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Armstrong E, Harvey LA, Payne NL, Zhang J, Ye P, Harris IA, Tian M, Ivers RQ. Do we understand each other when we develop and implement hip fracture models of care? A systematic review with narrative synthesis. BMJ Open Qual 2023; 12:e002273. [PMID: 37783525 PMCID: PMC10565304 DOI: 10.1136/bmjoq-2023-002273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/02/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND A hip fracture in an older person is a devastating injury. It impacts functional mobility, independence and survival. Models of care may provide a means for delivering integrated hip fracture care in less well-resourced settings. The aim of this review was to determine the elements of hip fracture models of care to inform the development of an adaptable model of care for low and middle-income countries (LMICs). METHODS Multiple databases were searched for papers reporting a hip fracture model of care for any part of the patient pathway from injury to rehabilitation. Results were limited to publications from 2000. Titles, abstracts and full texts were screened based on eligibility criteria. Papers were evaluated with an equity lens against eight conceptual criteria adapted from an existing description of a model of care. RESULTS 82 papers were included, half of which were published since 2015. Only two papers were from middle-income countries and only two papers were evaluated as reporting all conceptual criteria from the existing description. The most identified criterion was an evidence-informed intervention and the least identified was the inclusion of patient stakeholders. CONCLUSION Interventions described as models of care for hip fracture are unlikely to include previously described conceptual criteria. They are most likely to be orthogeriatric approaches to service delivery, which is a barrier to their implementation in resource-limited settings. In LMICs, the provision of orthogeriatric competencies by other team members is an area for further investigation.
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Affiliation(s)
- Elizabeth Armstrong
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Lara A Harvey
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Narelle L Payne
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Jing Zhang
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Pengpeng Ye
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Ian A Harris
- Orthopaedic Department, Liverpool Hospital, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Rebecca Q Ivers
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Cianferotti L, Porcu G, Ronco R, Adami G, Alvaro R, Bogini R, Caputi AP, Frediani B, Gatti D, Gonnelli S, Iolascon G, Lenzi A, Leone S, Michieli R, Migliaccio S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Rossini M, Tarantino U, Brandi ML, Corrao G, Biffi A. The integrated structure of care: evidence for the efficacy of models of clinical governance in the prevention of fragility fractures after recent sentinel fracture after the age of 50 years. Arch Osteoporos 2023; 18:109. [PMID: 37603196 PMCID: PMC10442313 DOI: 10.1007/s11657-023-01316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023]
Abstract
Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were examined. Literature was systematically reviewed and summarized by a panel of experts who formulated recommendations for the Italian guideline. PURPOSE After experiencing a fracture, several strategies may be adopted to reduce the risk of recurrent fragility fractures and associated morbidity and mortality. Clinical governance models, such as the fracture liaison service (FLS), have been introduced for the identification, treatment, and monitoring of patients with secondary fragility fractures. A systematic review was conducted to evaluate the association between multidisciplinary care systems and several outcomes in patients with a fragility fracture in the context of the development of the Italian Guidelines. METHODS PubMed, Embase, and the Cochrane Library were investigated up to December 2020 to update the search of the Scottish Intercollegiate Guidelines Network. Randomized clinical trials (RCTs) and observational studies that analyzed clinical governance models in patients who had experienced a fragility fracture were eligible. Three authors independently extracted data and appraised the risk of bias in the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random-effects models. Primary outcomes were bone mineral density values, antiosteoporotic therapy initiation, adherence to antiosteoporotic medications, subsequent fracture, and mortality risk, while secondary outcomes were quality of life and physical performance. RESULTS Fifteen RCTs and 62 observational studies, ranging from very low to low quality for bone mineral density values, antiosteoporotic initiation, adherence to antiosteoporotic medications, subsequent fracture, mortality, met our inclusion criteria. The implementation of clinical governance models compared to their pre-implementation or standard care/non-attenders significantly improved BMD testing rate, and increased the number of patients who initiated antiosteoporotic therapy and enhanced their adherence to the medications. Moreover, the treatment by clinical governance model respect to standard care/non-attenders significantly reduced the risk of subsequent fracture and mortality. The integrated structure of care enhanced the quality of life and physical function among patients with fragility fractures. CONCLUSIONS Based on our findings, clinicians should promote the management of patients experiencing a fragility fracture through structured and integrated models of care. The task force has formulated appropriate recommendations on the implementation of multidisciplinary care systems in patients with, or at risk of, fragility fractures.
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Affiliation(s)
- L Cianferotti
- Italian Bone Disease Research Foundation (FIRMO), Florence, Italy
| | - G Porcu
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - R Ronco
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - G Adami
- Rheumatology Unit, University of Verona, Verona, Italy
| | - R Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - R Bogini
- Local Health Unit (USL) Umbria, Perugia, Italy
| | - A P Caputi
- Department of Pharmacology, School of Medicine, University of Messina, Sicily, Italy
| | - B Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - D Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | - S Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - G Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - S Leone
- AMICI Onlus, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino, Milan, Italy
| | - R Michieli
- Italian Society of General Medicine and Primary Care (SIMG), Florence, Italy
| | - S Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - T Nicoletti
- CnAMC, Coordinamento nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, Rome, Italy
| | - M Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - E Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Orthopedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - M Rossini
- Rheumatology Unit, University of Verona, Verona, Italy
| | - U Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Orthopedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - M L Brandi
- Italian Bone Disease Research Foundation (FIRMO), Florence, Italy
| | - G Corrao
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - A Biffi
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
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Verdonck C, Willems R, Borgermans L. Implementation and operationalization of Integrated People-Centred Health Services delivery strategies in integrated osteoporosis care (IOC) initiatives: a systematic review. Osteoporos Int 2023; 34:841-865. [PMID: 36695826 DOI: 10.1007/s00198-023-06678-x] [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: 07/13/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
Integrated Osteoporosis Care (IOC) has been emerging over the past decade. To support integrated care initiatives, the World Health Organisation (WHO) has developed the Integrated People Centred Health Services (IPCHS) framework, which consists of five interdependent strategies. Five electronic databases (PubMed, Embase, World of Science, CINAHL, and Scopus) were searched for relevant studies published from January 1, 2010 to December 2022. Initiatives implementing collaborative practices and at least two IPCHS strategies were included. Quality assessment was performed using the Effective Public Health Practice Project checklist. Seventy-six publications describing 69 implementations met the inclusion criteria; 90% of them were implemented at the hospital level, and over half focused on secondary fracture prevention. Three implementations captured all five IPCHS strategies, and half applied three. Substrategies targeting individuals as beneficiaries were frequently employed. Substrategies requiring fundamental shifts (e.g., systemic coordination and updating) were seldomly implemented. Substantive heterogeneity in substrategy operationalization was observed. Patient education, standardized care, team-based care, care coordinators, and health care provider training were commonly pursued. IOC interventions have focused mainly on secondary fracture prevention in a hospital setting and have been narrowly operationalized. Future implementation should: employ all five IPCHS strategies; better align programmes, providers, and regulatory frameworks, while adapting funding mechanisms; and operationalize broader and more innovative substrategies.Registration: This review has been registered at the international prospective register of systematic reviews PROSPERO (CRD42021250244).
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Affiliation(s)
- Caroline Verdonck
- Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Ruben Willems
- Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Liesbeth Borgermans
- Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
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4
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Corrao G, Biffi A, Porcu G, Ronco R, Adami G, Alvaro R, Bogini R, Caputi AP, Cianferotti L, Frediani B, Gatti D, Gonnelli S, Iolascon G, Lenzi A, Leone S, Michieli R, Migliaccio S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Rossini M, Tarantino U, Brandi ML. Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021. Front Endocrinol (Lausanne) 2023; 14:1137671. [PMID: 37143730 PMCID: PMC10151776 DOI: 10.3389/fendo.2023.1137671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/27/2023] [Indexed: 05/06/2023] Open
Abstract
Background Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field. Purpose This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline. Methods The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations. Results Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively. Conclusions The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.
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Affiliation(s)
- Giovanni Corrao
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
- *Correspondence: Giovanni Corrao, ; Maria Luisa Brandi,
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Raffaella Ronco
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | | | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Luisella Cianferotti
- Italian Bone Disease Research Foundation, Fondazione Italiana Ricerca sulle Malattie dell’Osso (FIRMO), Florence, Italy
| | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Davide Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - Salvatore Leone
- AMICI Onlus, Associazione Nazionale per le Malattie Infiammatorie Croniche dell’Intestino, Milan, Italy
| | - Raffaella Michieli
- Italian Society of General Medicine and Primary Care Società Italiana di Medicina Generale e delle cure primarie (SIMG), Florence, Italy
| | - Silvia Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - Tiziana Nicoletti
- CnAMC, Coordinamento nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, Rome, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Annalisa Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | | | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | - Maria Luisa Brandi
- Italian Bone Disease Research Foundation, Fondazione Italiana Ricerca sulle Malattie dell’Osso (FIRMO), Florence, Italy
- *Correspondence: Giovanni Corrao, ; Maria Luisa Brandi,
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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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6
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Resultados en salud tras la implantación de una guía multidisciplinar para la atención a la fractura de cadera. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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7
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Health outcomes after the implementation of multidisciplinary clinical guidelines for the care of hip fractures. Rev Clin Esp 2021; 222:73-81. [PMID: 34548255 DOI: 10.1016/j.rceng.2021.04.007] [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: 12/29/2020] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES This study aims to evaluate the impact of implementing multidisciplinary clinical guidelines in the process of caring for patients with hip fractures. MATERIALS AND METHODS This work is a pre- and post-intervention prospective study in the Orthogeriatrics Unit of a second-level hospital after implementing multidisciplinary clinical guidelines for hip fracture care. We analyzed patients' baseline characteristics and the variations observed in care provided and in outcome variables in the two periods studied (June 2015-May 2016 and June 2016-May 2017). RESULTS The baseline characteristics of the population were similar in the pre-intervention period (n = 455) compared to the post-intervention period (n = 456). Patients' mean age was 84.8 ± 6.8 years and 70.8% were women. The implementation of the multidisciplinary clinical guidelines led to a reduction in the mean length of hospital stay (16.9 days vs. 15.6 days, p= .014); improved osteoporosis treatment prescribing (51.6% vs. 88%, p< .001); and reduced episodes of delirium (44% vs. 31.2%, p < .001), bronchospasm (18.3% vs. 12%, p = .019), heart failure (20% vs. 11.5%, p < .001), and COPD exacerbation (7.9% vs. 3.8%, P = .017). We observed an increase in pressure ulcers at discharge (2.9 vs. 9%, P < .001). There were no differences in the percentage of operations in less than 48 h (56% vs. 61.2% p = .64), hospital readmissions (6.9% vs. 5.9%, p = .51), or mortality (5.0% vs. 7.2%, p = .17). CONCLUSIONS The implementation of multidisciplinary clinical guidelines improved aspects of the care process for patients with hip fracture.
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Morri M, Forni C, Guberti M, Chiari P, Pecorari A, Orlandi AM, Gazineo D, Bozzo M, Ambrosi E. Post-hospital care pathway for individuals with hip fracture: what is the optimal setting and rehabilitation intensity? An observational study. Disabil Rehabil 2021; 44:4241-4248. [PMID: 33725460 DOI: 10.1080/09638288.2021.1897692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Health systems are using ever-increasing resources on treating hip fractures. Optimal post-hospital care needs to be defined to design an effective care pathway. The aim of the present study was to describe the post-hospital care pathway of individuals with hip fracture and to assess its association with the degree of recovery of independence achieved four months after surgery. MATERIALS AND METHODS A prognostic multicentric cohort study was conducted. All patients aged 65 years and over who were admitted with a diagnosis of fragility hip fracture were enrolled. After the hospital discharge, the patients were followed either at an inpatient rehabilitation facility with an intensive or extensive regimen, a nursing home, a long-term care facility or at home. Among the various care pathways, the intensity of rehabilitation differed according to its duration, frequency of sessions, and activities proposed. Primary outcome was the patient's degree of independence achieved four months after surgery, as measured with Activities of Daily Living scale. Several covariates were collected to test the correlation between the different post-hospital care pathways and the recovery of independence. RESULTS A total of 923 patients completed the follow-up. A post- hospital rehabilitation pathway was indicated for 88.2% of the patients. The extensive rehabilitation pathway, indicated for 36.7% of the patients, was the most common. The intensive rehabilitation pathway gave better results in terms of independence at four-month follow up, leading to a median ADL score of 1.4 (95% CI 1.0-2.0). The other care pathways did not show significant difference between each other. CONCLUSIONS High-intensity rehabilitation was associated to better results in terms of recovering of Activities of Daily Living.IMPLICATIONS FOR REHABILITATIONPost-hospital care pathways that include an intensive rehabilitation treatment should be improved/supported to make them available to a larger number of hip fracture patients.Patient selection criteria for post-hospital rehabilitation pathways should be standardized to optimize available healthcare resources.A cost-effectiveness analysis should be performed to analyze the economic sustainability of each post-hospital care pathway.
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Affiliation(s)
- Mattia Morri
- Servizio di Assistenza Infermieristica, Tecnica e Riabilitativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Cristiana Forni
- Servizio di Assistenza Infermieristica, Tecnica e Riabilitativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Monica Guberti
- Azienda USL- IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Paolo Chiari
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italia
| | | | - Antonella Magli Orlandi
- Servizio di Assistenza Infermieristica, Tecnica e Riabilitativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Domenica Gazineo
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italia
| | - Maria Bozzo
- Azienda USL- IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elisa Ambrosi
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italia
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Maxwell BG, Mirza A. Medical Comanagement of Hip Fracture Patients Is Not Associated with Superior Perioperative Outcomes: A Propensity Score-Matched Retrospective Cohort Analysis of the National Surgical Quality Improvement Project. J Hosp Med 2020; 15:468-474. [PMID: 31869291 DOI: 10.12788/jhm.3343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/07/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Medical comanagement entails a significant commitment of clinical resources with the aim of improving perioperative outcomes for patients admitted with hip fractures. To our knowledge, no national analyses have demonstrated whether patients benefit from this practice. METHODS We performed a retrospective cohort analysis of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted user file for hip fracture 2016-2017. Medical comanagement is a dedicated variable in the NSQIP. Propensity score matching was performed to control for baseline differences associated with comanagement. Matched pairs binary logistic regression was then performed to determine the effect of comanagement on the following primary outcomes: mortality and a composite endpoint of major morbidity. RESULTS Unadjusted analyses demonstrated that patients receiving medical comanagement were older and sicker with a greater burden of comorbidities. Comanagement did not have a higher proportion of patients participating in a standardized hip fracture program (53.6% vs 53.7%; P > .05). Comanagement was associated with a higher unadjusted rate of mortality (6.9% vs 4.0%, odds ratio [OR] 1.79: 1.44-2.22; P < .0001) and morbidity (19.5% vs 9.6%, OR 2.28: 1.98-2.63; P < .0001). After propensity score matching was used to control for baseline differences associated with comanagement, patients in the comanagement cohort continued to demonstrate inferior mortality (OR 1.36: 1.02-1.81; P = .033) and morbidity (OR 1.82: 1.52-2.20; P < .0001). CONCLUSIONS This analysis does not provide evidence that dedicated medical comanagement of hip fracture patients is associated with superior perioperative outcomes. Further efforts may be needed to refine opportunities to modify the significant morbidity and mortality that persists in this population.
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Affiliation(s)
- Bryan G Maxwell
- Department of Anesthesiology, Legacy Emanuel Medical Center, Portland, Oregon
| | - Amer Mirza
- Department of Surgery, Legacy Emanuel Medical Center, Portland, Oregon
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