Fewer patients undergo surgery when adding a comprehensive geriatric assessment in older patients with a hip fracture

Palliative care is a viable option for frail elderly patients with neurocognitive disorders admitted for hip fractures

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.

Patient and proxy perspectives in decision-making for geriatric hip fracture management in the Netherlands: a qualitative study

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.

Strategies to improve care for older adults who present to the emergency department: a systematic review

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.

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

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.

Hip Fractures in Patients with Dementia: An Emerging Orthopedic Concern

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.

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

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.

Moderators and Mediators of the Relationship of Shared Decision-Making and Satisfaction

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.

Prognostic significance of frailty in older patients with hip fracture: a systematic review and meta-analysis

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.

Proxy-reported experiences of palliative, non-operative management of geriatric patients after a hip fracture: a qualitative study

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.

Comprehensive geriatric assessment for older orthopedic patients and analysis of risk factors for postoperative complications

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.

Shared decision-making for the treatment of proximal femoral fractures in frail institutionalised older patients: healthcare providers' perceived barriers and facilitators

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.

Evaluation of Whether Emergency Physicians Should Join the Multidisciplinary Team for Older Hip Fracture Patients

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.

Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study

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.

Nonoperative management of hip fractures in very frail elderly patients may lead to a predictable short survival as part of advance care planning

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.

The social construction of the patient-physician relationship in the clinical encounter: Media frames on shared decision making in Germany

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.

Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery

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.

Understanding the Health Characteristics and Treatment Choices of Older Men with Stress Urinary Incontinence

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.

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

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.