short survival as part of advance care planning. Acta Orthop 2021; 92:728-732. [PMID: 34319206 PMCID: PMC8635672 DOI: 10.1080/17453674.2021.1959155] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Surgical treatment is still the mainstay of care even in very frail elderly hip fracture patients. However, one may argue whether surgery is in the best interest of all patients. We elucidated mortality rates of nonoperative management (NOM) of a hip fracture after shared decision-making in a cohort of very frail elderly patients.Patients and methods - Orthogeriatric patients (age > 70 years) admitted with a hip fracture between 2011 and 2019 were included. In the presence of fragility features the motivation for surgery or NOM was supported by advance care planning (ACP) and shared decision-making through geriatric assessment. Mortality rates after NOM were assessed and also presented for the remaining surgical group for reference.Results - In 1,279 out of 3,467 patients, geriatric assessment was indicated and subsequently 1,188 (93%) had surgery versus 91 (7%) NOM. The motivation for NOM was based on patient and family preferences in only 20% of patients, medical grounds in 54%, and a combination of both in 26%. The 30-day and 1-year mortality in the frail NOM group was 87% and 99% respectively, whereas this was 7% and 28% in the surgery group. No statistical comparison between groups was performed due to profound bias by indication.Interpretation - This study provides further insight into the predictable and high short-term mortality after NOM in carefully selected very frail elderly hip fracture patients. This information may help to consider NOM as an alternative treatment option to surgery when no significant gain from surgery is anticipated.
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Affiliation(s)
- Hugo H Wijnen
- Department of Clinical Geriatrics, Rijnstate, Arnhem
| | - Peter P Schmitz
- Department of Orthopedics, Rijnstate, Arnhem;;,Correspondence:
| | | | - Lian A Roovers
- Clinical Research Department, Rijnstate, Arnhem, the Netherlands
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Affiliation(s)
- Cecilia Rogmark
- Department of Orthopaedics, Lund University, Skane University Hospital, Malmö, Sweden;,E-mail:
| | - Niels Lynøe
- Department of Learning, Informatics, Management and Ethics, Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden
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Vogel A, Balzer F, Fürstenau D. The social construction of the patient-physician relationship in the clinical encounter: Media frames on shared decision making in Germany. Soc Sci Med 2021; 289:114420. [PMID: 34607053 DOI: 10.1016/j.socscimed.2021.114420] [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: 05/04/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 11/28/2022]
Abstract
The literature on healthcare management has noted that shared decision-making (SDM) - a practice of organizing joint decisions between healthcare professionals and patients - should improve healthcare outcomes through patient engagement and autonomy, fostering patient-centeredness. While SDM projects are implemented across Europe and the US, the diffusion of the practice remains partial, and its' conceptualization scattered. Healthcare management literature explores SDM on the underlying assumption that its limited diffusion results from an information problem, implying objective criteria and rational behavior. The purpose of this research is to study the social construction of SDM within the clinical setting and the underlying rationales using the case of one of the largest healthcare markets worldwide - Germany. To capture the complexity of SDM, a frame analysis is conducted on its medial representations. News media is both influential in shaping public opinion, as well as in generating public discourse. This analysis enables one to elaborate different facets of the construct of SDM, to capture inherent patterns of facilitating and obstructing aspects and to explore consequences for the diffusion of SDM. Three facilitating and three obstructive frames on the implementation of SDM were identified. The polarities of these frames range from the questioning of one's decision-making authority to the perception of individual competence and decision-making agency. Moreover, this study reflects on how physicians' and patients' role for SDM is conceived.
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Affiliation(s)
- Amyn Vogel
- Freie Universität Berlin, School of Business & Economics, Department of Information Systems, Germany.
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Daniel Fürstenau
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Department of Digitalization, Copenhagen Business School, Denmark.
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18
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Haines LK, Cook AC, Hatchimonji JS, Ho VP, Kalbfell EL, O'Connell KM, Robenstine JC, Schlögl M, Toevs CC, Jones CA, Krouse RS, Martin ND. Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery. J Palliat Med 2021; 24:1072-1077. [PMID: 34128716 DOI: 10.1089/jpm.2021.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.
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Affiliation(s)
- Lindsay K Haines
- Department of Medicine and the Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allyson C Cook
- Department of Medicine and University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elle L Kalbfell
- Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Kathleen M O'Connell
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Christine C Toevs
- Department of Surgery, Terre Haute Regional Hospital, Indiana University School of Medicine, Terre Haute, Indiana, USA
| | | | - Robert S Krouse
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Hampson LA, Suskind AM, Breyer BN, Lai L, Cooperberg MR, Sudore RL, Keyhani S, Allen IE, Walter LC. Understanding the Health Characteristics and Treatment Choices of Older Men with Stress Urinary Incontinence. Urology 2021; 154:281-287. [PMID: 34004214 PMCID: PMC9012599 DOI: 10.1016/j.urology.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To describe the health characteristics and current treatment choices of male stress urinary incontinence (mSUI) patients to inform patient-centered decision-making. METHODS We identified a cohort of mSUI patients aged ≥65 at UCSF and San Francisco VA. Using retrospective chart review and telephone interviews, we ascertained demographics, incontinence characteristics, Charlson Comorbidity Index (score ≥ 4 indicates significant morbidity), frailty with Timed Up and Go (TUG) test, functional dependence with activities of daily living (ADL), calculated life expectancy, and assessed mental health and quality of life (QOL). Bivariate analysis evaluated associations between subject characteristics and ultimate treatment type (conservative vs surgery; sling vs sphincter). Logistic multivariable models evaluating treatment choice were also constructed. RESULTS The 130 participants had a mean age of 75 and a mean incontinence score of 14.2 representing moderately bothersome incontinence. Nearly 80% had significant morbidity, three-quarters had >50% 10-year mortality risk, 10% needed help with 1 + ADL and 22% had a TUG >10 seconds indicating frailty. The mean physical and mental QOL scores were similar to the general population. Anxiety and depression were reported by 3.9% and 10%. In univariate and multivariable analysis, only incontinence characteristics were associated with conservative vs surgical treatment choice (P < .01). CONCLUSION Multi-morbidity, functional dependence, frailty, and limited life expectancy are common among older men with mSUI, yet current treatment choices appear to be driven by incontinence characteristics. As such, mSUI surgery should be considered among men across the spectrum of health and life expectancy.
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Affiliation(s)
- Lindsay A Hampson
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA.
| | - Anne M Suskind
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Benjamin N Breyer
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Lillian Lai
- Department of Urology, University of Michigan Medical School, Ann Arbor, MICH
| | - Matthew R Cooperberg
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Rebecca L Sudore
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Salomeh Keyhani
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - I Elaine Allen
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Louise C Walter
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
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20
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Tarazona-Santabalbina FJ, Ojeda-Thies C, Figueroa Rodríguez J, Cassinello-Ogea C, Caeiro JR. Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3049. [PMID: 33809573 PMCID: PMC7999190 DOI: 10.3390/ijerph18063049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.
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Affiliation(s)
- Francisco José Tarazona-Santabalbina
- Department of Geriatric Medicine, Hospital Universitario de la Ribera, Alzira, 46600 Valencia, Spain
- CIBERFES, Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable, Instituto Carlos III, 28029 Madrid, Spain
| | - Cristina Ojeda-Thies
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
| | - Jesús Figueroa Rodríguez
- Department of Physical Medicine and Rehabilitation, Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | | | - José Ramón Caeiro
- Department of Orthopaedics and Traumatology, Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain;
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21
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Cannada LK, Mears SC, Quatman C. Clinical Faceoff: When Should Patients 65 Years of Age and Older Have Surgery for Hip Fractures, and When is it a Bad Idea? Clin Orthop Relat Res 2021; 479:24-27. [PMID: 33315622 PMCID: PMC7899710 DOI: 10.1097/corr.0000000000001596] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/05/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Lisa K Cannada
- L. K. Cannada, Orthopaedic Trauma Surgeon, Novant Health Orthopedics, Charlotte, NC, USA
- S. C. Mears, Professor, Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- C. Quatman, Associate Professor, Department of Orthopaedic Surgery, The Ohio State University, Columbus, OH, USA
| | - Simon C Mears
- L. K. Cannada, Orthopaedic Trauma Surgeon, Novant Health Orthopedics, Charlotte, NC, USA
- S. C. Mears, Professor, Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- C. Quatman, Associate Professor, Department of Orthopaedic Surgery, The Ohio State University, Columbus, OH, USA
| | - Carmen Quatman
- L. K. Cannada, Orthopaedic Trauma Surgeon, Novant Health Orthopedics, Charlotte, NC, USA
- S. C. Mears, Professor, Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- C. Quatman, Associate Professor, Department of Orthopaedic Surgery, The Ohio State University, Columbus, OH, USA
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