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Johnson SA, Whipple M, Kendrick DR, Gouttsoul A, Eppich K, Wu C, Rupp AB, Signor EA, Reddy SP. Clinical Outcomes of Orthopedic Surgery Co-Management by Internal Medicine Advanced Practice Clinicians: A Cohort Study. Am J Med 2024:S0002-9343(24)00345-0. [PMID: 38866301 DOI: 10.1016/j.amjmed.2024.05.034] [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: 04/23/2024] [Revised: 05/25/2024] [Accepted: 05/26/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Comanagement of orthopedic surgery patients by internal medicine hospitalists is associated with improvements in clinical outcomes including complications, length of stay, and cost. Clinical outcomes of orthopedic comanagement performed solely by internal medicine advanced practice clinicians have not been reported. Our objecyive was to compare clinical outcomes between advanced practice clinician-based comanagement and usual orthopedic care. METHODS This is a retrospective cohort study in patients 18 years or older, hospitalized for orthopedic joint or spine surgery between May 1, 2014 and January 1, 2022. Outcomes assessed were length of stay, intensive care unit (ICU) transfer, return to operating room, in-hospital and 30-day mortality, 30-day readmission, and total direct cost, excluding surgical implants. Generalized boosted regression and propensity score weighting was used to compare clinical outcomes and health care cost between usual care and advanced practice clinician comanagement. RESULTS Advanced practice clinician comanagement was associated with a 5% reduction in mean length of stay (rate ratio = 0.95, P = .009), decreased odds of returning to the operating room (odds ratio [OR] 0.51, P = .002), and a significant reduction in 30-day mortality (OR 0.32, P = .037) compared with usual orthopedic care in a weighted analysis. Need for ICU transfer was higher with advanced practice clinician comanagement (OR 1.54, P = .009), without significant differences in 30-day readmission or in-hospital mortality. CONCLUSIONS We observed reductions in length of stay, health care costs, return to the operating room, and 30-day mortality with advanced practice clinician comanagement compared with usual orthopedic care. Our findings suggest that advanced practice clinician-based comanagement may represent a safe and cost-effective model for orthopedic comanagement.
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Affiliation(s)
- Stacy A Johnson
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City.
| | - Melissa Whipple
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - David R Kendrick
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Alexander Gouttsoul
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Kaleb Eppich
- Study Design and Biostatistics Center, Center for Clinical and Translational Science, University of Utah School of Medicine, Salt Lake City
| | - Chaorong Wu
- Study Design and Biostatistics Center, Center for Clinical and Translational Science, University of Utah School of Medicine, Salt Lake City
| | - Austin B Rupp
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Emily A Signor
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Santosh P Reddy
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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Tago M, Hirata R, Takahashi H, Yamashita S, Nogi M, Shikino K, Sasaki Y, Watari T, Shimizu T. How Do We Establish the Utility and Evidence of General Medicine in Japan? Int J Gen Med 2024; 17:635-638. [PMID: 38410241 PMCID: PMC10896665 DOI: 10.2147/ijgm.s451260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/05/2024] [Indexed: 02/28/2024] Open
Abstract
Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.
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Affiliation(s)
- Masaki Tago
- Department of General Medicine, Saga University Hospital, Saga, Japan
| | - Risa Hirata
- Department of General Medicine, Saga University Hospital, Saga, Japan
| | - Hiromizu Takahashi
- Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Shun Yamashita
- Department of General Medicine, Saga University Hospital, Saga, Japan
- Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Masayuki Nogi
- Hospitalist Division, The Queen's Medical Center, Honolulu, HI, USA
- Department of General Internal Medicine, Kameda Medical Center, Chiba, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Yosuke Sasaki
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan
| | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Shimane, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, Japan
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Rosa PRM, Spagnól MF, Rothlisberger L, Gelain MAS, de Brida MS, Teixeira C. Internal medicine consultation for high-risk surgical patients: reflection on hospital mortality and readmission rates in a low-income country. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230468. [PMID: 37909615 PMCID: PMC10610760 DOI: 10.1590/1806-9282.20230468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/03/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE The objective of this study was to assess the impact of internal medicine consultation on mortality, 30-day readmission, and length of stay in surgical patients. METHODS This is a retrospective descriptive study developed in a public Brazilian teaching hospital with 850 beds. RESULTS A total of 70,245 patients were admitted from 2010 to 2018 to the surgery departments. The main outcomes measured were patients' mortality, 30-day readmission, and length of stay. Mortality of high-risk patients was lower when followed by internal medicine consultation: patients with ASA≥3 (RR 0.89 [95% confidence interval (95%CI) 0.80-0.99], p=0.02), patients with ASA≥3 plus≥65 years (RR 0.88 [95%CI 0.78-0.99], p=0.04), patients with ASA≥3 plus high-risk surgery (RR 0.86 [95%CI 0.77-0.97], p=0.01), and patients with ASA≥4 plus age ≥65 years (RR 0.83 [95%CI 0.72-0.96], p=0.01). The 30-day readmission of high-risk patients was lower when followed by internal medicine consultation: patients with ≥65 years (RR 0.57 [95%CI 0.37-0.89], p=0.01) and patients with high-risk surgery (RR 0.63 [95%CI 0.46-0.57], p=0.005). The Poisson multivariate regression with adjustment in variances showed that all the variables (namely, age, ASA, morbidity index, surgery risk, and internal medicine consultation) were associated with higher mortality of patients; however, internal medicine consultation was associated with a reduction of mortality in high-risk patients (RR 0.72 [95%CI 0.65-0.84], p=0.02) and an increase of mortality in low-risk patients (RR 1.55 [95%CI 1.31-1.67], p=0.01). CONCLUSION High-risk surgical patients may benefit from perioperative internal medicine consultations, which probably decrease hospital mortality and 30-day hospital readmission.
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Affiliation(s)
| | | | | | | | | | - Cassiano Teixeira
- Universidade Federal de Ciências da Saúde de Porto Alegre, Medical School, Internal Medicine Department – Porto Alegre (RS), Brazil
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Cacciola G, Mancino F, Holzer LA, De Meo F, De Martino I, Bruschetta A, Risitano S, Sabatini L, Cavaliere P. Predictive Value of the C-Reactive Protein to Albumin Ratio in 30-Day Mortality after Hip Fracture in Elderly Population: A Retrospective Observational Cohort Study. J Clin Med 2023; 12:4544. [PMID: 37445579 DOI: 10.3390/jcm12134544] [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: 03/04/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND C-reactive protein (CRP) to Albumin ratio (CAR) has been used in multiple clinical settings to predict early mortality. However, there is a lack of evidence on the predictive role of CAR in 30-day mortality after a hip fracture. The purpose of this study was to establish a potential association between CAR and 30-day mortality and to assess if the CAR Receiving Operating Characteristics curve (ROC) can be a reliable predictor of early mortality. METHODS We retrospectively reviewed the charts of 676 patients (>65 years) treated for hip fracture between 2006 and 2018. All hip fractures were included. Treatment strategies included closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty, or total joint arthroplasty. Statistical analysis included T-test, Pearson correlation for CAR and other markers, ROC curves and area under the curve, Youden Model, and Odds Ratio. RESULTS The 30-day mortality rate analysis showed that higher preoperative levels of CAR were associated with higher early mortality. When analyzing the area under the ROC curve (AUROC) for 30-day mortality, the reported value was 0.816. The point of the ROC curve corresponding to 14.72 was considered a cut-off with a specificity of 87% and a sensibility of 40.8%. When analyzing values higher than 14.72, the 30-day mortality rate was 17.9%, whilst, for values lower than 14.72, the 30-day mortality rate was 1.8%. CONCLUSIONS Patients older than 65 years affected by a hip fracture with increased preoperative levels of CAR are associated with higher 30-day mortality. Despite a moderate sensibility, considering the low cost and the predictivity of CAR, it should be considered a standard predictive marker.
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Affiliation(s)
- Giorgio Cacciola
- Orthopaedic Institute of Southern Italy "Franco Scalabrino", 98165 Messina, Italy
| | - Fabio Mancino
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia (ORFWA), Fiona Stanley Fremantle Hospitals Group, Perth, WA 6150, Australia
| | - Lukas A Holzer
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia (ORFWA), Fiona Stanley Fremantle Hospitals Group, Perth, WA 6150, Australia
| | - Federico De Meo
- Orthopaedic Institute of Southern Italy "Franco Scalabrino", 98165 Messina, Italy
| | - Ivan De Martino
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
- Adult Reconstruction and Joint Replacement Unit, Division of Sports Traumatology and Joint Replacement, Department of Ageing, Orthopaedic and Rheumatologic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | | | - Salvatore Risitano
- A.O.U. Città della Salute e della Scienza, Centro Traumatologico Ortopedico (C.T.O.), Universitá di Torino, 10024 Turin, Italy
| | - Luigi Sabatini
- A.O.U. Città della Salute e della Scienza, Centro Traumatologico Ortopedico (C.T.O.), Universitá di Torino, 10024 Turin, Italy
| | - Pietro Cavaliere
- Orthopaedic Institute of Southern Italy "Franco Scalabrino", 98165 Messina, Italy
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Hawley S, Inman D, Gregson CL, Whitehouse M, Johansen A, Judge A. Risk Factors and 120-day Functional Outcomes of Delirium After Hip Fracture Surgery: A Prospective Cohort Study Using the UK National Hip Fracture Database (NHFD). J Am Med Dir Assoc 2023; 24:694-701.e7. [PMID: 36933569 DOI: 10.1016/j.jamda.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES To identify risk factors of postoperative delirium among patients with hip fracture with normal preoperative cognition, and examine associations with returning home or recovery of mobility. DESIGN Prospective cohort study. SETTING AND PARTICIPANTS We used the National Hip Fracture Database (NHFD) to identify patients presenting with hip fracture in England (2018-2019), but excluded those with abnormal cognition (abbreviated mental test score [AMTS] < 8) on presentation. METHODS We examined the results of routine delirium screening performed using the 4 A's Test (4AT), to assess alertness, attention, acute change, and orientation in a 4-item mental test. Associations between 4AT score and return home or to outdoor mobility at 120 days were estimated, and risk factors identified for abnormal 4AT scores: (1) 4AT ≥4 suggesting delirium and (2) 4AT = 1-3 being an intermediate score not excluding delirium. RESULTS Overall, 63,502 patients (63%) had a preoperative AMTS ≥8, in whom a postoperative 4AT score ≥4 suggestive of delirium was seen in 4454 (7%). These patients were less likely to return home (odds ratio [OR], 0.46; 95% CI, 0.38-0.55) or regain outdoor mobility (OR, 0.63; 95% CI, 0.53-0.75) by 120 days. Multiple factors including any deficit in preoperative AMTS and malnutrition were associated with higher risk of 4AT ≥4, while use of preoperative nerve blocks was associated with lower risk (OR, 0.88; 95% CI, 0.81-0.95). Poorer outcomes were also seen in 12,042 (19%) patients with 4AT = 1-3; additional risk factors associated with this score included socioeconomic deprivation and surgical procedure types that were not compliant with National Institute of Health and Care Excellence guidance. CONCLUSION AND IMPLICATIONS Delirium after hip fracture surgery significantly reduces the likelihood of returning home or to outdoor mobility. Our findings underline the importance of measures to prevent postoperative delirium, and aid the identification of high-risk patients for whom delirium prevention might potentially improve outcomes.
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Affiliation(s)
- Samuel Hawley
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Dominic Inman
- Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK; Care Quality Improvement Department, Royal College of Physicians, London, UK
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Antony Johansen
- Care Quality Improvement Department, Royal College of Physicians, London, UK; University Hospital of Wales and School of Medicine, Cardiff University, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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Interfacility Transfer Patients With Pelvic, Acetabular, and Lower Extremity Fractures Are at Higher Risk for Major Complications and Readmissions. J Orthop Trauma 2023; 37:51-56. [PMID: 36026567 DOI: 10.1097/bot.0000000000002478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home. METHODS A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables. RESULTS The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32). CONCLUSIONS This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Würdemann FS, van Zwet EW, Krijnen P, Hegeman JH, Schipper IB, van Egmond PW, van Eijk M, van Heijl M, Luyten MC, Schutte BG, Voeten SC, Arends AJ, Heetveld MJ, Trappenburg MC. Is hospital volume related to quality of hip fracture care? Analysis of 43,538 patients and 68 hospitals from the Dutch Hip Fracture Audit. Eur J Trauma Emerg Surg 2023; 49:1525-1534. [PMID: 36670302 DOI: 10.1007/s00068-022-02205-5] [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: 10/03/2022] [Accepted: 12/17/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Evidence for a hospital volume-outcome relationship in hip fracture surgery is inconclusive. This study aimed to analyze the association between hospital volume as a continuous parameter and several processes and outcomes of hip fracture care. METHODS Adult patients registered in the nationwide Dutch Hip Fracture Audit (DHFA) between 2018 and 2020 were included. The association between annual hospital volume and turnaround times (time on the emergency ward, surgery < 48 h and length of stay), orthogeriatric co-treatment and case-mix adjusted in-hospital and 30 days mortality was evaluated with generalized linear mixed models with random effects for hospital and treatment year. We used a fifth-degree polynomial to allow for nonlinear effects of hospital volume. P-values were adjusted for multiple comparisons using the Bonferoni method. RESULTS In total, 43,258 patients from 68 hospitals were included. The median annual hospital volume was 202 patients [range 1-546]. Baseline characteristics did not differ with hospital volume. Provision of orthogeriatric co-treatment improved with higher volumes but decreased at > 367 patients per year (p < 0.01). Hospital volume was not significantly associated with mortality outcomes. No evident clinical relation between hospital volume and turnaround times was found. CONCLUSION This is the first study analyzing the effect of hospital volume on hip fracture care, treating volume as a continuous parameter. Mortality and turnaround times showed no clinically relevant association with hospital volume. The provision of orthogeriatric co-treatment, however, increased with increasing volumes up to 367 patients per year, but decreased above this threshold. Future research on the effect of volume on complications and functional outcomes is indicated.
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Affiliation(s)
- Franka S Würdemann
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands. .,Dutch Institute for Clinical Auditing, Scientific Bureau, Rijnsburgerweg 10, 2333 AA, Leiden, The Netherlands.
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Johannes H Hegeman
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Severity of Illness Impacts Outcomes More than Admitting Service for Isolated Hip Fracture Patients. World J Surg 2022; 46:2344-2349. [PMID: 35849173 DOI: 10.1007/s00268-022-06659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Isolated hip fractures (IHF) are common injuries in the elderly. Controversy exists about which hospital service is best suited to manage these patients. We hypothesize that baseline patient severity of illness (SOI) score drives patient outcomes, not the hospital service managing these patients. METHODS Retrospective review of all IHF patients from 2014 to 2018 at our Level 1 trauma center. Basic demographics were obtained. Patients were divided into service line they were admitted; surgical vs non-surgical. Primary outcomes included hospital length of stay (HLOS), time to OR, time to VTE prophylaxis, complication rate (defined by the Trauma Quality Improvement Program), 30-day mortality, and readmissions. SOI score (which is DRG-based) was controlled to see if any differences in primary outcomes occurred between cohorts. Chi-square was used for categorical variables and regression analysis for continuous variables. Significance was p < 0.05. RESULTS A total of 366 total patients were analyzed with the same ISS. A total of 102 were admitted to a surgical service and 264 to a non-surgical service. Average overall age was 80 year, 66.9% were female, and 86% were Caucasian. There was no statistical difference between outcomes when comparing admitting services. Controlling for SOI score, there was no difference between admitting service for outcomes as well. SOI score was a significant predictor for increased HLOS and complication occurrence (p < 0.001) via regression analysis, with a 6.06-fold increase in complication rate from mild to moderate SOI score (p = 0.001). CONCLUSION There is no difference in outcomes based on admitting service and process measures. However, the SOI score is perhaps a better predictor of outcomes for isolated hip fracture patients.
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Houserman DJ, Raszewski JA, Palmer B, Chavan B, Sferrella A, Campbell M, Santanello S. The Impact of the Fascia Iliaca Block Beyond Perioperative Pain Control in Hip Fractures: A Retrospective Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221099107. [PMID: 35794869 PMCID: PMC9251979 DOI: 10.1177/21514593221099107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Geriatric hip fractures are common injuries that are associated with high morbidity and mortality. Adequate pain control remains a challenge as the altered physiology in elderly patients makes use of traditional analgesics challenging. The use of regional anesthetics, specifically the fascia iliaca compartment block (FICB), in the perioperative period has been shown to decrease opioid use in this population. This study aimed to investigate the effect the FICB had on pain control, length of stay, readmissions, and complications in a 30-day postoperative period. Methods This was a retrospective cohort study comparing patients who sustained hip fractures; one cohort (110 patients) received a preoperative fascia iliaca block with continuous infusion (FICB), whereas the other cohort (110 patients) did not receive a block (NO-FICB). Both cohorts were from level II trauma centers. Data were collected between 2016 and 2019. Descriptive statistics was performed to describe and summarize the data. Bivariate analysis was performed using chi-square test, with 2 tailed P-values ≤ .05 were considered statistically significant. Results The FICB group had a lower length of stay (3.9 days vs 4.8 days; P < .001), and lower pain scores on post-operative days 2 and 3 (P = .019). There was no difference in time from admission to surgery (P = .112) or narcotic use between cohorts (P = .304). However, the FICB group was more likely to discharge to a skilled nursing facility (P=.002), and more likely to be readmitted within 30 days (P = .047). There were no differences in medical complications or mortality between the 2 groups. Conclusions The primary study endpoint, length of stay, was found to be significantly shorter in the patients who underwent the FICB vs the group who did not undergo the FICB. Pain scores on POD2 and POD3 were lower in patients who received a FICB. This study adds to the body of evidence that the FICB is an effective addition to a multimodal pain pathway. Level of Evidence Level III Evidence – Retrospective Cohort Study
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Affiliation(s)
| | | | - Brandi Palmer
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA
| | | | - Abby Sferrella
- College of Osteopathic Medicine, Marian University, Indianapolis, IN, USA
| | - Melody Campbell
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA
| | - Steven Santanello
- Department of Trauma Surgery, Kettering Medical Center, Kettering Health Network, Dayton, OH, USA.,Parkview Health, Parkview Regional Medical Center, Fort Wayne, IN, USA
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Bub C, Stapleton E, Iturriaga C, Garbarino L, Aziz H, Wei N, Mota F, Goldin ME, Sinvani LD, Carney MT, Goldman A. Implementation of a Geriatrics-Focused Orthopaedic and Hospitalist Fracture Program Decreases Perioperative Complications and Improves Resource Utilization. J Orthop Trauma 2022; 36:213-217. [PMID: 34483320 DOI: 10.1097/bot.0000000000002258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate whether the implementation of a geriatrics-focused orthopaedic and hospitalist comanagement program can improve perioperative outcomes and decrease resource utilization. DESIGN A retrospective chart review study was conducted before and after the implementation of a geriatrics-focused orthopaedic and hospitalist comanagement program, based on the American Geriatrics Society (AGS) AGS CoCare:Ortho. SETTING A large urban, academic tertiary center, located in the greater New York metropolitan area. PARTICIPANTS Patients 65 years and older hospitalized for operative hip fracture. Those with pathologic or periprosthetic fractures and chronic substance use were excluded. MAIN OUTCOME MEASUREMENTS Outcome measures included time to operating room (TtOR), length of stay, daily and total morphine milligram equivalents, use of preoperative transthoracic echocardiogram and blood transfusions, perioperative complications (eg, urinary tract infections), and 6-month mortality. RESULTS Our study included 290 patients hospitalized with hip fracture, before (N = 128) and after (N = 162) implementation. When compared with the preimplementation group, the postimplementation comanagement group had a lower TtOR (36.2 vs. 30.0 hours, P = 0.026) and hospital length of stay, decreased use of indwelling bladder catheters preoperatively and postoperatively (68.0% vs. 46.9%, P < 0.001, and 83.6 vs. 58.0%, P < 0.001, respectively), reduced daily opiate use (16.0 vs. 11.1 morphine milligram equivalents, P = 0.011), and decreased 30-day complications (32.8% vs. 16.7%, P = 0.002). There was no difference in 6-month mortality between the 2 groups. CONCLUSIONS The implementation of an AGS CoCare:Ortho-based comanagement program led to decreased perioperative complications and resource utilization. Comanagement programs are essential to improving and standardizing hip fracture care for older adults. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christine Bub
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY
| | - Erik Stapleton
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, Plainview Hospital, Plainview, NY
| | - Cesar Iturriaga
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY
| | - Luke Garbarino
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY
| | - Hadi Aziz
- Sophie Davis Biomedical Education/CUNY School of Medicine, New York, NY
| | - Nicole Wei
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX
| | - Frank Mota
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, Lennox Hill Hospital, New York, NY; and
| | - Mark Eliot Goldin
- Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Long Island Jewish Hospital, Northwell Health, Great Neck, NY
| | - Liron Danay Sinvani
- Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Long Island Jewish Hospital, Northwell Health, Great Neck, NY
| | - Maria Torroella Carney
- Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Long Island Jewish Hospital, Northwell Health, Great Neck, NY
| | - Ariel Goldman
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY
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11
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Zhang X, Shen ZL, Duan XZ, Zhou QR, Fan JF, Shen J, Ji F, Tong DK. Postoperative Pneumonia in Geriatric Patients With a Hip Fracture: Incidence, Risk Factors and a Predictive Nomogram. Geriatr Orthop Surg Rehabil 2022; 13:21514593221083824. [PMID: 35340623 PMCID: PMC8949772 DOI: 10.1177/21514593221083824] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/03/2022] [Accepted: 02/08/2022] [Indexed: 11/20/2022] Open
Abstract
Objectives To evaluate the incidence and risk factors of postoperative pneumonia (POP) in geriatric patients with a hip fracture after surgery, to design a predictive nomogram, and to validate the accuracy of the nomogram. Design Retrospective study. Setting A tertiary hospital affiliated to a medical university. Patients/Participants We retrospectively studied 1285 surgical-treated geriatric patients with a hip fracture from April 2010 to April 2018. Intervention Surgical treatment was performed on the patients of this study. The procedure methods were classified as: total hip arthroplasty, hemiarthroplasty, percutaneous fixation, intramedullary nail fixation, and plate/screw fixation. Main Outcome Measurement The primary interest of end point of this study is the development of POP during the postoperative period. The postoperative period in this study was defined as the time from 24 hours after surgery to discharge. The diagnostic criteria for pneumonia were set according to the guidelines built by the Infectious Diseases Society of America and the American Thoracic Society (Guidelines for the Management of Adults with Hospital-Acquired, Ventilator-Associated, and Healthcare-Associated Pneumonia, 2005). Potential variables for developing POP were identified using logistic regression analyses initially and were further selected via the method of LASSO. Then the independent risk factors were identified by multivariable regression analyses. A predictive nomogram was built based on the multiple regression model, and the calibration abilities of the nomogram was measured by Harrel C-index, calibration plot and Hosmer–Lemeshow test, respectively. Decision curve analysis was carried out to assess the net benefit due to threshold probability and an on-line questionnaire survey was conducted among the clinicians to assess the applicability of the nomogram coherently. Results Of the 1285 patients, 70 (5.4%) developed POP. COPD, number of comorbidities, ASA classification >2, preoperative dependent functional status and cognitive impairment were identified as independent risk factors of POP. The nomogram built based on the results showed good accordance between the predicted probabilities and the observed frequency. The decision curve analysis confirmed the clinical utility of the nomogram when the threshold probabilities were between 5% and 65% due to the net benefit, while the results of on-line questionnaire among 200 clinicians showed that 91.5% of the participants had a mental threshold of intervention between 5-50%. Conclusion (1). COPD, number of comorbidities, ASA classification >2, preoperative dependent functional status and cognitive impairment are independent risk factors for POP. (2). The nomogram built in this study has a good accordance between the predictive risk and the observational incidence. The results of decision curve and questionnaire among clinicians show well applicability of the nomogram.
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Affiliation(s)
- Xin Zhang
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | | | - Xu-Zhou Duan
- Department of Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qi-Rong Zhou
- Department of Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jie-Fu Fan
- Naval Medical University, Shanghai, China
| | - Jie Shen
- Naval Medical University, Shanghai, China
| | - Fang Ji
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Da-Ke Tong
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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12
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VanTienderen RJ, Bockelman K, Khalifa R, Reich MS, Adler A, Nguyen MP. Implementation of a Multidisciplinary "Code Hip" Protocol is Associated with Decreased Time to Surgery and Improved Patient Outcomes. Geriatr Orthop Surg Rehabil 2022; 12:21514593211004904. [PMID: 35186421 PMCID: PMC8848070 DOI: 10.1177/21514593211004904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 01/28/2021] [Accepted: 03/05/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The purpose of this study is to report outcomes data based on the implementation of a “Code Hip” protocol, a multidisciplinary approach to the care of fragility hip fracture patients focussing on medical optimization and early operative intervention. We hypothesized that implementation of this protocol would decrease time from presentation to surgical intervention and improve outcomes based on short term post-operative data. Methods: A retrospective chart review was performed on all patients aged greater than 65 years old with a fragility hip fracture from October 2015 through June 2018. In addition to demographic and patient factors, we recorded time to surgery, type of surgical interventions performed, ability to ambulate in the post-operative period, 90-day post-operative complications and overall hospital cost. Results: There were 114 patients in the pre-Code Hip cohort and 132 patients in the post-Code Hip cohort. Demographic factors were not different between the 2 cohorts. Time from presentation to surgery in the post-Code Hip cohort was shorter at 23.1 ± 16.4 hours versus 33.2 ± 27.2 hours (p < 0.001). 30.3% of patients in the post-Code Hip cohort had at least one post-operative complication compared to 42.1% in the pre-Code Hip cohort (RR = 0.72, CI = 0.51 -1.01, p = 0.05). The post-Code Hip cohort had a significantly lower rate of hospital readmission (p = 0.04), unplanned reoperation (p = 0.02), surgical site infection (p = 0.03), and sepsis (p = 0.05). Total hospital cost per patient decreased from an average of $14,079 +/- $10,305 pre-Code Hip cohort to $11,744 +/- $4,174 per patient in the post-Code Hip cohort (p = 0.02). Conclusions: Implementation of our Code Hip protocol, which invokes a multidisciplinary approach to the elderly patient with a fragility hip fracture, is associated with shorter times from presentation to surgery, increased ability to ambulate post-operatively, decreased short term post-operative complication, and decreased hospital costs. Level of Evidence: Therapeutic Level III
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Affiliation(s)
- Richard J VanTienderen
- Department of Orthopaedic Surgery, Texas Tech, El Paso, TX, USA.,Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA.,Department of Orthopaedic Surgery, Irwin Army Community Hospital, Fort Riley, KS.,Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Kyle Bockelman
- Department of Orthopaedic Surgery, Texas Tech, El Paso, TX, USA.,Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Rami Khalifa
- Department of Orthopaedic Surgery, Texas Tech, El Paso, TX, USA
| | - Michael S Reich
- Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Adam Adler
- Department of Orthopaedic Surgery, Texas Tech, El Paso, TX, USA
| | - Mai P Nguyen
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA.,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
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13
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Keramari G, Moisoglou I, Meimeti E, Galanis P, Fradelos EC, Papathanasiou IV. Clinical and Demographic Predictors of Health-Related Quality of Life After Orthopedic Surgery With Implant Placement. Cureus 2022; 14:e21348. [PMID: 35186604 PMCID: PMC8849382 DOI: 10.7759/cureus.21348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Orthopedic surgeries can rehabilitate injuries and at the same time improve the patients’ quality of life. The study aimed to assess patients’ health-related quality of life (HRQOL) six months after an orthopedic surgery with implant placement. Materials and methods: A cross-sectional study with the use of a structured questionnaire among 103 patients was conducted. The 36-Item Short Form Survey (SF-36) questionnaire was used to evaluate patients’ quality of life. Results:According to the findings of the multivariate linear regression analysis, low age, marital status (married in comparison to unmarried/ divorcees/widows), reduced intensity of the pain, and low educational attainment were associated with a better quality of life. Furthermore, the patients who were living with another person and the patients who underwent surgery on a part of the body other than the hip presented better quality of life. The results of the multivariate analysis explained 33%-67% of the variance of the SF-36 HRQOL. Conclusion: Measuring quality of life is a valuable asset that helps to reveal the frail patient groups, in which health professionals will prioritize their care and the state in turn will design primary care services to meet their needs after discharge from the hospital.
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14
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Salvador-Marín J, Ferrández-Martínez FJ, Lawton CD, Orozco-Beltrán D, Martínez-López JF, Kelly BT, Marzo-Campos JC. Efficacy of a multidisciplinary care protocol for the treatment of operated hip fracture patients. Sci Rep 2021; 11:24082. [PMID: 34916570 PMCID: PMC8677748 DOI: 10.1038/s41598-021-03415-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/16/2021] [Indexed: 12/13/2022] Open
Abstract
To assess the effects of a multidisciplinary care protocol on cost, length of hospital stay (LOS), and mortality in hip-fracture-operated patients over 65 years. Prospective cohort study between 2011 and 2017. The unexposed group comprised patients who did not receive care according to the multidisciplinary protocol, while the exposed group did. Variables analyzed were demographics, medical comorbidities, treatment, blood parameters, surgical delay, LOS, re-admissions, mortality, and a composite outcome considering in-hospital mortality and/or LOS > 10 days. We performed a Poisson regression and cost analysis. The cohort included 681 patients: 310 unexposed and 371, exposed. The exposed group showed a shorter surgical delay (3.0 vs. 3.6 days; p < 0.001), and a higher proportion received surgery within 48 h (46.1% vs. 34.2%, p = 0.002). They also showed lower rates of 30-day readmission (9.4% vs. 15.8%, p = 0.012), 30-day mortality (4.9% vs. 9.4%, p = 0.021), in-hospital mortality (3.5% vs. 7.7%; p = 0.015), and LOS (8.4 vs. 9.1 days, p < 0.001). Multivariable analysis showed a protective effect of the protocol on the composite outcome (risk ratio 0.62, 95% CI 0.48-0.80, p < 0.001). Hospital costs were reduced by EUR 112,153.3. A multidisciplinary shared care protocol was associated with a reduction in the LOS, surgical delay, 30-day readmissions, and in-hospital and 30-day mortality, in hip-fracture-operated patients.
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Affiliation(s)
- Jorge Salvador-Marín
- Orthopedic Surgery and Traumatology Service, Sant Joan d'Alacant University Hospital, Alicante, Spain
| | | | - Cort D Lawton
- Hospital for Special Surgery, Sports Medicine Institute, 535 East 70th Street, New York, NY, 10021, USA
| | | | | | - Bryan T Kelly
- Hospital for Special Surgery, Sports Medicine Institute, 535 East 70th Street, New York, NY, 10021, USA
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15
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Rubenstein W, Barry J, Rogers S, Grace TR, Tay B, Ward D. Reducing Time to Surgery for Hip Fragility Fracture Patients: A Resident Quality Improvement Initiative. J Healthc Qual 2021; 43:e77-e83. [PMID: 33239508 DOI: 10.1097/jhq.0000000000000288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT As part of an institutional quality improvement (QI) initiative for the 2018-2019 academic year, orthopedic residents at our tertiary center were incentivized to bring over 75% of hip fracture patients with American Society of Anesthesiologists (ASA) Class 2 or less to surgery in under 24 hours, compared to the baseline rate of 55.9%. The time between admission and surgery for hip fracture patients with ASA class 2 or less was prospectively recorded. At the end of the study period, a retrospective comparison was performed between patients treated before and after the resident QI initiative. The percentage of patients who underwent surgery within 24 hours of admission increased significantly in the Study Cohort compared to the Baseline Cohort (78.6% vs. 55.9%, p = .037). Length of stay was shorter in the Study Cohort compared to the Baseline Cohort (3 days vs. 4 days, p = .01), whereas readmissions (3.6% vs. 4.4%, p = .85) and discharges to skilled nursing facilities (60.7% vs. 57.4%, p = .76) were comparable between both cohorts. A goal-directed, resident-led QI initiative was associated with a significantly increased percentage of hip fragility fracture patients who underwent surgery in less than 24 hours.
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16
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Lyons M, McGregor PC, Pinzur MS, Adams W, Wilkos-Prostran L. Risk Reduction and Perioperative Complications in Patients With Diabetes and Multiple Medical Comorbidities Undergoing Charcot Foot Reconstruction. Foot Ankle Int 2021; 42:902-909. [PMID: 33629589 DOI: 10.1177/1071100721995422] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Modern patient safety programs focus on medical optimization of patients prior to surgery, regional anesthesia when possible, and hospitalist-orthopedic co-management during the perioperative period. METHODS Eighty-five consecutive patients with diabetes and multiple medical comorbidities underwent surgical reconstruction for acquired deformities secondary to Charcot foot arthropathy with circular ring fixation between 2016 and 2019. All patients participated in a standardized risk reduction program that included medical optimization prior to surgery, regional anesthesia whenever possible, and hospitalist-orthopedic co-management during the perioperative period. Charts were retrospectively reviewed for medical comorbidities, complications, and length of stay. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator was used to retrospectively calculate their predicted perioperative risk. RESULTS On multivariable analysis, longer lengths of stay were associated with low preoperative hemoglobin values (rate ratio [RR], 1.36; P = .01) and congestive heart failure (RR, 1.42; P = .02). There were 22 (26%) complications, though only 10 (12%) were serious. These included acute kidney injury (n = 6), sepsis (n = 2), 1 cardiac event, and 1 pulmonary embolism. Overall, the accuracy of predicting a complication using the ACS NSQIP Risk Calculator was 74% (95% CI, 63%-85%), which was comparable to the accuracy of predicting a complication using only patients' congestive heart failure and pin-tract infection statuses (c = 74%, 95% CI, 62%-86%). DISCUSSION Medical optimization of patients with diabetes and multiple medical comorbidities prior to elective complex reconstruction orthopedic surgery allows the surgery to be performed with a predictable risk for perioperative complications. Preoperative anemia and congestive heart failure are associated with longer hospitalizations in this patient group. The ACS NSQIP Risk Calculator appears to be a reliable predictor of complications during the perioperative period. This study demonstrates that reconstructive surgery in this complex patient population can be accomplished with a reasonable exposure to perioperative risk. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Madeline Lyons
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Patrick Cole McGregor
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Michael S Pinzur
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
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17
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A bibliometric analysis of orthogeriatric care: top 50 articles. Eur J Trauma Emerg Surg 2021; 48:1673-1682. [PMID: 34114053 PMCID: PMC9192394 DOI: 10.1007/s00068-021-01715-y] [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] [Received: 01/29/2021] [Accepted: 05/26/2021] [Indexed: 11/22/2022]
Abstract
Background Population is ageing and orthogeriatric care is an emerging research topic. Purpose This bibliometric review aims to provide an overview, to investigate the status and trends in research in the field of orthogeriatric care of the most influential literature. Methods From the Core Collection databases in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to orthogeriatric care were identified in December 2020 using a multistep approach. A total of 50 articles were included and analysed in this bibliometric review. Results The 50 most cited articles were published between 1983 and 2017. The number of total citations per article ranged from 34 to 704 citations (mean citations per article: n = 93). Articles were published in 34 different journals between 1983 and 2017. In the majority of publications, geriatricians (62%) accounted for the first authorship, followed by others (20%) and (orthopaedic) surgeons (18%). Articles mostly originated from Europe (76%), followed by Asia–pacific (16%) and Northern America (8%). Key countries (UK, Sweden, and Spain) and key topic (hip fracture) are key drivers in the orthogeriatric research. The majority of articles reported about therapeutic studies (62%). Conclusion This bibliometric review acknowledges recent research. Orthogeriatric care is an emerging research topic in which surgeons have a potential to contribute and other topics such as intraoperative procedures, fractures other than hip fractures or elective surgery are related topics with the potential for widening the field to research.
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18
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Reddy AK, Anderson JM, Gray HM, Fishbeck K, Vassar M. Clinical Trial Registry Use in Orthopaedic Surgery Systematic Reviews. J Bone Joint Surg Am 2021; 103:e41. [PMID: 33983151 DOI: 10.2106/jbjs.20.01743] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Results from systematic reviews and meta-analyses, which have the highest level of evidence (Level I), often drive clinical decision-making and health policy. Often, unpublished trial data are omitted from systematic reviews, raising concerns about the extent of the reliability and validity of results that have been drawn from systematic reviews. We aimed to determine the extent to which systematic review authors include searches of clinical trial registries for unpublished data when conducting systematic reviews in orthopaedic surgery. METHODS Systematic reviews and/or meta-analyses were gathered from the top 5 orthopaedic surgery journals based on the h5-index from Google Scholar Metrics. Systematic reviews that had been published in the Cochrane Database of Systematic Reviews, which requires the inclusion of a clinical trial registry search, served as controls. For the primary outcome, each systematic review from the top 5 orthopaedic journals was screened to determine whether the authors of each study searched for unpublished data in clinical trial registries. We then compared the rate of registry searches with those in the control group. For the secondary analysis, a search of ClinicalTrials.gov was performed for unpublished trial data for 100 randomized systematic reviews. RESULTS All 38 of the Cochrane systematic reviews (100%) included clinical trial registry searches, while the top 5 orthopaedic journals had only 31 of 480 studies (6.5%) that looked at clinical trial registries. The secondary analysis yielded 59 of 100 systematic review articles (59.0%) that could have included unpublished clinical trial data from ≥1 studies to their sample. CONCLUSIONS Systematic reviews that have been published in the top orthopaedic surgery journals seldom included a search for unpublished clinical trial data. CLINICAL RELEVANCE The exclusion of clinical trial registry searches potentially contributes to publication bias within the orthopaedic literature. Moving forward, systematic review authors should include clinical trial registry searches for unpublished clinical trial data to provide the most accurate representation of the available evidence for systematic reviews and meta-analyses.
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Affiliation(s)
- Arjun K Reddy
- Office of Medical Student Research (A.K.R., J.M.A., H.M.G., and M.V.) and Department of Psychiatry and Behavioral Sciences (M.V.), Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma
| | - J Michael Anderson
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Harrison M Gray
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Keith Fishbeck
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Matt Vassar
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
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Cang D, Zou G, Yang C, Shen X, Li F, Wu Y, Ji B. Dencichine prevents ovariectomy-induced bone loss and inhibits osteoclastogenesis by inhibiting RANKL-associated NF-κB and MAPK signaling pathways. J Pharmacol Sci 2021; 146:206-215. [PMID: 34116734 DOI: 10.1016/j.jphs.2021.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/05/2021] [Accepted: 04/19/2021] [Indexed: 02/06/2023] Open
Abstract
AIMS To investigate the effect of dencichine on osteoclastogenesis in vivo and in vitro. METHODS RANKL-induced osteoclastogenesis were treated with different concentrations of dencichine. Pit forming assays were applied to evaluate the degree of bone resorption. Osteoclastogenic markers were detected by real-time quantitative PCR (RT-qPCR) and Western blot. Micro CT was conducted to investigate the effects of dencichine on osteoclastogenesis in ovariectomized (OVX) mice. RESULTS Dencichine suppressed osteoclastogenesis through the inhibition of phosphorylation of p65, p50 (NF-κB pathway), p38, ERK and JNK (MAPKs pathway) in vitro. Furthermore, dencichine inhibited the function of osteoclasts in a dose-dependent manner. In addition, the expression levels of the nuclear factor of activated T cells 1 (NFATc1) and osteoclastogenesis markers were decreased by dencichine, including MMP-9, Cathepsin K (CTSK), Tartrate-Resistant Acid Phosphatase (TRAP), C-FOS, dendritic cell specific transmembrane protein (DC-STAMP). In vivo data proved that dencichine alleviated ovariectomy-induced bone loss and osteoclastogenesis in mice. CONCLUSION Our results demonstrate that dencichine alleviates OVX-induced bone loss in mice and inhibits RANKL-mediated osteoclastogenesis via inhibition of NF-κB and MAPK pathways in vitro, suggesting that dencichine might serve as a promising candidate for treatment of bone loss diseases, including PMOP and rheumatoid arthritis.
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Affiliation(s)
- Dingwei Cang
- Department of Orthopaedics, Yancheng City No.1 People's Hospital, Yancheng, Jiangsu 224006, China
| | - Guoyou Zou
- Department of Orthopaedics, Yancheng City No.1 People's Hospital, Yancheng, Jiangsu 224006, China
| | - Chi Yang
- Department of R& D, Rochen Pharma Co., Ltd, Shanghai 201514, China
| | - Xiaofei Shen
- Department of Orthopaedics, Yancheng City No.1 People's Hospital, Yancheng, Jiangsu 224006, China
| | - Feng Li
- Department of Orthopaedics, Yancheng City No.1 People's Hospital, Yancheng, Jiangsu 224006, China
| | - Ya Wu
- Department of Orthopaedics, Yancheng City No.1 People's Hospital, Yancheng, Jiangsu 224006, China.
| | - Biao Ji
- Department of Orthopaedics, Yancheng City No.1 People's Hospital, Yancheng, Jiangsu 224006, China.
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20
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Impact of Frailty and Malnutrition on Outcomes After Surgical Fixation of Lower Extremity Fractures in Young Patients. J Orthop Trauma 2021; 35:e126-e133. [PMID: 32910628 DOI: 10.1097/bot.0000000000001952] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Evaluate the relationship of nutrition parameters and the modified frailty index (mFI) on postsurgical complications within a young patient population sustaining lower extremity orthopaedic trauma. DESIGN Retrospective observational cohort study. SETTING Urban, American College of Surgeons-Verified, Level-1, Trauma Center. PATIENTS/PARTICIPANTS Seventeen-thousand one hundred nine adult patients under the age of 65 sustaining lower extremity fractures undergoing operative intervention from 2006 to 2018. MAIN OUTCOME MEASURES On admission, mFI and albumin levels were obtained, as well as complication data. Statistical analysis was used to analyze the association between frailty, malnutrition, and postoperative complications. Patients were stratified, healthy (mFI ≤1, albumin ≥3.5 g/dL), malnourished (mFI ≤1, albumin <3.5 g/dL), frail (mFI ≥2, albumin ≥3.5 g/dL), and frail and malnourished (mFI ≥2, albumin <3.5 g/dL). RESULTS 60.4% of patients were healthy, 18.8% were malnourished, 11.7% were frail, and 9.0% were frail and malnourished. Frailty and/or malnourishment on admission predicted significantly higher odds of postoperative complications and mortality when compared with healthy patients. Frailty and malnourishment in conjunction predicted a significantly higher odds ratio of 1.46 (1.22-1.75) for developing postoperative complications when compared with the only malnourished. This was also observed when compared with the only frail (odd ratio: 1.61, P < 0.001); however, there was also a 2.72 (P < 0.001) increased odds of mortality. CONCLUSIONS Frailty and malnutrition in conjunction predicts a subset of patients with a higher risk of postoperative complications beyond that of frailty or malnutrition in isolation. Identification of these physiological states on admission allows for interventional opportunities during hospitalization. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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21
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Hoehmann CL, Thompson J, Long M, DiVella M, Munnangi S, Ruotolo C, Galos DK. Unnecessary Preoperative Cardiology Evaluation and Transthoracic Echocardiogram Delays Time to Surgery for Geriatric Hip Fractures. J Orthop Trauma 2021; 35:205-210. [PMID: 33079839 DOI: 10.1097/bot.0000000000001941] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Delays to surgery for patients with geriatric hip fracture are associated with increased morbidity and mortality. The American Heart Association (AHA) and American College of Cardiology (ACC) Clinical Practice Guidelines (CPG) were created to standardize preoperative cardiology consultation and transthoracic echocardiogram (TTE). This study's purpose is to determine if these practices are over used and delay time to surgery at a safety net hospital. DESIGN Retrospective review. SETTING Level 1 trauma center and safety net hospital. PATIENTS Charts were reviewed for indications of preoperative cardiology consultation or TTE per AHA and ACC CPG in 412 patients admitted with geriatric hip fracture. INTERVENTION Criteria meeting the AHA/ACC guidelines for preoperative TTE and cardiac consultations. MAIN OUTCOME MEASUREMENTS Time to surgical intervention. RESULTS Despite 17.7% of patients meeting criteria, 44.4% of patients received cardiology consultation. Of those patients, 33.8% met criteria for receiving preoperative TTE but 89.4% received one. Time to surgery was greater for patients receiving cardiology consultation (25.42 ± 14.54 hours, P-value <0.001) versus those who did not (19.27 ± 13.76, P-value <0.001) and for those receiving preoperative TTE (26.00 ± 15.33 hours, P-value <0.001) versus those who did not (18.94 ± 12.92, P-value <0.001). CONCLUSIONS Cardiology consultation and TTE are frequently used against AHA/ACC CPG. These measures are expensive and delay surgery, which can increase morbidity and mortality. These findings persisted despite limited resources available in a safety net hospital. Hospitals should improve adherence to CPG, or modify protocols. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher L Hoehmann
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY; and
| | - Jeffrey Thompson
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY; and
| | - Mitchell Long
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY; and
| | - Michael DiVella
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY; and
| | - Swapna Munnangi
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Charles Ruotolo
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY; and
| | - David K Galos
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY; and
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22
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Häkkinen U, Sund R. What works? The association of organisational structure, reforms and interventions on efficiency in treating hip fractures. Soc Sci Med 2021; 274:113611. [PMID: 33685757 DOI: 10.1016/j.socscimed.2020.113611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/06/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Many studies indicate huge regional and hospital-level differences in health care performance. In order to increase health system efficiency, it is important to know the reasons behind the differences and analyse the effects of those factors that can be affected by health policy. The aim of this study is to evaluate and compare various organisational factors and health policy interventions in the performance of the care of hip fracture patients in Finland. We analysed the relationship between organisational factors (hospital volume, regional concentration of treatments) and performance. The focus is also on the effects of two macro-level organisational changes (integration of production of all health and social services in one provider) and two micro-level interventions (integrated patient pathway interventions, aiming to discharge patients as soon as possible). Our results indicate that macro-level integration of the production or financing of health and social services, bigger hospital volumes, and the concentration of the acute phase of care in fewer hospitals within hospital districts were not consistently related to efficiency in the care of hip fracture patients. Instead, efficiency can be increased using micro-level interventions aiming to coordinate patient pathways at the patient group level.
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Affiliation(s)
- Unto Häkkinen
- Centre for Health and Social Economics (CHESS), Finnish Institute for Health and Welfare, Finland.
| | - Reijo Sund
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Merits of Surgical Comanagement of Patients With Hip Fracture by Dedicated Orthopaedic Hospitalists. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202103000-00003. [PMID: 33720101 PMCID: PMC7954368 DOI: 10.5435/jaaosglobal-d-20-00231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/30/2021] [Indexed: 11/21/2022]
Abstract
Rotating medical consultants, hospitalists or geriatricians, are involved in the care of patients with hip fracture, often after medical complications have already occurred. In August 2012, we implemented a unique surgical comanagement (SCM) model in which the same Internal Medicine hospitalists are dedicated year-round to the orthopaedic surgery service. We examine whether this SCM model was associated with a decrease in medical complications, length of stay, and inpatient mortality in patients with hip fracture admitted at our institution, compared with the previous model.
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Clinical Practice Guidelines on Ordering Echocardiography Before Hip Fracture Repair Perform Differently from One Another. HSS J 2020; 16:378-382. [PMID: 33376460 PMCID: PMC7749896 DOI: 10.1007/s11420-020-09762-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteoporotic hip fractures typically occur in frail elderly patients with multiple comorbidities, and repair of the fracture within 48 h is recommended. Pre-operative evaluation sometimes involves transthoracic echocardiography (TTE) to screen for heart disease that would alter peri-operative management, yet TTE can delay surgery and is resource intensive. Evidence suggests that the use of clinical practice guidelines (CPGs) can improve care. It is unclear which guidelines are most useful in hip fracture patients. QUESTIONS/PURPOSES We sought to evaluate the performance of the five commonly used CPGs in determining which patients with acute fragility hip fracture require TTE and to identify common features among high-performing CPGs that could be incorporated into care pathways. PATIENTS AND METHODS We performed a retrospective study of medical records taken from an institutional database of osteoporotic hip fracture patients to identify those who underwent pre-operative TTE. History and physical examination findings were recorded; listed indications for TTE were compared against those given in five commonly used CPGs: those from the American College of Cardiology/American Heart Association (ACC/AHA), the British Society of Echocardiography (BSE), the European Society of Cardiology and the European Society of Anaesthesiology(ESC/ESA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Scottish Intercollegiate Guidelines Network (SIGN). We then calculated the performance (sensitivity and specificity) of the CPGs in identifying patients with TTE results that had the potential to change peri-operative management. RESULTS We identified 100 patients who underwent pre-operative TTE. Among those, the patients met criteria for TTE 32 to 66% of the time, depending on the CPG used. In 14% of those receiving TTE, the test revealed new information with the potential to change management. The sensitivity of the CPGs ranged from 71% (ESC/ESA and AAGBI) to 100% (ACC/AHA and SIGN). The CPGs' specificity ranged from 37% (BSE) to 74% (ESC/ESA). The more sensitive guidelines focused on a change in clinical status in patients with known disease or clinical concern regarding new-onset disease. CONCLUSIONS In patients requiring fixation of osteoporotic hip fractures, TTE can be useful for identifying pathologies that could directly change peri-operative management. Our data suggest that established CPGs can be safely used to identify which patients should undergo pre-operative TTE with low risk of missed pathology.
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Shi BY, Hannan CV, Jang JM, Ali I, Srikumaran U. Association Between Delays in Radiography and Surgery With Hip Fracture Outcomes in Elderly Patients. Orthopedics 2020; 43:e609-e615. [PMID: 32841359 DOI: 10.3928/01477447-20200812-06] [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: 04/02/2019] [Accepted: 08/05/2019] [Indexed: 02/03/2023]
Abstract
Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is "surgery delay" (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P=.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [Orthopedics. 2020;43(6):e609-e615.].
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Vincent C, Cram P. Surgical Comanagement for Hip Fracture: Time for a Randomized Trial. J Hosp Med 2020; 15:510-511. [PMID: 32804616 PMCID: PMC7518137 DOI: 10.12788/jhm.3415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Corita Vincent
- Department of Medicine, University of Toronto, Toronto,
Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto,
Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto,
Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto,
Canada
- Corresponding Author: Peter Cram, MD, MBA; ; Telephone: 647-767-5508; Twitter: @pmcram
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Peng K, Yang M, Tian M, Chen M, Zhang J, Wu X, Ivers R, Si L. Cost-effectiveness of a multidisciplinary co-management program for the older hip fracture patients in Beijing. Osteoporos Int 2020; 31:1545-1553. [PMID: 32219498 DOI: 10.1007/s00198-020-05393-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
UNLABELLED The multidisciplinary co-management program for geriatric patients with hip fracture is cost-effective in the Chinese population and it has the potential to be scaled up in China. INTRODUCTION The study aimed to investigate the cost-effectiveness of a multidisciplinary co-management program for patients with hip fracture in China. METHODS Hip fracture patients who were admitted to an orthopedic hospital in Beijing were included in the multidisciplinary co-management program. The cost-effectiveness of intervention was evaluated compared to the conventional management. A Markov microsimulation model was developed to simulate lifetime costs and effectiveness. Costs including intervention, hospitalization, medications, and long-term care costs were expressed using 2019 US dollars and the healthcare perspective was adopted. Effectiveness was evaluated using both 1-year mortality-averted and quality-adjusted life years (QALYs). Costs and effectiveness were discounted at 5% per annum. The willingness-to-pay (WTP) threshold was set at $26,481 per QALY gained which was three times gross domestic product (GDP) per capita in China. One-way and probabilistic sensitivity analyses were conducted. RESULTS The lifetime cost for the conventional management (n = 1839) and intervention group (n = 1192) was $11,975 and $13,309 respectively. The lifetime QALYs were 2.38 and 2.45 years and the first-year mortality was 17.8% and 16.1%. The incremental cost-effectiveness ratio was $19,437 per QALY gained or $78,412 per 1-year mortality-averted. Given the Chinese WTP threshold, the intervention had a 78% chance being cost-effective. The cost-effectiveness of the intervention was sensitive to cost of intervention and the proportion of patients who underwent surgery within 48 h. CONCLUSIONS The multidisciplinary co-management program for patients with hip fracture is cost-effective and it has the potential to be scaled up in the Chinese population.
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Affiliation(s)
- K Peng
- School of Public Health, The University of Sydney, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, NSW, 2042, Australia
| | - M Yang
- Department of Orthopedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - M Tian
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, NSW, 2042, Australia
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - M Chen
- School of Health Policy & Management, Nanjing Medical University, Nanjing, China
| | - J Zhang
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
- School of Public Health and Community Medicine, UNSW, Kensington, Australia
| | - X Wu
- Department of Orthopedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - R Ivers
- School of Public Health, The University of Sydney, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, NSW, 2042, Australia
- School of Public Health and Community Medicine, UNSW, Kensington, Australia
| | - L Si
- The George Institute for Global Health, University of New South Wales, Level 5, 1 King St, Newtown, NSW, 2042, Australia.
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A 3i hip fracture liaison service with nurse and physician co-management is cost-effective when implemented as a standard clinical program. Arch Osteoporos 2020; 15:113. [PMID: 32699946 DOI: 10.1007/s11657-020-00781-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/30/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture. PURPOSE/INTRODUCTION To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice. METHODS The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses. RESULTS One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7-63.5) H-FLS patients relative to 20.9% (95% CI: 13.3-28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%). CONCLUSION A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings.
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Abstract
BACKGROUND The aim of our study was to explore the impact of elective-surgery deferment on the United States health-care system and subsequent recovery after COVID-19 containment. Using an orthopaedic elective surgery model, we aimed to answer the following: (1) What is the expected recovery time until the health-care system is back to nearly full capacity for performing elective surgery? (2) What will be the expected backlog of elective surgery over time? (3) How should health care change to address the backlog? METHODS A Monte Carlo stochastic simulation-based analysis was performed to forecast the post-pandemic volume of elective, inpatient total joint arthroplasty and spinal fusion surgical cases. The cumulative backlog was calculated and analyzed. We tested model assumptions with sensitivity analyses. RESULTS Assuming that elective orthopaedic surgery resumes in June 2020, it will take 7, 12, and 16 months-in optimistic, ambivalent, and pessimistic scenarios, respectively-until the health-care system can perform 90% of the expected pre-pandemic forecasted volume of surgery. In the optimistic scenario, there will be a cumulative backlog of >1 million surgical cases at 2 years after the end of elective-surgery deferment. CONCLUSIONS The deferment of elective surgical cases during the SARS-CoV-2 pandemic will have a lasting impact on the United States health-care system. As part of disaster mitigation, it is critical to start planning for recovery now.
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Affiliation(s)
- Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | | | - Shruti Aggarwal
- Cornea and Refractive Surgery, Katzen Eye Institute, Baltimore, Maryland
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Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in the Elderly: A Cost-Effectiveness Analysis. J Orthop Trauma 2020; 34:348-355. [PMID: 32398470 DOI: 10.1097/bot.0000000000001747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of screw fixation versus hemiarthroplasty for nondisplaced femoral neck fractures in low-demand elderly patients. METHODS We constructed a Markov decision model using a low-demand, 80-year-old patient as the base case. Costs, health-state utilities, mortality rates, and transition probabilities were obtained from published literature. The simulation model was cycled until all patients were deceased to estimate lifetime costs and quality-adjusted life years (QALYs). The primary outcome was the incremental cost-effectiveness ratio with a willingness-to-pay threshold set at $100,000 per QALY. We performed sensitivity analyses to assess our parameter assumptions. RESULTS For the base case, hemiarthroplasty was associated with greater quality of life (2.96 QALYs) compared with screw fixation (2.73 QALYs) with lower cost ($23,467 vs. $25,356). Cost per QALY for hemiarthroplasty was $7925 compared with $9303 in screw fixation. Hemiarthroplasty provided better outcomes at lower cost, indicating dominance over screw fixation. CONCLUSIONS Hemiarthroplasty is a cost-effective option compared with screw fixation for the treatment of nondisplaced femoral neck fractures in the low-demand elderly. Medical comorbidities and other factors that impact perioperative mortality should also be considered in the treatment decision. LEVEL OF EVIDENCE Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Anighoro K, Bridges C, Graf A, Nielsen A, Court T, McKeon J, Schwab JM. From ER to OR: Results After Implementation of Multidisciplinary Pathway for Fragility Hip Fractures at a Level I Trauma Center. Geriatr Orthop Surg Rehabil 2020; 11:2151459320927383. [PMID: 32547814 PMCID: PMC7249548 DOI: 10.1177/2151459320927383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/21/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction: Hip fractures are one of the most common indications for hospitalization and orthopedic
intervention. Fragility hip fractures are frequently associated with multiple
comorbidities and thus may benefit from a structured multidisciplinary approach for
treatment. The purpose of this article was to retrospectively analyze patient outcomes
after the implementation of a multidisciplinary hip fracture pathway at a level I trauma
center. Materials and Methods: A retrospective review of 263 patients over the age of 65 with fragility hip fracture
was performed. Time to surgery, hospital length of stay, Charlson Comorbidity Index
(CCI), American Society of Anesthesiologists, complication rates, and other clinical
outcomes were compared between patients treated in the year before and after
implementation of a multidisciplinary hip fracture pathway. Results: Timing to OR, hospital length of stay, and complication rates did not differ between
pre- and postpathway groups. The postpathway group had a greater CCI score (pre: 3.10 ±
3.11 and post: 3.80 ± 3.18). Fewer total blood products were administered in the
postpathway group (pre: 1.5 ± 1.8 and post: 0.8 ± 1.5). Discussion: The maintenance of clinical outcomes in the postpathway cohort, while having a greater
CCI, indicates the same quality of care was provided for a more medically complex
patient population. With a decrease in total blood products in the postpathway group,
this highlights the economic importance of perioperative optimization that can be
obtained in a multidisciplinary pathway. Conclusion: Implementation of a multidisciplinary hip fracture pathway is an effective strategy for
maintaining care standards for fragility hip fracture management, particularly in the
setting of complex medical comorbidities.
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Affiliation(s)
- Kenoma Anighoro
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Carla Bridges
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alexander Graf
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alexander Nielsen
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tannor Court
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jack McKeon
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joseph M Schwab
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Sinvani L, Mendelson DA, Sharma A, Nouryan CN, Fishbein JS, Qiu MG, Zeltser R, Makaryus AN, Wolf-Klein GP. Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study. J Am Geriatr Soc 2020; 68:1690-1697. [PMID: 32526816 DOI: 10.1111/jgs.16555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 03/04/2020] [Accepted: 03/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN Retrospective chart review. SETTING Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality. RESULTS Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE. CONCLUSION This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690-1697, 2020.
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Affiliation(s)
- Liron Sinvani
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Center for Health Innovations Research, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Daniel A Mendelson
- Department of Medicine, Division of Geriatrics and Aging, University of Rochester, Rochester, New York, USA
| | - Ankita Sharma
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA
| | - Christian N Nouryan
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Center for Health Innovations Research, Feinstein Institutes for Medical Research, Manhasset, New York, USA.,Zucker School of Medicine at Hofstra/Northwell, Hempstead,, New York, USA
| | - Joanna S Fishbein
- Biostatistics Division, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Michael G Qiu
- Department of Medicine, Northwell Health System, Manhasset, New York, USA
| | - Roman Zeltser
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Cardiology, Nassau University Medical Center, East Meadow, New York, USA
| | - Amgad N Makaryus
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Cardiology, Nassau University Medical Center, East Meadow, New York, USA
| | - Gisele P Wolf-Klein
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Zucker School of Medicine at Hofstra/Northwell, Hempstead,, New York, USA
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Artificial Neural Network and Cox Regression Models for Predicting Mortality after Hip Fracture Surgery: A Population-Based Comparison. ACTA ACUST UNITED AC 2020; 56:medicina56050243. [PMID: 32438724 PMCID: PMC7279348 DOI: 10.3390/medicina56050243] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 01/31/2023]
Abstract
This study purposed to validate the accuracy of an artificial neural network (ANN) model for predicting the mortality after hip fracture surgery during the study period, and to compare performance indices between the ANN model and a Cox regression model. A total of 10,534 hip fracture surgery patients during 1996–2010 were recruited in the study. Three datasets were used: a training dataset (n = 7374) was used for model development, a testing dataset (n = 1580) was used for internal validation, and a validation dataset (1580) was used for external validation. Global sensitivity analysis also was performed to evaluate the relative importances of input predictors in the ANN model. Mortality after hip fracture surgery was significantly associated with referral system, age, gender, urbanization of residence area, socioeconomic status, Charlson comorbidity index (CCI) score, intracapsular fracture, hospital volume, and surgeon volume (p < 0.05). For predicting mortality after hip fracture surgery, the ANN model had higher prediction accuracy and overall performance indices compared to the Cox model. Global sensitivity analysis of the ANN model showed that the referral to lower-level medical institutions was the most important variable affecting mortality, followed by surgeon volume, hospital volume, and CCI score. Compared with the Cox regression model, the ANN model was more accurate in predicting postoperative mortality after a hip fracture. The forecasting predictors associated with postoperative mortality identified in this study can also bae used to educate candidates for hip fracture surgery with respect to the course of recovery and health outcomes.
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Meinberg E, Ward D, Herring M, Miclau T. Hospital-based Hip fracture programs: Clinical need and effectiveness. Injury 2020; 51 Suppl 2:S2-S4. [PMID: 32386840 DOI: 10.1016/j.injury.2020.03.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/29/2020] [Indexed: 02/02/2023]
Abstract
Hospital-based hip fracture programs are essential for effective, efficient care of elderly patients who have sustained hip fractures. Many of the gains in outcomes and patient survival are a result of such integrated care models. We review the rationale, elements, and benefits of such programs across the spectrum of inpatient centers, including low-volume and high-volume community hospitals and trauma centers.
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Affiliation(s)
- Eric Meinberg
- University of California, San Francisco Department of Orthopaedic Surgery, San Francisco, US; Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, US
| | - Derek Ward
- University of California, San Francisco Department of Orthopaedic Surgery, San Francisco, US
| | - Matthew Herring
- University of California, San Francisco Department of Orthopaedic Surgery, San Francisco, US; Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, US
| | - Theodore Miclau
- University of California, San Francisco Department of Orthopaedic Surgery, San Francisco, US; Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, US.
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Navarro SM, Frankel WC, Haeberle HS, Billow DG, Ramkumar PN. Evaluation of the volume-value relationship in hip fracture care using evidence-based thresholds. Hip Int 2020; 30:347-353. [PMID: 30912450 DOI: 10.1177/1120700019837130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies have shown high-volume surgeons and hospitals deliver higher value care. The aims of this study were to establish meaningful thresholds defining high-volume surgeons and hospitals performing hip fracture surgery and to examine the relative market share of hip fracture cases using these surgeon and hospital strata. METHODS We performed a retrospective cohort study in a database of 103,935 patients undergoing hip fracture repair. We generated stratum-specific likelihood ratio (SSLR) models of a receiver operating characteristic (ROC) curve using length of stay (LOS) and cost value metrics. Volume thresholds predictive of decreased LOS and costs for surgeons and hospitals were identified. RESULTS Analysis of annual surgeon hip fracture volume produced two volume categories for LOS and cost: 0-30 (low) and 31+ (high). Analysis of LOS by annual hospital hip fracture volume produced strata at: 0-59 (low), 60-146 (medium), and 147 or more (high). Analysis of cost by annual hospital volume produced strata at: 0-125 (low) and 126+ (high). LOS and cost both decreased significantly (p < 0.05) in progressively higher volume categories. Low-volume surgeons performed the majority of hip fracture cases, although they were performed at medium- or high-volume centres. CONCLUSIONS This study demonstrates a direct relationship between volume and value, translating to improvement in hip fracture care delivery for both surgeons and hospitals. Higher volume hospitals while lower volume surgeons perform the majority of hip fracture cases, suggesting optimisation opportunities. However, systems-based practices at the hospital level likely drive value to a greater extent than individual surgeons.
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Affiliation(s)
- Sergio M Navarro
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - William C Frankel
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Heather S Haeberle
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Damien G Billow
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Prem N Ramkumar
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Surgical comanagement (SCM), in which surgeons and hospitalists share responsibility of care for surgical patients, has been increasingly utilized. In August 2012, we implemented SCM in Orthopedic and Neurosurgery services in which the same Internal Medicine hospitalists are dedicated year round to each of these surgical services to proactively prevent and manage medical conditions. In this article, we evaluate if SCM was associated with continued improvement in patient outcomes between 2012 and 2018 in Orthopedic and Neurosurgery services at our institution. We conducted regression analysis on 26,380 discharges to assess yearly change in our outcomes. Since 2012, the odds of patients with ≥1 medical complication decreased by 3.8% per year (P = .01), the estimated length of stay decreased by 0.3 days per year (P < .0001), and the odds of rapid response team calls decreased by 12.2% per year (P = .001). Estimated average direct cost savings were $3,424 per discharge.
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Affiliation(s)
- Nidhi Rohatgi
- Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Yingjie Weng
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Neera Ahuja
- Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
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Abstract
Despite the same latitude on earth, Israel and South Africa have a wide variety of healthcare systems and approaches. Israel is a developed country with life expectancy within the first decile of the modern world. South Africa is a developing country where available resources and health care varies greatly across the country. Israeli policy makers have realized in 1999 the importance of early surgery for hip fractures as the single most important factor contributing to decreased mortality. After an introduction of a newer reimbursement system in 2004, and public advertising of early hip fracture treatment as a quality tag for hospitals, in more than 85% of the cases patients are operated on early (within 8 hours) with a significant decrease in mortality. However, other issues such as patient preparation, rehabilitation, and prevention are still at their beginning. South Africa deals with significant challenges with high energy hip fractures in a younger population, although osteoporosis is on the rise in certain parts of the country. Due to limited resources and distances, time to surgery differs among hospital systems in the country. In public hospitals, a delay up to a week may be common, whereas in private hospitals most patients are operated early within 48 to 72 hours. Due to decreased life expectancy, arthroplasty is more aggressively used in displaced femoral neck fractures. Rehabilitation is mostly done within the families. Prevention and orthogeriatric teamwork are not being commonly practiced. Generally speaking, more attention to hip fractures is needed from healthcare funders.
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Abstract
Hip fractures, among the most common geriatric injuries, are associated with adverse patient outcomes and significant costs. The incidence of these fractures continues to rise with an aging population worldwide. While many factors that negatively impact patient outcomes are nonmodifiable, others, which include pre- and postoperative medical management, timing of surgical stabilization, and fracture fixation methods, are modifiable and have been shown to affect outcomes. Treatment pathways are dependent upon available resources and established systems, and comparative guidelines from different regions and countries are not well documented. This special issue seeks to highlight regional differences in hip fracture care globally and represents a collaborative work of member societies of the International Orthopaedic Trauma Association, an international association of orthopaedic societies dedicated to the promotion of musculoskeletal trauma care through advancements in patient care, research, and education. The expectation is that better understanding these differences will aid efforts to better understand, improve, and standardize existing approaches to hip fracture management worldwide.
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Affiliation(s)
- Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
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Pablos-Hernández C, González-Ramírez A, da Casa C, Luis MM, García-Iglesias MA, Julián-Enriquez JM, Rodríguez-Sánchez E, Blanco JF. Time to Surgery Reduction in Hip Fracture Patients on an Integrated Orthogeriatric Unit: A Comparative Study of Three Healthcare Models. Orthop Surg 2020; 12:457-462. [PMID: 32167674 PMCID: PMC7189046 DOI: 10.1111/os.12633] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/10/2020] [Accepted: 01/21/2020] [Indexed: 12/17/2022] Open
Abstract
Objective To investigate the clinical efficacy of three different healthcare models (Traditional Model, Geriatric Consultant Model, and Orthogeriatric Unit Model) consecutively applied to a single academic center (University Hospital of Salamanca, Spain) for older hip fracture patients. Methods We performed a retrospective study, including 2741 hip fracture patients older than 64 years, admitted between 1 January 2003 and 31 December 2014 to the University Hospital of Salamanca. Patients were divided into three groups according to the healthcare model applied. There were 983 patients on the Traditional Model, 945 patients on the Geriatric Consultant Model, and 813 patients on the Orthogeriatric Unit Model. We recorded age and gender of patients, functional status at admission (Barthel Index, Katz Index, and Physical Red Cross Scale), type of fracture, and intervention, and we analyzed the length of stay, time to surgery, post‐surgical stay, and in‐hospital mortality according to the healthcare model applied. Results Hip fractures are much more frequent in women, and an increase in the average age of patients was observed along with the study (P < 0.001). The most common type of fracture in the three models studied was an extracapsular fracture, for which the most common surgical procedure used was osteosynthesis. On the functional status of patients, there were no differences on the ambulatory ability previous to fracture, measured by the Physical Red Cross Scale, and the percentage of patients with a slight dependence determined by the Barthel Index (>60) was similar in both groups, but considering the Katz Index, the percentage of patients with a high degree of independence (A‐B) was significantly higher for the group of patients treated on the Orthogeriatric Unit Model period (56%, P = 0.009). The Orthogeriatric Unit Model registered the greatest percentage of patients undergoing surgery (96.1%, P < 0.001) and the greatest number of early surgical procedures (<24 h) (24.8%, P < 0.001). The orthogeriatric unit model showed the shortest duration of stay (9 days median), decreasing by one day in respect of each of the other models studied (P < 0.001). Time to surgery was also significantly reduced with the Orthogeriatric Unit Model (median of 3 days, P < 0.001). With regard to in‐hospital follow‐up, there was a reduction in in‐hospital mortality during the study period. We observed differences among the three healthcare models, but without statistical significance. Conclusions The healthcare model based on an Orthogeriatric Unit seems to be the most efficient, because it reaches a reduction in time to surgery, with an increased number of patients surgically treated on in the first 24 h, and the greatest frequency of surgically‐treated patients.
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Affiliation(s)
- Carmen Pablos-Hernández
- Unidad de Ortogeriatría, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Alfonso González-Ramírez
- Unidad de Ortogeriatría, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Carmen da Casa
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Maria Margarida Luis
- Servicio de Medicina Interna, Centro Hospitalario de Vila Nova de Gaia, Espinho, Portugal
| | | | | | - Emiliano Rodríguez-Sánchez
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Unidad de Investigación en Atención Primaria, Salamanca, Spain
| | - Juan F Blanco
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Salamanca, Salamanca, Spain
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Patel JN, Klein DS, Sreekumar S, Liporace FA, Yoon RS. Outcomes in Multidisciplinary Team-based Approach in Geriatric Hip Fracture Care: A Systematic Review. J Am Acad Orthop Surg 2020; 28:128-133. [PMID: 31977613 DOI: 10.5435/jaaos-d-18-00425] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This systematic review analyzes the literature on the treatment of geriatric hip fractures by a multidisciplinary hip fracture service including geriatricians/internists and orthopaedic surgeons and what impact this has on patient outcomes. METHODS A systematic review of several databases was conducted according to PRISMA guidelines. Studies comparing an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model to treat hip fractures with reported outcomes for time to surgery, length of stay, readmission rates, and postoperative mortality were included. RESULTS Seventeen articles fitting the inclusion criteria were included. Differences between the results of an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model were assessed using chi-squared tests. With patients admitted under a coordinated orthogeriatrics care model or a geriatrics-led care model, there is a statistically significant decrease in time to surgery (P = 0.045), length of stay (P = 0.0036), and postoperative mortality rates (P = 0.0034). CONCLUSIONS Although a heterogeneous group of studies, the aggregate data from several studies using an orthogeriatrics care model or a geriatrics-led care model trend toward improvements across several clinical and cost-related outcome measures: decreased time to surgery, shorter length of stay, improved postoperative clinical outcomes, decreased mortality, and lower cost.
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Affiliation(s)
- Jay N Patel
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center, RWJBarnabas Health (Dr. Patel, Dr. Klein, Dr. Liporace, and Dr. Yoon); and Department of Internal Medicine, Jersey City Medical Center, RWJBarnabas Health (Dr. Sreekumar), Jersey City, NJ
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Zhou Y, Rui Y, Lu P, Qiu X, Zou J, Li X, Ren L, Liu S, Yang Y, Ma M, Wang C, Chen H. [Research progress of multidisciplinary team co-management models for geriatric hip fracture treatment]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:132-138. [PMID: 31939248 DOI: 10.7507/1002-1892.201904133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To summarize the research progress of multidisciplinary team (MDT) co-management models in the clinical treatment of geriatric hip fractures. Methods The literature about types and characteristics of MDT for geriatric hip fracture treatment were extensively reviewed, and the advantages of its clinical application were analysed and summarised. Finally, the MDT model and characteristics of geriatric hip fracture in the Zhongda Hospital affiliated to Southeast University were introduced in detail. Results Clinical models of MDT are diverse and have their own characteristics, and MDT can shorten the length of stay and waiting time before operation, reduce the incidence of internal complications, save labor costs, and reduce patient mortality. Conclusion The application of MDT in the treatment of geriatric hip fracture has achieved remarkable results, which provides an optimal scheme for the treatment of geriatric hip fracture.
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Affiliation(s)
- Yangyang Zhou
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yunfeng Rui
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009,
| | - Panpan Lu
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xiaodong Qiu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Jihong Zou
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xingjuan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Liqun Ren
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Songqiao Liu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yi Yang
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Ming Ma
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Rehabilitation Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Chen Wang
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Hui Chen
- Department of Traumatic Orthopedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
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Gallardo P, Clavel O. FRACTURA DE CADERA Y GERIATRÍA, UNA UNIÓN NECESARIA. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Neuerburg C, Förch S, Gleich J, Böcker W, Gosch M, Kammerlander C, Mayr E. Improved outcome in hip fracture patients in the aging population following co-managed care compared to conventional surgical treatment: a retrospective, dual-center cohort study. BMC Geriatr 2019; 19:330. [PMID: 31775659 PMCID: PMC6880371 DOI: 10.1186/s12877-019-1289-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 09/23/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Hip fracture patients in the aging population frequently present with various comorbidities, whilst preservation of independency and activities of daily living can be challenging. Thus, an interdisciplinary orthogeriatric treatment of these patients has recognized a growing acceptance in the last years. As there is still limited data on the impact of this approach, the present study aimed to evaluate the long-term outcome in elderly hip fracture patients, by comparing the treatment of a hospital with integrated orthogeriatric care (OGC) with a conventional trauma care (CTC). METHODS We conducted a retrospective, two-center, cohort study. In two maximum care hospitals all patients presenting with a hip fracture at the age of ≥ 70 years were consecutively assigned within a 1 year period and underwent follow-up examination 12 months after surgery. Patients treated in hospital site A were treated with an interdisciplinary orthogeriatric approach (co-managed care), patients treated in hospital B underwent conventional trauma care. Main outcome parameters were 1 year mortality, readmission rate, requirement of care (RC) and personal activities of daily living (ADL). RESULTS A total of 436 patients were included (219 with OGC / 217 with CTC). The mean age was 83.55 (66-99) years for OGC and 83.50 (70-103) years for CTC (76.7 and 75.6% of the patients respectively were female). One year mortality rates were 22.8% (OGC) and 28.1% (CTC; p = 0.029), readmission rates were 25.7% for OGC compared to 39.7% for CTC (p = 0.014). Inconsistent data were found for activities of daily living. After 1 year, 7.8% (OGC) and 13.8% (CTC) of the patients were lost to follow-up. CONCLUSIONS Interdisciplinary orthogeriatric management revealed encouraging impact on the long-term outcome of hip fracture patients in the aging population. The observed reduction of mortality, requirements of care and readmission rates to hospital clearly support the health-economic impact of an interdisciplinary orthogeriatric care on specialized wards. TRIAL REGISTRATION The study was approved and registered by the bavarian medical council (BLAEK: 7/11192) and the local ethics committee of munich university (Reg. No. 234-16) and was conducted as a two-center, cohort study at a hospital with integrated orthogeriatric care and a hospital with conventional trauma care.
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Affiliation(s)
- Carl Neuerburg
- Department of General, Trauma and Reconstructive Surgery, University Hospital Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, D-81377, Munich, Germany.
| | - Stefan Förch
- Department of Trauma, Orthopedic, Hand and Reconstructive surgery, University Hospital Augsburg, Augsburg, Germany
| | - Johannes Gleich
- Department of General, Trauma and Reconstructive Surgery, University Hospital Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, D-81377, Munich, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, D-81377, Munich, Germany
| | - Markus Gosch
- Department of Medicine 2/Geriatrics, General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, D-81377, Munich, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopedic, Hand and Reconstructive surgery, University Hospital Augsburg, Augsburg, Germany
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Magidson PD, Thoburn AK, Hogan TM. Emergency Orthogeriatrics: Concepts and Therapeutic Considerations for the Geriatric Patient. Emerg Med Clin North Am 2019; 38:15-29. [PMID: 31757248 DOI: 10.1016/j.emc.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Appropriate recognition of the physiologic, psychological, and clinical differences among geriatric patients, with respect to orthopedic injury and disease, is paramount for all emergency medicine providers to ensure they are providing high-value care for this vulnerable population.
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Affiliation(s)
- Phillip D Magidson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, A1 East Suite 150, Baltimore, MD 21224, USA.
| | - Allison K Thoburn
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, IL 60637, USA
| | - Teresita M Hogan
- Department of Medicine, Division of Emergency Medicine, University of Chicago School of Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, IL 60637, USA
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Bücking B, Neuerburg C, Knobe M, Liener U. [Treatment of patients with fragility fractures]. Unfallchirurg 2019; 122:755-761. [PMID: 31428807 DOI: 10.1007/s00113-019-00707-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fragility fractures are fractures in multimorbid, geriatric patients. Currently, their number is already high and is likely to increase in the future. OBJECTIVE This article gives an overview of the principles in the management of patients with fragility fractures. MATERIAL AND METHODS A selective literature review was performed to describe the epidemiology and relevance of fragility fractures. In addition, the principles of the perioperative management and surgical treatment of patients with fragility fractures are shown. RESULTS Due to the significant number of comorbidities, the treatment of patients with fragility fractures represents an interdisciplinary challenge. Ideally, treatment should be carried out in an interdisciplinary team under the leadership of orthopedic surgeons and geriatricians. Treatment should be based on consensus guidelines, which have been adapted to the local circumstances. Attention should be paid to some special aspects of the surgical treatment in this vulnerable patient cohort. Important are optimal soft tissue management, cement augmentation procedures and joint replacement in cases of periarticular fractures. CONCLUSION There is evidence that with optimal care the treatment of patients with fragility fractures can be significantly improved.
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Affiliation(s)
- B Bücking
- Klinik für Orthopädie, Unfallchirurgie und Alterstraumatologie, DRK-Kliniken Nordhessen Gemeinnützige GmbH, Standort Wehlheiden, Hansteinstr. 29, 34121, Kassel, Deutschland.
| | - C Neuerburg
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, München, Deutschland
| | - M Knobe
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Luzern, Schweiz
| | - U Liener
- Klinik für Orthopädie, Unfallchirurgie und Wiederherstellungschirurgie, Vinzenz von Paul Kliniken gGmbH Marienhospital Stuttgart, Stuttgart, Deutschland
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Siu A, Allore H, Brown D, Charles ST, Lohman M. National Institutes of Health Pathways to Prevention Workshop: Research Gaps for Long-Term Drug Therapies for Osteoporotic Fracture Prevention. Ann Intern Med 2019; 171:51-57. [PMID: 31009943 DOI: 10.7326/m19-0961] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
On 30 and 31 October 2018, the National Institutes of Health convened the Pathways to Prevention (P2P) Workshop: Appropriate Use of Drug Therapies for Osteoporotic Fracture Prevention to assess the available evidence on long-term (>3 years) use of drug therapies to prevent osteoporotic fractures and identify research gaps and needs for advancing the field. The workshop was cosponsored by the NIH Office of Disease Prevention (ODP), National Institute of Arthritis and Musculoskeletal and Skin Diseases, and National Institute on Aging. A multidisciplinary working group developed the agenda, and an Evidence-based Practice Center prepared an evidence report through a contract with the Agency for Healthcare Research and Quality to facilitate the discussion. During the 1.5-day workshop, invited experts discussed the body of evidence and attendees had the opportunity to comment during open discussions. After data from the evidence report, expert presentations, and public comments were weighed, an unbiased independent panel prepared a draft report that was posted on the ODP Web site for 5 weeks for public comment. This final report summarizes the panel's findings and recommendations. Current gaps in knowledge are highlighted, and a set of recommendations for new, strengthened research to better inform the long-term use of osteoporotic drug therapies is delineated.
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Affiliation(s)
- Albert Siu
- Icahn School of Medicine at Mount Sinai, New York, New York (A.S.)
| | - Heather Allore
- Yale School of Medicine, Yale School of Public Health, New Haven, Connecticut (H.A.)
| | - Darryl Brown
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania (D.B.)
| | | | - Matthew Lohman
- University of South Carolina, Arnold School of Public Health, Columbia, South Carolina (M.L.)
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Standardized Hospital-Based Care Programs Improve Geriatric Hip Fracture Outcomes: An Analysis of the ACS NSQIP Targeted Hip Fracture Series. J Orthop Trauma 2019; 33:e223-e228. [PMID: 30702503 DOI: 10.1097/bot.0000000000001443] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine relative complication rates and outcome measures in patients treated under a standardized hip fracture program (SHFP). METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who underwent operative fixation of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures in 2016. Cohorts of patients who were and were not treated under a documented SHFP were identified. Relevant perioperative clinical and outcomes data were collected. Multivariate regression was used to assess risk-adjusted complication rates and outcomes for patients treated in SHFPs. RESULTS A total of 9360 hip fracture patients were identified of whom 5070 (54.2%) were treated under a documented SHFP. Median age was 84 years, and 69.9% of patients were women. Patients in an SHFP had a lower risk-adjusted incidence of postoperative deep vein thrombosis [odds ratio (OR) 0.48 (0.32-0.72), P < 0.001]. Rates of other medical and surgical complications and 30-day mortality were statistically comparable. Risk-adjusted evaluation showed that SHFP patients were less likely to be discharged to an inpatient facility versus home [OR 0.72 (0.63-0.81), P < 0.001] and had a lower 30-day readmission rate [OR 0.83 (0.71-0.97), P = 0.023]. Furthermore, the SHFP patients had higher rates of immediate postoperative weight-bearing as tolerated [OR 1.23 (1.10-1.37), P < 0.001], adherence to deep vein thrombosis prophylaxis at 28 days [OR 1.27 (1.16-1.38), P < 0.001], and initiation of bone protective medications [OR 1.79 (1.64-1.96), P < 0.001]. CONCLUSIONS Care in a modern hospital-based SHFP is associated with improved short-term outcome measures. Further development and widespread implementation of organized, multidisciplinary orthogeriatric hip fracture protocols is recommended. LEVEL OF EVIDENCE Therapeutic Level III.
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Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay. J Am Acad Orthop Surg 2019; 27:e293-e300. [PMID: 30358636 PMCID: PMC6411423 DOI: 10.5435/jaaos-d-17-00447] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway. METHODS A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016. RESULTS LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications. DISCUSSION Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program. LEVEL OF EVIDENCE III.
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Federer AE, Mather RC, Ramsey ML, Garrigues GE. Cost-effectiveness analysis of total elbow arthroplasty versus open reduction-internal fixation for distal humeral fractures. J Shoulder Elbow Surg 2019; 28:102-111. [PMID: 30551781 DOI: 10.1016/j.jse.2018.08.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/21/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty (TEA) and open reduction-internal fixation (ORIF) are 2 viable surgical treatment options for acute, intra-articular distal humeral fractures in elderly patients. Whereas recent systematic reviews and randomized trials have suggested that TEA and ORIF result in similar functional outcome scores, no previous study has assessed the comparative cost-effectiveness between TEA and distal humeral ORIF in this specific demographic. METHODS A Markov model was created with the highest-level data available from the literature depicting transitioning health states based on treatment strategies. To populate the quality-of-life data points in the model lacking in the literature, a survey was conducted of patients at 2 referral institutions who underwent TEA or ORIF for acute, intra-articular distal humeral fractures via the European Quality of Life, 5 Domains (EQ-5D) questionnaire at least 2 years postoperatively. Cost data from 2016 for each strategy were used to calculate the comparative cost-effectiveness of TEA versus ORIF. RESULTS For patients aged 65 years, the total cost of TEA was $19,407 compared with $20,669 for ORIF. The effectiveness of TEA and ORIF was 8.17 and 7.72, respectively. Overall, the incremental cost-effectiveness ratio of TEA ($2375.76/quality-adjusted life-year) was favored more than ORIF ($2677.26/quality-adjusted life-year). CONCLUSION These findings suggest TEA is a slightly more cost-effective procedure than ORIF for most elderly patients who sustain acute, intra-articular distal humeral fractures. Still, the unique limitations, complications, and revision rates for each strategy must be carefully weighed for each patient when making a decision.
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Affiliation(s)
- Andrew E Federer
- Sports Division, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Richard C Mather
- Sports Division, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew L Ramsey
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
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Navarro SM, Ramkumar PN, Egger AC, Goodwin RC. Evidence-Based Thresholds for the Volume-Value Relationship in Adolescent Idiopathic Scoliosis: Outcomes and Economies of Scale. Spine Deform 2018; 6:156-163. [PMID: 29413738 DOI: 10.1016/j.jspd.2017.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/17/2017] [Accepted: 08/01/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Increased surgeon and hospital volume has been associated with improved patient outcomes and cost effectiveness for adolescent idiopathic scoliosis (AIS). However, no evidence-based thresholds that clarify the volume at which these strata occur exist. The objective of this study was to establish statistically meaningful thresholds that define high-volume surgeons and hospitals performing spinal fusion for AIS from those that are low volume with respect to length of stay (LOS) and cost. METHODS Using 3,224 patients undergoing spinal fusion for AIS from an administrative database, we created and applied four models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. We generated four sets of thresholds predictive of adverse outcomes, namely, increased cost and LOS, for both surgeon and hospital volume. RESULTS For both LOS and cost, surgeon volume produced the same strata with low volume identified as 0-5 annual surgeries and high as greater than 5. LOS and cost decreased significantly (p < .05) between volume strata. For hospital volume in terms of LOS, low volume was identified as 0-10 annual surgeries and high as greater than 10; in terms of cost, low volume was identified as 0-15 annual surgeries and high as greater than 15. LOS decreased significantly (p < .05) and cost was $1,500 less but not statistically significant between volume strata for hospital volume. CONCLUSIONS Our study of risk-based volume stratification established a direct volume-value relationship for surgeons and hospitals performing fusion for AIS. A meaningful threshold for low- and high-volume surgeons was established at 5 annual surgeries, but no consensus or clinically meaningful conclusion was reached for hospitals, although the threshold approached 10-15 annual surgeries. This analysis should aid patients, surgeons, and administration reach value-based decisions in the optimal delivery of pediatric spinal fusion for AIS.
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Affiliation(s)
- Sergio M Navarro
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Prem N Ramkumar
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - Anthony C Egger
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Ryan C Goodwin
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
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