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Rehm A, Hatzantoni K, Sheharyar K. Examining Gender Disparities Among Physicians When Sample Sizes Differ. JAMA Surg 2024; 159:468. [PMID: 38231507 DOI: 10.1001/jamasurg.2023.7024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Andreas Rehm
- Department of Paediatric Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Katerina Hatzantoni
- Department of Paediatric Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Khurram Sheharyar
- Department of Paediatric Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
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Nabatame M, Takeuchi M, Takeda C, Kawakami K. Association between sedation during spinal anesthesia and mortality in older patients undergoing hip fracture surgery: A nationwide retrospective cohort study in Japan. J Clin Anesth 2024; 92:111322. [PMID: 37952283 DOI: 10.1016/j.jclinane.2023.111322] [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: 04/21/2023] [Revised: 09/13/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
STUDY OBJECTIVE Intraoperative sedation plays an important role in the management of regional anesthesia. Few studies have investigated the association of sedation during spinal anesthesia with postoperative mortality in older patients as a primary outcome. This study aimed to test the hypothesis that sedation during spinal anesthesia increases postoperative mortality in older patients undergoing hip fracture surgery. DESIGN Retrospective, cohort study. SETTING Acute and subacute care hospitals in Japan. PATIENTS Patients aged 65 years and older who received hip fracture surgery under spinal anesthesia between April 2014 and May 2022. EXPOSURE Sedation during spinal anesthesia. MEASUREMENTS Postoperative in-hospital all-cause mortality within 30 days. MAIN RESULTS In total, 25,554 eligible patients were identified. Propensity score matching created 4735 pairs, and baseline patient characteristics were acceptably balanced between the sedation and non-sedation groups. There was no significant difference in 30-day postoperative mortality between the two groups (hazard ratio [95% CIs]: 0.92 [0.59-1.44]). CONCLUSIONS There was no association between sedation during hip fracture surgery in older patients under spinal anesthesia and postoperative mortality. However, these results are limited to our population, and further prospective studies are needed to determine the safety of sedation.
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Affiliation(s)
- Maki Nabatame
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Chikashi Takeda
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan; Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.
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Viderman D, Aubakirova M, Nabidollayeva F, Abdildin YG. The Analysis of Multiple Outcomes between General and Regional Anesthesia in Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2023; 12:7513. [PMID: 38137582 PMCID: PMC10743918 DOI: 10.3390/jcm12247513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
Surgical interventions in hip fracture have been associated with multiple adverse events, including perioperative hypotension and mortality, making the choice of the anesthetic method for this procedure crucial. There is still no consensus on whether regional (RA) or general (GA) anesthesia should be used to maintain hemodynamic stability and more favorable outcomes. Therefore, this meta-analysis examines the differences between RA and GA groups in the incidence of mortality, intraoperative hypotension, and other intra- and postoperative complications. The comparison is essential given the rising global prevalence of hip fractures and the need to optimize anesthesia strategies for improved patient outcomes, particularly in an aging population. We followed PRISMA guidelines (PROSPERO #CRD42022320413). We conducted the search for studies published in English before March 2022 in PubMed, Google Scholar, and the Cochrane Library. We included RCTs that compared general and regional anesthesia in adult patients having hip fracture surgical interventions. The primary outcome was perioperative mortality. The secondary outcomes were peri- or postoperative complications and duration of hospital stay. We conducted a meta-analysis in RevMan (version 5.4). We examined the quality of the methodology with the Cochrane risk of bias 2 tool, while the quality of evidence was determined with GRADE. Fifteen studies with 4110 patients were included. Our findings revealed no significant difference between general and regional anesthesia in risk of perioperative mortality (RR = 1.42 [0.96, 2.10], p-value = 0.08), intraoperative complications, or duration of hospital length of stay. Our results suggest that regional anesthesia and general anesthesia have comparable safety and can be used as alternatives based on specific patient requirements.
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Affiliation(s)
- Dmitriy Viderman
- Department of Surgery, School of Medicine, Nazarbayev University, Astana 020000, Kazakhstan;
| | - Mina Aubakirova
- Department of Surgery, School of Medicine, Nazarbayev University, Astana 020000, Kazakhstan;
| | - Fatima Nabidollayeva
- School of Engineering and Digital Sciences, Nazarbayev University, Astana 010000, Kazakhstan; (F.N.); (Y.G.A.)
| | - Yerkin G. Abdildin
- School of Engineering and Digital Sciences, Nazarbayev University, Astana 010000, Kazakhstan; (F.N.); (Y.G.A.)
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Pennestrì F, Lega F, Banfi G. From volume to value: Improving peri-operative elective pathways through a roadmap from fast-track orthopedic surgery. Health Serv Manage Res 2023; 36:284-290. [PMID: 36444939 PMCID: PMC10552341 DOI: 10.1177/09514848221127623] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Healthcare institutions face the pressure generated by modern medicine and society, in terms of increasing expectations and financial constraints. Chronic patients need multidisciplinary care pathways to preserve their wellbeing across the entire journey.The orthopaedic community has been particularly receptive in testing solutions to align good clinical outcomes and financial sustainability, given the increase in elective procedures provided among aging populations to alleviate pain and reduce disability. Fast-track (FT) total joint arthroplasty (TJA) and bundled payments (BPs) offer relevant examples both from the clinical and the financial perspective; however, they have not been evaluated in combination yet.The aim of this manuscript is to provide a road map to improve the value of high-volume, multidisciplinary elective procedures, with potential applications in a vast number of surgical specialties, (1) based on an integrated financial budget per episode of care (the BP), (2) building on lessons from a review of the literature on FT TJA.Although clinical outcomes vary from procedure to procedure, the coordination between the single treatments and providers involved across the patient journey; the commitment of patients and relatives; and the systematic adoption of patient-reported outcomes; can add further value for the benefit of patients, healthcare funders and providers, once essential clinical, financial and administrative conditions are guaranteed.
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Affiliation(s)
| | - Federico Lega
- Research Center on Health Administration, University of Milan, Italy
| | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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Sivanathan M, Rabes C. Fast-track and person-centred care in geriatric traumatology in a German-speaking Swiss hospital - A practice development project. Int J Orthop Trauma Nurs 2023; 51:101065. [PMID: 37979241 DOI: 10.1016/j.ijotn.2023.101065] [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: 08/25/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION Elderly persons have an increased risk for negative health-related outcomes, including higher mortality rates. A centre for geriatric traumatology was established in a German-speaking Swiss hospital to provide more specialised, person-centred care and to lower negative health outcomes. Adaptations and changes in the patient pathway were made by implementing fast-track and person-centred care to better address individual needs. METHODS The current patient pathway was analysed by an interprofessional and interdisciplinary geriatric traumatology expert team. The practice development methodology and the Person-Centred Practice Framework (PCP-Framework) were used throughout this engagement process. In consensus within the expert team, the sample was defined as elderly persons aged 65 years or older with suspected hip joint closed fractures. The focus was on three elements of "practice environment" from the PCP-Framework. These were: (1) supportive organisational systems; (2) the physical environment; (3) appropriate skill mix. RESULTS Several adaptations and changes were made addressing the three elements of "practice environment". These were for example: (1) use of specific assessments, shared decision-making; (2) proper and effective use of aids; (3) integration of Advanced Practice Nurses. The adaptations in the patient pathway were integrated into the standard operating procedures. CONCLUSIONS Through active engagement with the practice development methodology and the focus on person-centredness, the process of care for elderly persons was adapted. Thus, by addressing individual needs, fast-track and person-centred care in geriatric traumatology is provided. Further research is needed to evaluate and to verify implications in clinical practice.
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Affiliation(s)
- Mayuri Sivanathan
- University Hospital Basel, Department of Musculoskeletal System, Hebelstrasse 2, 4031 Basel, Switzerland.
| | - Clemens Rabes
- University Hospital Basel, Department of Musculoskeletal System, Hebelstrasse 2, 4031 Basel, Switzerland.
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Zhu R, Yang F, Li C, Zhu H, Lin L, Zhao X. Effect of Enhanced Recovery After Surgery on the Prognosis of Patients With Hip Fractures: A Systematic Review and Meta-Analysis. J Trauma Nurs 2023; 30:271-281. [PMID: 37702729 DOI: 10.1097/jtn.0000000000000741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Hip fractures, predominantly occurring in the elderly, are a significant public health concern due to associated morbidity, disability, and mortality. Prolonged bed rest following the fracture often leads to complications, further threatening patient health. Enhanced recovery after surgery, a modern approach to postoperative care, is being explored for its potential to improve outcomes and quality of life in hip fracture patients. OBJECTIVE This study investigates the impact of enhanced recovery after surgery on hip fracture patients. METHODS In this systematic review, we addressed the PICO question: Does the enhanced recovery after surgery program reduce 1-year mortality, readmissions, and postoperative pain and improve Harris Hip Score compared with traditional care in elderly hip fracture patients? We searched key databases and gray literature and analyzed outcomes through a meta-analysis using RevMan, Stata, and the Newcastle-Ottawa Scale for quality assessment. RESULTS Nine studies involving 10,359 patients were included. Compared with the control group, the enhanced recovery after surgery group showed significant reduction in length of stay (mean difference [MD] = -2.00; 95% confidence interval [CI] [-2.87, -1.14]; p < .0001) and overall complication rate (risk ratio [RR] = 0.76; 95% CI [0.67, 0.85]; p < .0001), with a lower delirium rate (RR = 0.42; 95% CI [0.26, 0.68]; p = .004). No significant differences were observed in Harris Hip Score, pain score, 1-year mortality, readmission rate, or incidences of urinary tract infection, respiratory tract infection, and deep vein thrombosis. CONCLUSION Enhanced recovery after surgery is associated with reduced length of stay, complication rate, and delirium rate in hip fracture patients.
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Affiliation(s)
- Ruiqi Zhu
- Departments of Nursing (Zhu, Drs Lin and Zhao) and Orthopedic (Zhu), the First Affiliated Hospital of Soochow University, Suzhou, China; and School of Nursing, Medical College of Soochow University, Suzhou, China (Zhu, Yang, Li, Drs Lin and Zhao)
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Zhang J, Ye P, Yang M, Wu X, Webster R, Ivers R, Tian M. Development of a conceptual framework to scale up co-managed care for older patients with hip fracture in China: a qualitative study. BMC Health Serv Res 2023; 23:898. [PMID: 37612703 PMCID: PMC10463518 DOI: 10.1186/s12913-023-09910-w] [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: 12/07/2022] [Accepted: 08/12/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Hip fracture creates a major burden on society due to high mortality, loss of independence and excess medical costs for older people. A multidisciplinary co-managed model of care is widely considered as the best practice for the management of older patients with hip fracture. The study aims to develop a conceptual framework to inform the future scale-up of this model of care through the identification of barriers and enablers that may influence successful uptake. METHODS This qualitative study was conducted within an interventional study, which aimed to test the effectiveness of co-managed model of care for older patients with hip fracture. Health providers and health administrators from three hospitals were purposively selected and interviewed in-depth. The Consolidated Framework for Implementation Research (CFIR) was used to develop interview guides, collect and analyse data. Inductive and deductive approaches were used to generate enablers or barriers, aligned with the CFIR constructs. All barriers or enablers were inductively summarised to a conceptual framework with essential components to guide the implementation of co-managed model of care in other hospitals. RESULTS A total of 13 health providers and 3 health administrators were recruited. The main barriers to co-managed care implementation included perceived complexity of implementation, insufficient international collaboration and incentives, the absence of national guideline support and lack of digital health applications for communication between health providers, insufficient number of health providers and beds, and poor understanding about the effectiveness of this care model. A conceptual framework for future scale-up was then developed, consisting of the following essential components: hospital authority support, enabling environment, adequate number of beds, sufficient and skilled health providers, use of digital health technology, regular quality supervision, evaluation and feedback, and external collaborations. CONCLUSIONS Despite the complexity of the intervention, the co-managed model of care has the potential to be implemented and promoted in China and in similar settings, although there is a need to demonstrate feasibility in different settings.
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Affiliation(s)
- Jing Zhang
- Clinical Epidemiology Research Centre, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
- National Centre for Orthopaedics, Beijing, China
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Pengpeng Ye
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Minghui Yang
- National Centre for Orthopaedics, Beijing, China.
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China.
| | - Xinbao Wu
- National Centre for Orthopaedics, Beijing, China
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Ruth Webster
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Rebecca Ivers
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Maoyi Tian
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- School of Public Health, Harbin Medical University, Harbin, China
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A Retrospective Cohort Study on Chronic Opioid Use After Geriatric Hip Fracture Surgery-Risk Factors, Trends, and Outcomes. J Am Acad Orthop Surg 2023; 31:312-318. [PMID: 36595589 DOI: 10.5435/jaaos-d-22-00458] [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] [Received: 05/06/2022] [Accepted: 11/19/2022] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The purpose of this study is to identify the risk factors for prolonged opioid use after surgery in geriatric hip fracture patients and the effects of prolonged use on mortality and readmission rates. METHODS An institutional registry was queried for all patients older than 65 years who underwent surgical treatment of a hip fracture between January 2016 and June 2017. Using the Controlled Substance Utilization Review and Evaluation System (CURES), we identified patients who had filled an opioid prescription within 3 months of hospital admission as opioid exposed and patients without a history of opioid use as opioid naïve (ON). RESULTS Of 500 patients who underwent hip-fracture surgery during the study period, a total of 322 had complete Controlled Substance Utilization Review and Evaluation System data. 36.0% (116) were OE, and 64.0% (206) were ON. 23.0% (74) patients filled an opioid prescription 6 months after surgery, 59.5% (44) were OE, and 40.5% (30) were ON. OE and patients on antidepressants were more likely to continue opioids at 6 months. Age, sex, fracture pattern, implant, benzodiazepine use, smoking, and alcohol status were not notable risk factors for prolonged opioid use. Antidepressant use was a risk factor for readmission within 90 days. Previous opioid exposure predicted mortality within 6 months. DISCUSSION Opioid use in geriatric hip fracture patients is high both preoperatively and postoperatively. Opioid exposed patients and patients on antidepressants are more likely to continue opioids at 6 months. A substantial proportion of ON patients became prolonged opioid users. Although prolonged opioid use postoperatively did not increase the risk of readmission or death, antidepressant use predicted readmission and previous opioid exposure predicted mortality. By identifying predictors of prolonged postoperative opioid use in geriatric hip fracture patients, we can better prepare physicians and their patients on what to expect in the postoperative period. LEVEL OF EVIDENCE Level III.
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Internal fixation with fast rehabilitation for the elderly with intertrochanteric fracture. Asian J Surg 2023; 46:1293-1294. [PMID: 36064482 DOI: 10.1016/j.asjsur.2022.08.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/17/2022] [Indexed: 11/21/2022] Open
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Mortality following hip fracture: Trends and geographical variations over the last SIXTY years. Injury 2023; 54:620-629. [PMID: 36549980 DOI: 10.1016/j.injury.2022.12.008] [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: 08/17/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The management of hip fractures has advanced on all aspects from prevention pre-operatively, specialised hip fracture units, early operative intervention and rehabilitation. This is in line with the appropriate recognition over the past years of an important presentation with significant mortality and socioeconomic consequences of ever increasing incidence in an aging population. It is therefore imperative to continue to gather data on the incidence and trends of hip fractures to guide future management planning of this important presentation. METHODS A review of all articles published on the outcome after hip fracture over a twenty year period (1999-2018) was undertaken to determine any changes that had occurred in the demographics and mortality over this period. This article complements and expands upon the findings of a previous article by the authors assessing a four decade period (1959 - 1998) and attempts to present trends and geographical variations over sixty years. RESULTS The mean age of patients sustaining hip fractures continues to be steadily increasing at approximately just over 1 year of age for every 5-year time period. The mean age of patients sustaining hip fractures increased from 73 years (1960s) to 81 years (2000s) to 82 years (2010s). Over the six decade period one-year mortality has reduced from an overall mean of 27% (1960s) to 20% (2010s). The proportion of female hip fractures has decreased from 84% (1960s) to 70% (2010s). There is a decreasing trend in the proportion of intracapsular fractures from 54% (1970s) to 49% (2000s) and 48% (2010s). CONCLUSION Our study indicates that significant progress has been made with preventative planning, medical management, specialised orthogeriatric units and surgical urgency all playing a role in the improvements in mean age of hip fracture incidence and reduction in mortality rates. While geographical variations do still exist there has been an increase in the study of hip fractures globally with results now being published from more widespread institutions indicating appropriate increased attention and commitment to an ever-increasing presentation.
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Maher S, Moore Z, Avsar P, Patton D. What is the impact of a fast-track pathway on length of stay for adult patients with a hip fracture? A systematic review. Arch Orthop Trauma Surg 2022; 142:3803-3816. [PMID: 34853866 DOI: 10.1007/s00402-021-04248-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/01/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION In orthopaedic surgery, hip fracture patients represent one of the largest cohorts. Hip fracture is a serious injury commonly occurring in frail and elderly patients. Fast-track admission pathways aim to streamline patients through accident and emergency departments, resulting in shorter wait times and less negative patient outcomes. AIM To examine the impact of a fast-track pathway on length of stay for adults admitted to an acute hospital with a hip fracture. METHODS CINAHL Plus with Full text (via EBSCO host), MEDLINE, Cochrane Library, and Embase database searches were carried out in January 2021, to find all relevant literature for this review, as well as through searching additional sources. Eligible studies were quantitative primary research, focusing on the use of fast-track admission pathway care versus usual care, for adults with a hip fracture. The assessment of study suitability, data extraction, and critical appraisal was carried out by two independent authors. A narrative analysis of the data was conducted, and data were meta-analysed using RevMan where possible. Quality appraisal of the included studies was undertaken using the EBL checklist. RESULTS Seven studies reporting data on 5723 patients were included. Length of stay, time to surgery, and mortality did not differ significantly between the fast-track care, and usual care. One study reported on delirium and found statistically significantly fewer encounters of delirium in fast-track care versus usual care. Four of the seven studies satisfied rigorous quality appraisal (> 75%) using the EBL. CONCLUSION The fast-track pathway avoided unnecessary delays in emergency departments due to faster X-rays, direct admission to orthopaedic wards, and reduced delirium rates. However, results were unable to show the impact of fast-track on length of stay, time to surgery, and mortality.
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Affiliation(s)
- Sarah Maher
- University Hospital Limerick, Limerick, Ireland.
| | - Zena Moore
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
- Lida Institute, Shanghai, People's Republic of China
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Cardiff University, Wales, UK
| | - Pinar Avsar
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Declan Patton
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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Tewari P, Sweeney BF, Lemos JL, Shapiro L, Gardner MJ, Morris AM, Baker LC, Harris AS, Kamal RN. Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review. JAMA Netw Open 2022; 5:e2231911. [PMID: 36112373 PMCID: PMC9482052 DOI: 10.1001/jamanetworkopen.2022.31911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors. OBJECTIVE To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS. EVIDENCE REVIEW A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components. FINDINGS Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements. CONCLUSIONS AND RELEVANCE In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.
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Affiliation(s)
- Pariswi Tewari
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Brian F. Sweeney
- Stanford University School of Medicine, Mountain View, California
| | - Jacie L. Lemos
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lauren Shapiro
- Department of Orthopaedic Surgery, University of California, San Francisco
| | - Michael J. Gardner
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Arden M. Morris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Laurence C. Baker
- Department of Health Research and Policy, Stanford University, Stanford, California
| | - Alex S. Harris
- Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Robin N. Kamal
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- VOICES Health Policy Research Center, Stanford University, Stanford, California
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Backman C, Harley A, Papp S, Webber C, Poitras S, Berdusco R, Beaulé PE, French-Merkley V. Feasibility, acceptability, and preliminary effects of PATH FOR timely transfer of geriatric HIP fracture patients from hospital to rehabilitation to home (PATH4HIP): a protocol for a mixed method study. Pilot Feasibility Stud 2022; 8:124. [PMID: 35690813 PMCID: PMC9188093 DOI: 10.1186/s40814-022-01079-z] [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: 05/14/2021] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hip fractures in older adults are significant contributors to severe functional decline and disability as well as hospitalization and increased health care costs. Research shows that timely referral to geriatric rehabilitation leads to better patient outcomes. Currently, a wide variability in the timing, the frequency, and the choice of appropriate setting for rehabilitation of hip fracture patients exists. AIM Evaluate the feasibility, acceptability, and preliminary effectiveness of PATH4HIP, a pathway intervention for timely transfer of post-operative geriatric hip fracture patients from hospital to rehabilitation to home. METHODS This is a single-arm, pragmatic feasibility study to measure reach, effectiveness, adoption, implementation, and maintenance of PATH4HIP, a pathway for post-operative hip fracture patients from a large academic health science center to a geriatric rehabilitation service in Ottawa, Canada. During a 6-month period, all hip fracture patients, 65 years of age or older who have undergone surgery and have met the eligibility criteria (n = 96), will be transferred to the geriatric rehabilitation service no later than post-operative day 6. Patients (n = 10-12) and clinicians who are working on the orthopedic team (n = 10-12) and on the geriatric rehabilitation service (n = 10-12) will be invited to participate in an interview to share their feedback on the intervention's feasibility and acceptability and to provide suggestions to improve PATH4HIP. Descriptive statistics will be used to summarize results of the quantitative data and content analysis will be used to analyze the qualitative data. The study will be open for recruitment from January to July 2022. DISCUSSION If feasible, PATH4HIP will result in the reduction of the post-operative acute care length of stay to less than or equal to 6 days, while having no detrimental effect on rehabilitation outcomes such as functional gains, or discharge destination.
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Affiliation(s)
- Chantal Backman
- School of Nursing, Faculty of Health Sciences, University of Ottawa; Affiliate Investigator, Ottawa Hospital Research Institute, Affiliate Investigator, Bruyère Research Institute, 451, Smyth Road, RGN 3239, Ottawa, ON, K1H 8M5, Canada.
| | - Anne Harley
- Bruyere Continuing Care; Assistant Professor Faculty of Medicine, University of Ottawa, 43 Bruyère St, Ottawa, ON, K1N 5C8, Canada
| | - Steve Papp
- Faculty of Medicine, University of Ottawa, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Stéphane Poitras
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, 451, Smyth Road, Ottawa, ON, K1H 8M5, Canada
| | - Randa Berdusco
- Faculty of Medicine, University of Ottawa, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery at The Ottawa Hospital, Faculty of Medicine, University of Ottawa, General Campus, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
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14
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Thiam CN, Khor HM, Pang GHM, Lim WC, Shanmugam T, Chandrasekaran CSK, Singh S, Zakaria MIB, Ong T. Hip fracture management in the emergency department and its impact on hospital outcomes: a retrospective cross-sectional analysis. Eur Geriatr Med 2022; 13:1081-1088. [PMID: 35567676 DOI: 10.1007/s41999-022-00654-0] [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: 07/26/2021] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The emergency department (ED) plays an important role in initiating early treatment for hip fractures and ensuring prompt transfer to orthopaedic wards. This study reported on the care delivered in a tertiary centre ED in Malaysia and the association between time spent in ED with hospital outcomes. METHODS Patients aged ≥ 65 years with fragility hip fractures and seen by the geriatric team were recruited. Data were collected on patient characteristics, key time points for treatment and hospital outcomes. Median time in ED was used to dichotomise long and short waiting time. RESULTS 447 patients were recruited. The mean (SD) age was 80.5 (7.0) years and 69.8% were women. 74.9% were prescribed analgesia within 30 min. Median (Q1,Q3) time to diagnostic imaging was 27.0 (24.0-43.0) minutes, clinician confirmation of fracture was 83.0 (49.0-129.0) minutes, and time in ED was 4.8 (3.5-6.9) h. A weekday, weekend, in-hour or out-of-hour admission did not demonstrate a difference in the time important care was delivered. Patients who spent ≥ 5 h in ED had more cardiac events (4.6 vs 10.1%, p = 0.023) and more spent ≥ 14 days in hospital (17.5 vs 29.0%, p = 0.004) compared to those < 5 h. No significant increase in inpatient complications (43.5 vs 34.6%, p = 0.054), length of stay (median, 8 vs 7 days, p = 0.119), care home discharge (5.3 vs 4.6%, p = 0.772), or in-hospital death (6.3 vs 4.2%, p = 0.313) were observed. CONCLUSION Time to early hip fracture pain relief and diagnosis was adequate in this ED. Time ≥ 5 h in ED was associated with cardiac events and 2 weeks or more inpatient stay.
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Affiliation(s)
- Chiann Ni Thiam
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of General Medicine, Hospital Kuala Lumpur, Ministry of Health, Jalan Pahang, 50586, Kuala Lumpur, Malaysia
| | - Hui Min Khor
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of Medicine, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Gordon Hwa Mang Pang
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of General Medicine, Hospital Kuala Lumpur, Ministry of Health, Jalan Pahang, 50586, Kuala Lumpur, Malaysia
| | - Wan Chieh Lim
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of General Medicine, Hospital Kuala Lumpur, Ministry of Health, Jalan Pahang, 50586, Kuala Lumpur, Malaysia
| | - Tharshne Shanmugam
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia
| | - C Sankara Kumar Chandrasekaran
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of Orthopaedic Surgery, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Simmrat Singh
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Department of Orthopaedic Surgery, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Mohd Idzwan Bin Zakaria
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.,Academic Unit Trauma and Emergency, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Terence Ong
- University Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia. .,Department of Medicine, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia.
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15
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Henriksen BT, Andersson Y, Davies MN, Mathiesen L, Krogseth M, Andersen RD. Development and initial validation of MedHipPro-Q: a questionnaire assessing medication management of hip fracture patients in different care settings. BMC Health Serv Res 2022; 22:240. [PMID: 35193572 PMCID: PMC8862359 DOI: 10.1186/s12913-022-07524-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 01/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background A validated questionnaire to assess medication management of hip fracture patients within and outside the hospital setting was lacking. The study aims were to describe the hip fracture patient pathway, and develop a valid and feasible questionnaire to assess clinicians’ experience with medication management of hip fracture patients in different care settings throughout the patient pathway. Methods This qualitative, descriptive methodological study used strategic and snowball sampling. The questionnaire was developed, and face and content validity explored through interviews with stakeholders. Phase I described the hip fracture patient pathway, and identified questionnaire dimensions in semi-structured interviews with management and clinicians (n = 37). The patient pathway was also discussed in six meetings (n = 70). Phase II refined a first draft of the questionnaire through cognitive interviews with future respondents (n = 23). The draft was modified after each interview. Post hoc, cognitive interview data were analysed using matrix analysis to condense problems and solutions into themes and subthemes. Phase III, converted the final version to a digital format, and tested its feasibility with a subset of the cognitive interview participants (n = 21) who completed the questionnaire and provided feedback. Results Phase I: Hip fracture patients were cared for in at least three different care settings, and went through at least four handovers between and within primary and secondary care. Three questionnaire dimensions were identified: 1) Medication reconciliation and review, 2) Communication of key information, and 3) Profession and setting. Phase II: The MedHipPro-Q was representative of how the different professions experienced medication management in all settings, and hence showed face and content validity. Post hoc analysis: Problem themes (with sub-themes) were Representativeness (-of patient pathway and -of respondent reality) and Presentation (Language and Appearance). Solution themes (with sub-themes) were: Content (added or deleted) and Presentation (modified appearance or corrected language). Phase III: Participants did not identify technical, linguistic or content flaws in the questionnaire, and the digital version was considered feasible for use. Conclusion The novel MedHipPro-Q showed good face and content validity, and was feasible for use throughout the hip fracture patient pathway. The rigorous development process supports its construct validity and reliability. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07524-2.
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Affiliation(s)
- Ben Tore Henriksen
- Tonsberg Hospital Pharmacy, Hospital Pharmacies Enterprise, South-Eastern Norway, Tonsberg, Norway. .,Vestfold Hospital Trust, Tonsberg, Norway. .,Department of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.
| | - Yvonne Andersson
- Hospital Pharmacies Enterprise, South-Eastern Norway, Oslo, Norway
| | - Maren Nordsveen Davies
- Tonsberg Hospital Pharmacy, Hospital Pharmacies Enterprise, South-Eastern Norway, Tonsberg, Norway
| | - Liv Mathiesen
- Department of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Maria Krogseth
- Department of Internal Medicine, Telemark Hospital Trust, Skien, Norway.,Old Age Psychiatry Research Network, Telemark Hospital Trust and Vestfold Hospital Trust, Tonsberg, Norway.,University of South-Eastern Norway, Drammen, Norway
| | - Randi Dovland Andersen
- Department of Research, Telemark Hospital Trust, Skien, Norway.,Research Centre for Habilitation and Rehabilitation Models & Services (CHARM), The Faculty of Medicine, University of Oslo, Oslo, Norway
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16
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Health care services and costs after hip fracture, comparing conventional versus standardised care: A retrospective study with 12-month follow-up. Injury 2021; 52:3434-3439. [PMID: 33551261 DOI: 10.1016/j.injury.2021.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 02/02/2023]
Abstract
AIMS To compare costs related to a standardised versus conventional hospital care for older patients after fragility hip fracture and determine whether a shift in hospital care led to cost-shifts between specialists and primary health care. METHODS We retrospectively collected and calculated volumes of care and accompanying costs from fracture time until 12 months after hospital discharge for 979 patients. All patients aged ≥ 65 years had fragility hip fractures. The data set had few missing data points because of the patient registry, administrative databases, and a low migration rate. RESULTS Total costs per patient at 12 months were EUR 78 164 (standard deviation [SD] 58 056) and EUR 78 068 (SD 60 131) for conventional and standardised care, respectively (p = 0.480). Total specialist care costs were significantly lower for the standardised care group (p < 0.001). Total primary care costs were higher for the standardised care group (p = 0.424). Total costs per day of life for the conventional and standardised care groups were EUR 434 and EUR 371, respectively (p = 0.003). Patients in the standardised care group had 17 more days of life. CONCLUSIONS Implementation of a standardised care to improve outcomes for patients with hip fracture caused lower specialist care costs and higher primary care costs, indicating care- and cost-shifts from specialist to primary health care.
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17
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Liu SY, Li C, Zhang PX. Enhanced recovery after surgery for hip fractures: a systematic review and meta-analysis. Perioper Med (Lond) 2021; 10:31. [PMID: 34511117 PMCID: PMC8436561 DOI: 10.1186/s13741-021-00201-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 06/22/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs have achieved promising results in many surgical specialties. However, uncertainty still remains regarding the effect of ERAS on hip fractures. The objective of this review was to investigate the clinical prognosis of ERAS programs in terms of (1) hospital-related endpoints (time to surgery [TTS], length of stay [LOS]), (2) readmission rate, (3) complications, and (4) mortality. METHODS Published literature was searched in the PubMed, EMBASE, and Cochrane Library databases. All of the included studies met the inclusion criteria. The primary outcomes were TTS and LOS. The secondary outcomes included the 30-day readmission rate, overall complication rate, specific complication rate (delirium and urinary tract infection), and 30-day and 1-year mortality. Language was restricted to English. The data analysis was carried out by Review Manager 5.3. RESULTS A total of 7 published studies (9869 patients) were finally included, and these were all cohort studies. The meta-analysis showed that the TTS, LOS, and overall complication rate were significantly reduced in the ERAS group compared with the control group (p < 0.01). Moreover, no significant change was found in the 30-day readmission rate or 30-day and 1-year mortality. CONCLUSIONS ERAS significantly decreases the TTS, LOS, and complication rate without increasing readmission rate and mortality, which adds to the evidence that the implementation of ERAS is beneficial to patients undergoing hip fracture repair surgeries.
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Affiliation(s)
- Song-Yang Liu
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Ci Li
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Pei-Xun Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China.
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18
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Kjaervik C, Gjertsen JE, Engeseter LB, Stensland E, Dybvik E, Soereide O. Waiting time for hip fracture surgery: hospital variation, causes, and effects on postoperative mortality : data on 37,708 operations reported to the Norwegian Hip fracture Register from 2014 to 2018. Bone Jt Open 2021; 2:710-720. [PMID: 34472378 PMCID: PMC8479844 DOI: 10.1302/2633-1462.29.bjo-2021-0079.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Aims This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Methods Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720.
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Affiliation(s)
- Cato Kjaervik
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromso, Norway.,Department of Surgery, Nordland Hospital Trust, Vesteraalen Hospital, Stokmarknes, Norway
| | - Jan-Erik Gjertsen
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Møllendalsbakken, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars B Engeseter
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Møllendalsbakken, Bergen, Norway
| | - Eva Stensland
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromso, Norway.,Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Sykehusveien, Tromsø, Norway
| | - Eva Dybvik
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Møllendalsbakken, Bergen, Norway
| | - Odd Soereide
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Sykehusveien, Tromsø, Norway
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19
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Wahlsten LR, Palm H, Gislason GH, Brorson S. Sex differences in incidence rate, and temporal changes in surgical management and adverse events after hip fracture surgery in Denmark 1997-2017: a register-based study of 153,058 hip fracture patients. Acta Orthop 2021; 92:424-430. [PMID: 33988073 PMCID: PMC8381898 DOI: 10.1080/17453674.2021.1923256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Extensive research and national multidisciplinary programs have striven to introduce uniform standards of treatment and mitigate mortality and adverse events after hip fracture surgery over the past decades. A large-scale overview of temporal developments in hip fracture surgery and care is warranted.Patients and methods - We studied Danish patients aged ≥ 60 years, sustaining their first ever hip fracture between 1997 and 2017. Patients were identified from the Danish National Patient Registry (DNPR). Incidence rates of first hip fracture were calculated per 1,000 patient-years and stratified by age group and sex. Information on pre-injury living settings, comorbidities, and medications were obtained from national administrative registers. Type of fracture and treatment choice were recorded, and patients were followed for 1 year to observe mortality, readmission, and surgical complications.Results - Data from 153,058 patients was analyzed. Incidence rate decreased in both sexes, but only led to a reduction in the annual number of hip fractures in the female population. Choice of surgery shifted away from sliding hip screws and parallel implants (SHS-PI), towards intramedullary nailing and hemi-/arthroplasties for trochanteric and femoral neck fractures, respectively. Pre-injury diagnosed morbidity and 1-year readmissions increased contrary to mortality. Median age remained stable around 83 (IQR 77-88) for women and 80 (IQR 73-86) for men.Interpretation - Over the past 2 decades important aspects of hip fracture management have improved. However, sex differences were observed, and men remain more vulnerable than women in terms of morbidity, mortality, and incidence rate.
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Affiliation(s)
- Liv R Wahlsten
- Department of Orthopaedics, Copenhagen University Hospital Herlev-Gentofte,Correspondence:
| | - Henrik Palm
- Department of Orthopaedics, Copenhagen University Hospital Bispebjerg
| | - Gunnar H Gislason
- Department of Cardiology, Research 1, Copenhagen University Hospital Herlev-Gentofte
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital Køge, Denmark
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20
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Impact of multiple nerves blocks anaesthesia on intraoperative hypotension and mortality in hip fracture surgery intermediate-risk elderly patients: A propensity score-matched comparison with spinal and general anaesthesia. Anaesth Crit Care Pain Med 2021; 40:100924. [PMID: 34217841 DOI: 10.1016/j.accpm.2021.100924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND A Hip fracture in the intermediate-risk elderly patient is common and associated with a high rate of postoperative morbidity and mortality. There is a lack of consensus on the optimal anaesthetic technique but there is a clear association between intraoperative hypotension and postoperative morbidity and mortality. We aimed to compare the haemodynamic stability of three anaesthesia techniques: general anaesthesia (GA), continuous spinal anaesthesia (CSA), and multiple nerve blocks (MNB). METHODS The primary outcome was the occurrence of intraoperative hypotension defined by a 30% decrease in mean arterial pressure (MAP) from baseline. Secondary outcomes included incidence of hypotension under 50 mmHg of MAP, time spent below MAP 50 mmHg, use of vasopressors, in-hospital and 30-day mortality. A propensity score-matched analysis was performed. RESULTS After screening and application of the exclusion criteria, 593 patients undergoing hip fracture surgery between the 1st of January 2015 and the 31st of December 2016 were included. The propensity score match analysis selected 43 patients in each group. The incidence of hypotension was significantly higher in the GA group than in the MNB and CSA groups: 39 (90%), 22 (51%), and 23 (53.5%), respectively; p < 0.0001. The incidence of MAP < 50 mmHg (59.5%, 23.3%, and 16.3%; p < 0.0001) and the use of vasopressors (93%, 39.5%, and 25.6%; p < 0.0001) were increased significantly in the GA group. With the GA group as a reference, odds ratios were reported in the MNB group at 0.08 [0.022-0.30] (p = 0.0002) for hypotension episodes; 0.17 [0.04-0.66] (p = 0.01) for hypotension < 50 mmHg for more than 3 min and 0.049 [0.013-0.018] (p < 0.0001) for use of vasopressors. The duration of hospital stay, postoperative complications, in-hospital and 30-day mortality rates did not differ significantly between the groups. CONCLUSION CSA and MNB provide better haemodynamic stability than GA. However, whatever the anaesthesia technique used, the mortality rates do not change even if MNB leads to less hypotension. IRB contact information: CERAR IRB 00010254-2016-118. Clinical Trial Number: ClinicalTrials.gov. ID: NCT03356704.
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21
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Jiang M, Liu S, Deng H, Liang X, Bo Z. The efficacy and safety of fast track surgery (FTS) in patients after hip fracture surgery: a meta-analysis. J Orthop Surg Res 2021; 16:162. [PMID: 33639957 PMCID: PMC7913454 DOI: 10.1186/s13018-021-02277-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 02/01/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Fast track surgery (FTS) has been gradually applied in perioperative management of orthopedic surgery, but there still some research suspected that the prognosis of patients is not as expected and the cost is high, the effect of the FTS still urgently needed for support by evidence-based medicine. METHODS We retrieved RCTs from medical research literature databases. Risk ratios (RR), standard mean difference (SMD), and 95% confidence intervals (CI) were calculated to compare the primary and safety endpoints. RESULTS Overall, a total of 8886 patients were retrieved from 57 articles, of which 4448 patients (50.06%) were randomized to experimental group whereas 4438 patients (49.94%) were randomized to control group. The result showed that FTS could significantly shorten the length of stay (LOS), decrease the visual analog scale (VAS), reduce the leaving bed time and the hospitalization costs, and improve Harris hip joint function score. The incidence of complications such as respiratory system infection, urinary system infection, venous thrombus embolism (VTE), pressure sore, incision infection, constipation, and prosthesis dislocation also has been decreased significantly. Meanwhile, FTS improved patients' satisfaction apparently. CONCLUSIONS This meta-analysis reveals that FTS could significantly shorten the length of stay, alleviate the pain, reduce the leaving bed time and the hospitalization costs, and improve hip function. The incidence of complications also has been decreased significantly. Meanwhile, FTS has been spoken highly in patients in terms of nursing satisfaction. Its efficacy and safety were proved to be reliable.
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Affiliation(s)
- Mingyang Jiang
- Department of Bone and Joint Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Siyi Liu
- Guangxi Medical University, Nanning, Guangxi, China
| | - Huachu Deng
- Guangxi Medical University, Nanning, Guangxi, China
| | - Xuzhi Liang
- Guangxi Medical University, Nanning, Guangxi, China
| | - Zhandong Bo
- Department of Bone and Joint Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
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22
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Wolf O, Mukka S, Ekelund J, Möller M, Hailer NP. How deadly is a fracture distal to the hip in the elderly? An observational cohort study of 11,799 femoral fractures in the Swedish Fracture Register. Acta Orthop 2021; 92:40-46. [PMID: 33103546 PMCID: PMC7919867 DOI: 10.1080/17453674.2020.1831236] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Unlike hip fractures, diaphyseal and distal femoral fractures in elderly patients have not been widely studied. We investigated the demographics, comorbidities and mortality of patients with femoral fractures at any anatomical level with a focus on early mortality.Patients and methods - We analyzed 11,799 patients ≥ 65 years with a femoral fracture registered in the Swedish Fracture Register from 2011 to 2014. The cohort was matched with the National Patient Register to obtain data on comorbidities classified according to the Charlson Comorbidity Index (CCI). Generalized linear models were fitted to estimate the adjusted relative risk of mortality.Results - Mean age of the cohort was 83 years and 69% were women. Patients with distal femoral fractures had the lowest degree of comorbidity, with 9% having a CCI of ≥ 3 compared with 14% among those with proximal and 16% among those with diaphyseal fractures. Unadjusted 90-day mortalities were 13% (95% CI 9.4-16) after fractures in the distal, 13% (CI 10-16) in the diaphyseal, and 15% (CI 14-15) in the proximal segment. The adjusted relative risk for 90-day mortality was 1.1 (CI 0.86-1.4) for patients with distal and 0.97 (CI 0.76-1.2) for patients with diaphyseal femoral fractures when compared with patients with hip fractures.Interpretation - Elderly patients with femoral fractures distal to the hip may have similar adjusted early mortality risks to those with hip fractures. There is a need for larger, preferably prospective, studies investigating the effect of rapid pathways and geriatric co-management for patients with diaphyseal and distal femoral fractures.
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Affiliation(s)
- Olof Wolf
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala; ,Correspondence:
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences at Umeå University, Umeå;
| | - Jan Ekelund
- Centre of Registers Västra Götaland, Gothenburg;
| | - Michael Möller
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nils P Hailer
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala;
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Vanni F, Foglia E, Pennestrì F, Ferrario L, Banfi G. Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment. BMC Health Serv Res 2020; 20:773. [PMID: 32829712 PMCID: PMC7444253 DOI: 10.1186/s12913-020-05634-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 08/06/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The number of patients undergoing joint arthroplasty is increasing worldwide. An Enhanced Recovery After Surgery (ERAS) pathway for hip and knee arthroplasty was introduced in an Italian high-volume research hospital in March 2018. METHODS The aim of this mixed methods observational study is to perform a health technology assessment (HTA) of the ERAS pathway, considering 938 procedures performed after its implementation, by means of a hospital-based approach derived from the EUnetHTA (European Network for Health Technology Assessment) Core Model. The assessment process is based on dimensions of general relevance, safety, efficacy, effectiveness, economic and financial impact, equity, legal aspects, social and ethical impact, and organizational impact. A narrative review of the literature helped to identify general relevance, safety and efficacy factors, and a set of relevant sub-dimensions submitted to the evaluation of the professionals who use the technology through a 7-item Likert Scale. The economic and financial impact of the ERAS pathway on the hospital budget was supported by quantitative data collected from internal or national registries, employing economic modelling strategies to identify the amount of resources required to implement it. RESULTS The relevance of technology under assessment is recognized worldwide. A number of studies show accelerated pathways to dominate conventional approaches on pain reduction, functional recovery, prevention of complications, improvements in tolerability and quality of life, including fragile or vulnerable patients. Qualitative surveys on clinical and functional outcomes confirm most of these benefits. The ERAS pathway is associated with a reduced length of stay in comparison with the Italian hospitalization average for the same procedures, despite the poor spread of the pathway within the country may generate postcode inequalities. The economic analyses show how the resources invested in training activities are largely depreciated by benefits once the technology is permanently introduced, which may generate hospital cost savings of up to 2054,123.44 € per year. CONCLUSIONS Galeazzi Hospital's ERAS pathway for hip and knee arthroplasty results preferable to traditional approaches following most of the HTA dimensions, and offers room for further improvement. The more comparable practices are shared, the before this potential improvement can be identified and addressed.
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Affiliation(s)
- Francesco Vanni
- IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Emanuela Foglia
- Centre for Health Economics, Social and Health Care Management, LIUC Business School, LIUC - Università Cattaneo, Corso Matteotti 22, 21053, Castellanza, Varese, Italy
| | - Federico Pennestrì
- IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy.
| | - Lucrezia Ferrario
- Centre for Health Economics, Social and Health Care Management, LIUC Business School, LIUC - Università Cattaneo, Corso Matteotti 22, 21053, Castellanza, Varese, Italy
| | - Giuseppe Banfi
- IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy.,Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
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Svenøy S, Watne LO, Hestnes I, Westberg M, Madsen JE, Frihagen F. Results after introduction of a hip fracture care pathway: comparison with usual care. Acta Orthop 2020; 91:139-145. [PMID: 31928088 PMCID: PMC7144204 DOI: 10.1080/17453674.2019.1710804] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - We established a care pathway for hip fracture patients, a "Hip Fracture Unit" (HFU), aiming to provide better in-hospital care and thus improve outcome. We compared the results after introduction of the HFU with a historical control group.Patients and methods - The HFU consisted of a series of measures within the orthopedic ward, such as reducing preoperative waiting time, increased use of nerve blocks, early mobilization, and osteoporosis treatment. 276 patients admitted from May 2014 to May 2015 constituted the HFU group and 167 patients admitted from September 2009 to January 2012 constituted the historical control group. Patients were followed prospectively up to 12 months post fracture.Results - Mean preoperative waiting time was 24 hours in the HFU group and 29 hours in the control group (p = 0.003). 123 patients (47%) in the HFU were started on anti-osteoporosis treatment while in hospital. "Short Physical Performance Battery" score (SPPB) was mean 5.5 in the HFU group and 3.8 in the control group at 4 months (p < 0.001), and 5.7 vs. 3.6 at 12 months (p < 0.001). The mortality rate at 4 months was 15% in both groups. No statistically significant differences were found in readmissions, complications, new nursing home admissions, in Barthel ADL index or a mental capacity test at the follow-ups.
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Affiliation(s)
- Stian Svenøy
- Division of Orthopaedic Surgery, Oslo University Hospital; ,Institute of Clinical Medicine, University of Oslo; ,Correspondence:
| | - Leiv Otto Watne
- Department of Geriatric Medicine, Oslo University Hospital, Norway
| | | | | | - Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital; ,Institute of Clinical Medicine, University of Oslo;
| | - Frede Frihagen
- Division of Orthopaedic Surgery, Oslo University Hospital;
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25
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He W, You YY, Sun K, Xie C, Ming Y, Yu LN, Zhang FJ, Yan M. Admission delay is associated with worse surgical outcomes for elderly hip fracture patients: A retrospective observational study. World J Emerg Med 2020; 11:27-32. [PMID: 31893000 DOI: 10.5847/wjem.j.1920-8642.2020.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The influence of surgical delay on mortality and morbidity has been studied extensively among elderly hip fracture patients. However, most studies only focus on the timing of surgery when patients have already been hospitalized, without considering pre-admission waiting time. Therefore, the present study aims to explore the influence of admission delay on surgical outcomes. METHODS In this retrospective study, we recorded admission timing and interval from admission to surgery for included patient. Other covariates were also collected to control confounding. The primary outcome was 1-year mortality. The secondary outcomes were 1-month mortality, 3-month mortality, ICU admission and postoperative pneumonia. We mainly used multivariate logistic regression to determine the effect of admission timing on postoperative outcomes. An additional survival analysis was also performed to assess the impact of admission delay on survival status in the first year after operation. RESULTS The proportion of patients hospitalized on day 0, day 1, day 2 after injury was 25.4%, 54.7% and 66.3%, respectively. And 12.6% patients visited hospital one week later after injury. Mean time from admission to surgery was 5.2 days (standard deviation 2.8 days). Hospitalization at one week after injury was a risk factor for 1-year mortality (OR 1.762, 95% CI 1.026-3.379, P=0.041). CONCLUSION Admission delay of more than one week is significantly associated with higher 1-year mortality. As a supplement to the current guidelines which emphasizes early surgery after admission, we also advocate early admission once patients get injured.
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Affiliation(s)
- Wei He
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yue-Yang You
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Kai Sun
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Chen Xie
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou 221004, China
| | - Yue Ming
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Li-Na Yu
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Feng-Jiang Zhang
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Min Yan
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China.,Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou 221004, China
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26
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Wang PW, Li YZ, Zhuang HF, Yu HM, Cai SQ, Xu H, Chen ZH, Lin JK, Yao XD. Anti-Osteoporosis Medications Associated with Decreased Mortality after Hip Fracture. Orthop Surg 2019; 11:777-783. [PMID: 31429532 PMCID: PMC6819189 DOI: 10.1111/os.12517] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/25/2019] [Accepted: 07/21/2019] [Indexed: 12/31/2022] Open
Abstract
Objective To study the effect of anti‐osteoporosis therapies on mortality after hip fracture. Methods This retrospective study was carried out in the Second Affiliated Hospital of Fujian Medical University and enrolled 690 patients 50 years of age and older who were admitted with hip fractures between 2010 and 2015. The patients were followed in 2017: 690 patients aged was from 50 to 103 years. There were 456 women and 234 men. There were 335 patients with fractures of the femoral neck and 355 patients with intertrochanteric fractures of the femur. There were 444 (64.35%) patients who also had internal diseases. The Charlson comorbidity index was 0–6. The anti‐osteoporosis medications were classified into no anti‐osteoporosis medication, calcium + vitamin D supplementations, non‐bisphosphonate medication, and bisphosphonate medication. The physicians followed the patients or family members by personal visit and telephone. Multivariable Cox regression analyses were done with known risk factors for mortality of hip fracture, such as gender, age, number of combined internal diseases, fracture type, place of residence, and Charlson comorbidity index, to show which anti‐osteoporosis medications had significant effects on mortality after adjustment for these variables. Results Out of 690 patients with hip fractures, 149 patients received no anti‐osteoporosis medication, 63 patients received calcium +vitamin D supplementations, 398 patients received non‐bisphosphonate medication, and 80 patients received bisphosphonate medication. The patients were followed between 7 months and 52 months, with the average of 28.53 ± 9.75 months. A total of 166 patients died during the follow‐up period. Of 166 deaths, 43 occurred within 3 months, 65 within 6 months, and 99 within 1 year after the hip fracture. In this study, fracture type, place of residence, and Charlson comorbidity index were not associated with the mortality, and the male gender, age > 75 years, and ≥ 2 combined internal diseases were the independent factors for deaths post‐hip fracture. The cumulative mortality was 36.24% in the patients receiving no anti‐osteoporosis medication. The hazard ratio for mortality after hip fracture with bisphosphonate medication, non‐bisphosphonate medication, and calcium/vitamin D supplementation was 0.355 (95% CI, 0.194–0.648), 0.492 (95% CI, 0.347–0.699) and 0.616 (95% CI, 0.341–1.114), respectively, as compared with no anti‐osteoporosis group. Bisphosphonate and non‐bisphosphonate medications for osteoporosis were significantly associated with the reduction of cumulative mortality post‐hip fracture (P < 0.01). Conclusions Bisphosphonate and non‐bisphosphonate medications for osteoporosis were significantly associated with decreased mortality after fragility hip fracture.
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Affiliation(s)
- Pei-Wen Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yi-Zhong Li
- Department of Orthopaedics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hua-Feng Zhuang
- Department of Orthopaedics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hai-Ming Yu
- Department of Orthopaedics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Si-Qing Cai
- Department of Radiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hao Xu
- Department of Orthopaedics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Zhen-Hui Chen
- Department of Orthopaedics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Jin-Kuang Lin
- Department of Orthopaedics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xue-Dong Yao
- Department of Orthopaedics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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Pollmann CT, Røtterud JH, Gjertsen JE, Dahl FA, Lenvik O, Årøen A. Fast track hip fracture care and mortality - an observational study of 2230 patients. BMC Musculoskelet Disord 2019; 20:248. [PMID: 31122228 PMCID: PMC6533651 DOI: 10.1186/s12891-019-2637-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 05/16/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hip fracture patients are frail and have a high mortality. We investigated whether the introduction of fast track care reduced the 30-day mortality after hip fractures. METHODS Fast track hip fracture care was established at our institution in October 2013. Data from the Norwegian Hip Fracture Register and electronic hospital records were merged for 2230 hip fracture patients operated in our department from January 2012 through December 2015. 1090 of these patients were operated before (conventional treatment group) and 1140 patients were operated after the introduction of fast track care (fast track group). Data were analysed by univariate analysis and binary logistic regression. RESULTS Mortality did not differ significantly between the conventional treatment group and the fast track group at 30 days (7.9% vs. 6.5%), 90 days (13.5% vs. 12.5%) and one year (22.8% vs. 22.8%). Median admission time and time to surgery were significantly shorter in the fast track group than in the conventional treatment group (1.1 h vs. 3.9 h and 23.6 h vs. 25.7 h, both p < 0.0001). The 30-day reoperation rate was significantly lower in the fast track group compared to the conventional treatment group (odds ratio = 0.35 (95% CI: 0.15-0.84), p = 0.019). A composite 30-day outcome (reoperation, surgical site infection and/or death) was significantly less frequent in the fast track group (8.1%) than in the conventional treatment group (10.7%) in unadjusted analysis (p = 0.006), but not after adjusting for age, gender, cognitive impairment and ASA score (odds ratio = 0.85 (95% CI: 0.63-1.16), p = 0.31, 8.0% missing). Reoperations within 1 year, surgical site infections, 30-day readmissions and length of hospital stay did not differ significantly between the conventional treatment group and the fast track group. CONCLUSIONS Fast track hip fracture care is safe. However, we observed no statistically significant change in 30-day, 90-day or 1-year mortality after the introduction of fast track hip fracture care. TRIAL REGISTRATION The study was registered retrospectively at ClinicalTrials.gov (Protocol Record 284907 ) 6 December 2016.
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Affiliation(s)
- Christian Thomas Pollmann
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.
| | - Jan Harald Røtterud
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Jan-Erik Gjertsen
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - Fredrik Andreas Dahl
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Olav Lenvik
- Department of Data and Analytics, Akershus University Hospital, Lørenskog, Norway
| | - Asbjørn Årøen
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Program for Minimally Invasive Lumbar Decompression Spine Surgery: Initial Experience. Spine (Phila Pa 1976) 2019; 44:E561-E570. [PMID: 30325887 DOI: 10.1097/brs.0000000000002905] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study of prospectively collected data. OBJECTIVE The aim of this study was to describe the development of and early experience with an evidence-based enhanced recovery after surgery (ERAS) pathway for lumbar decompression. SUMMARY OF BACKGROUND DATA ERAS protocols have been consistently associated with improved patient experience and outcomes, and reduced cost and length of hospital stay (LoS). Despite successes in other orthopedic subspecialties, ERAS has yet to be established in spine surgery. Here, we report the development of and initial experience with the first comprehensive ERAS pathway for MIS lumbar spine surgery. METHODS An evidence-based review of the literature was performed to select components of the ERAS pathway. The pathway was applied to 61 consecutive patients presenting for microdiscectomy or lumbar laminotomy/laminectomy between dates. Data collection was performed by review of the electronic medical record. We evaluated compliance with individual ERAS process measures, and adherence to the overall pathway. The primary outcome was LoS. Demographics, comorbidities, perioperative course, prevalence of opioid tolerance, and factors affecting LoS were also documented. RESULTS The protocol included 15 standard ERAS elements. Overall pathway compliance was 85.03%. Median LoS was 279 minutes [interquartile range (IQR) 195-398 minutes] overall, 298 minutes (IQR 192-811) for lumbar decompression and 285 minutes (IQR 200-372) for microdiscectomy. There was no correlation between surgical subtype or duration and LoS. Overall, 37% of the cohort was opioid-tolerant at the time of surgery. There was no significant effect of baseline opioid use on LoS, or on the total amount of intraoperative or PACU opioid administration. There were four complications (6.5%) resulting in extended LoS (>23 hours). CONCLUSION This report comprises the first description of a comprehensive, evidence-based ERAS for spine pathway, tailored for lumbar decompression/microdiscectomy resulting in short LoS, minimal complications, and no readmissions within 90 days of surgery. LEVEL OF EVIDENCE 3.
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29
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Rate and Outcome of Acute Kidney Injury Following Hip Fracture Surgery in Diabetic Older Patients Treated with Renin–Angiotensin–Aldosterone Antagonists. Drugs Aging 2019; 36:667-674. [DOI: 10.1007/s40266-019-00671-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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30
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Downey C, Kelly M, Quinlan JF. Changing trends in the mortality rate at 1-year post hip fracture - a systematic review. World J Orthop 2019; 10:166-175. [PMID: 30918799 PMCID: PMC6428998 DOI: 10.5312/wjo.v10.i3.166] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/30/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.
AIM To address recent 1-year post hip fracture mortality rates in the literature.
METHODS Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation (2013-2017), cohorts > 100, studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.
RESULTS Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.
CONCLUSION There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.
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Affiliation(s)
- Colum Downey
- Department of Trauma and Orthopaedics, Tallaght University Hospital, Dublin 01, Ireland
| | - Martin Kelly
- Department of Trauma and Orthopaedics, Tallaght University Hospital, Dublin 01, Ireland
| | - John F Quinlan
- Department of Trauma and Orthopaedics, Tallaght University Hospital, Dublin 01, Ireland
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Frenkel Rutenberg T, Rutenberg R, Vitenberg M, Cohen N, Beloosesky Y, Velkes S. Prediction of readmissions in the first post-operative year following hip fracture surgery. Eur J Trauma Emerg Surg 2018; 46:939-946. [PMID: 30167740 DOI: 10.1007/s00068-018-0997-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/20/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE To define risk factors for rehospitalization following fragility hip fractures and to create a predictive model. METHODS A retrospective cohort study of patients 65 years and older, who were treated operatively following fragility hip fractures between 01.2011 and 06.2016. Patients were allocated into two study groups based on the occurrence of recurrent hospitalizations in the year following surgery. Demographic information, comorbidities, and in-hospital characteristics were collected, as was information regarding 1-year readmissions. Multivariate analysis of factors predictive of rehospitalizations was performed, followed by a logistic regression using all predictors with p < 0.05. A stepwise backwards elimination method was used to create the predictive model. RESULTS Eight hundred and fifty-one patients were included; 369 (43.4%) had recurrent hospitalizations within the first post-operative year. Patients who were rehospitalized were more likely to be males, to use a walking aid and to live dependently. They had a higher age-adjusted Charlson's comorbidity index (ACCI) score, a higher perveance of atrial fibrillation, lower hemoglobin, worse renal function, less platelets, and longer time to surgery. Prevalence of in-hospital complications was similar. Six variables were found to independently influence the chance for readmissions: male gender, the use of a walking aid, higher ACCI score, lower hemoglobin, atrial fibrillation, and a longer surgical delay. Only the first four were found to be adequate predictors and were added to the prediction formula. CONCLUSION High 1-year readmission rates are seen following discharge in patients with fragility hip fractures. Addressing risk factors might aid to better rehabilitate patients and reduce morbidity.
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Affiliation(s)
- Tal Frenkel Rutenberg
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 39 Jabotinsky St., Petah Tikva, 49100, Tel Aviv, Israel.
| | | | - Maria Vitenberg
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 39 Jabotinsky St., Petah Tikva, 49100, Tel Aviv, Israel
| | - Nir Cohen
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 39 Jabotinsky St., Petah Tikva, 49100, Tel Aviv, Israel
| | - Yichayaou Beloosesky
- Geriatric Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven Velkes
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 39 Jabotinsky St., Petah Tikva, 49100, Tel Aviv, Israel
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Furuhata H, Araki K, Ogawa T, Ikeda M. Effect on Completion of Clinical Pathway for Improving Clinical Indicator: Cases of Hospital Stay, Mortality Rate, and Comprehensive-Volume Ratio. J Med Syst 2017; 41:206. [PMID: 29134334 DOI: 10.1007/s10916-017-0857-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/01/2017] [Indexed: 12/26/2022]
Abstract
Many studies have analyzed the effects of clinical pathways, but most have considered only single diseases. The purpose of the present study was to exploratively analyze electronic medical records related to the use of clinical pathways, seeking trends that could usefully benefit clinical activity. From the data warehouse of University of Miyazaki Hospital, collected from April 2014 to March 2016, we retrospectively identified 6523 patients for whom a clinical pathway was applied. Other inclusion criteria were single hospitalization, the type of medical fee was comprehensive, and data were available so that all clinical indicators could be calculated. Two types of deviation from the clinical pathway were defined: cancellation (described in the clinical pathway but not implemented) and addition (not described in the clinical pathway but nevertheless implemented). If the code of International Classification of Diseases describing the clinical pathway differed from that describing where the medical resource was mostly spent, we considered this as indicating a complication. We compared principal clinical indicators (length of hospital stay, mortality rate, and comprehensive-volume ratio) by completion rate for the clinical pathway. Regardless of whether patients had complications, completing the clinical pathway was associated with a significant reduction in length of hospital stay. This finding indicated that length of hospital stay could be shortened if all medical treatments described in the clinical pathway were implemented. Our results demonstrated that it is possible to shorten the length of hospital stay by improving clinical pathways to include medical treatment for preventing complications.
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Affiliation(s)
- Hiroki Furuhata
- School of Knowledge Science, Japan Advanced Institute of Science and Technology, Ishikawa, Japan.
- Department of Medical Informatics, University of Miyazaki Hospital, Miyazaki, Japan.
| | - Kenji Araki
- Department of Medical Informatics, University of Miyazaki Hospital, Miyazaki, Japan
| | - Taisuke Ogawa
- Department of Medical Informatics, University of Miyazaki Hospital, Miyazaki, Japan
| | - Mitsuru Ikeda
- School of Advanced Science, Japan Advanced Institute of Science and Technology, Ishikawa, Japan
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