Comparison of an organized geriatric fracture program to United States government data

Do we understand each other when we develop and implement hip fracture models of care? A systematic review with narrative synthesis

BACKGROUND

A hip fracture in an older person is a devastating injury. It impacts functional mobility, independence and survival. Models of care may provide a means for delivering integrated hip fracture care in less well-resourced settings. The aim of this review was to determine the elements of hip fracture models of care to inform the development of an adaptable model of care for low and middle-income countries (LMICs).

METHODS

Multiple databases were searched for papers reporting a hip fracture model of care for any part of the patient pathway from injury to rehabilitation. Results were limited to publications from 2000. Titles, abstracts and full texts were screened based on eligibility criteria. Papers were evaluated with an equity lens against eight conceptual criteria adapted from an existing description of a model of care.

RESULTS

82 papers were included, half of which were published since 2015. Only two papers were from middle-income countries and only two papers were evaluated as reporting all conceptual criteria from the existing description. The most identified criterion was an evidence-informed intervention and the least identified was the inclusion of patient stakeholders.

CONCLUSION

Interventions described as models of care for hip fracture are unlikely to include previously described conceptual criteria. They are most likely to be orthogeriatric approaches to service delivery, which is a barrier to their implementation in resource-limited settings. In LMICs, the provision of orthogeriatric competencies by other team members is an area for further investigation.

Risk Factors and Outcomes of Extended Length of Stay in Older Adults with Intertrochanteric Fracture Surgery: A Retrospective Cohort Study of 2132 Patients

We aimed to identify the risk factors associated with an extended length of hospital stay (eLOS) in older hip-fracture patients and to explore the relationships between eLOS and mortality and functional outcomes. In this retrospective analysis of surgically treated intertrochanteric fracture (IF) patients, all variables were obtained and compared between the eLOS group and the normal LOS group. All participants were followed-up for a minimum of two years and the relation between the eLOS and all-cause mortality and functional outcomes were compared. After adjustment for potential confounders, we identified that patients with high modified Elixhauser's Comorbidity Measure (mECM) had the highest likelihood of eLOS, followed by obesity, admission in winter, living in urban, pulmonary complications, admission in autumn, and time from injury to surgery. In addition, our results showed no significant difference in the mortality and functional outcomes between the two groups during follow-up. By identifying these risk factors in the Chinese geriatric population, it may be possible to risk-stratify IF patients and subsequently streamline inpatient resource utilization. However, the differences between health care systems must be taken into consideration. Future studies are needed to preemptively target the modifiable risk factors to demonstrate benefits in diminishing eLOS.

Barriers and Enablers to Early Identification, Referral and Access to Geriatric Rehabilitation Post-Hip Fracture: A Theory-Based Descriptive Qualitative Study

Background

Geriatric hip fracture patients often experience gaps in care including variability in the timing and the choice of an appropriate setting for rehabilitation following hip fracture surgery. Many guidelines recommend standardized processes, including timely access of no later than day 6 to rehabilitation services. A pathway for early identification, referral and access to geriatric rehabilitation post-hip fracture was created to facilitate the implementation. The study aimed to describe the barriers and enablers prior to the implementation of this pathway.

Methods

We conducted a qualitative descriptive study consisting of semi-structured interviews with geriatric hip fracture patients (n = 8), caregivers (n = 1), administrators (n = 12) and clinicians (n = 17) in 2 orthopaedics units and a geriatric rehabilitation service. Responses were analysed using a systematic approach, and overarching themes describing the barriers and enablers were identified.

Results

The clinicians’ and administrators’ top barriers to implementation of the pathway were competing demands (n = 24); lack of bed availability, community resources and funding (n = 19); and the need for extended hours and increased staff (n = 16). The top 3 enablers were clear communication with patients (n = 27), awareness of the benefits of geriatric rehabilitation (n = 24) and the need for education and resources to properly use the pathway (n = 15). Common barriers among patients and caregivers included lack of care coordination, overcoming some of their own specific challenges during their transition, gaps in the information they received before discharge, not knowing what questions to ask and lack of resources. Despite these barriers, patients were generally pleased with their transition from the hospital to geriatric rehabilitation.

Conclusion

We identified and described key barriers and enablers to early identification, referral and access to geriatric rehabilitation post-hip fracture. These influencing factors provide a basis for the development of a standardized pathway aimed at improving access to rehabilitative care for geriatric hip fracture patients.

Internal medicine physician embedded in an orthopedic service in a level 1 hospital: clinical impact

BACKGROUND

The aim of our study was to evaluate the impact of an internist physician specialized in diabetes, appointed as an in-house physician in the orthopedic wards, on improving clinical outcomes and in particular 30-day mortality.

METHODS

We analyzed a cohort of patients hospitalized more than 24 h in the orthopedic service. The analyses included a comparative analysis between the pre- and post-intervention time periods and an interrupted time series (ITS) analysis, which were conducted in stratification to three populations: whole population, patients with at least one chronic disease and/or older than 75 years of age and patients diagnosed with diabetes. The primary outcome was 30-day mortality following the hospitalization.

RESULTS

A total of 11,546 patients were included in the study, of which 19% (2212) were hospitalized in the post intervention period. Although in the comparative analysis there was no significant change in 30-day mortality, in the ITS there was a decrease in the mortality trend during the post intervention period in the entire and chronic disease/elderly populations, compared to no change during the pre-intervention period: a post-intervention slope of - 0.14(p value < 0.001) and  - 0.11(p value = 0.03), respectively. Additionally, we found decrease in length of stay, increase in transfers to the internal medicine department with a negative trend, increase in HbA1c testing during the hospitalization and changes in diabetes drugs administration.

CONCLUSION

The presence of an internist in the orthopedic wards is associated with health care improvement; decrease in the 30-day mortality trend, decrease in length of stay, increase in HbA1c testing during the hospitalization and an increase in diabetes drugs administration.

Improving outcomes after hip fracture at a safety net hospital with a standardised hip fracture protocol

INTRODUCTION

standardised protocols for the care of geriatric hip fractures demonstrate improved patient outcomes with decreased cost. The purpose of this study is to evaluate outcomes of a standardised hip fracture protocol at an urban safety-net hospital.

METHODS

All trauma patients presenting to our urban safety-net hospital are included in a trauma database and inpatient outcomes recorded. A hip fracture protocol was introduced at our institution in 2015, which depended on admission to a monitored setting due to the absence of a geriatric co-management service. The database was queried to identify patients surgically treated for a geriatric hip fracture in the 3 years prior to protocol implementation (2012-2014) and patients treated in the 3 years following protocol implementation (2016-2018). Demographics, time to surgery, inpatient complications, and length of stay were compared between groups.

RESULTS

A total of 633 patients treated operatively for isolated hip fractures were identified, 262 patients in the 2012-2014 pre-protocol cohort, and 371 patients in the 2016-2018 protocol cohort. Following implementation of a hip fracture protocol the number of patients admitted to a surgical service increased from 198 (76%) to 348 (94%, p < 0.005) with the number of patients being admitted to a monitored setting increasing from 40 (15%) to 83 (22%, p = 0.026). The time to surgery was reduced to 2.75 days (p = 0.054). The complication rate fell from 23% to 4% (p < 0.0005). Length of stay was significantly reduced from 13.2 days to 12 days (p = 0.045).

CONCLUSIONS

A hip fracture protocol including admission to a monitored setting can be effectively implemented at an urban safety-net hospital where geriatric co-management is not available. This resulted in a decrease in complications and length of stay. Additional interventions are required to decrease average time to surgery below 36 hours.

Risk Factors Associated With Extended Length of Hospital Stay After Geriatric Hip Fracture

Introduction:

Within the geriatric hip fracture population, there exists a subset of patients whose length of inpatient hospital stay is excessive relative to the average. A better understanding of the risk factors associated with this group would be of value so that targeted prevention efforts can be properly directed. The goal of this study was to identify and characterize the risk factors associated with an extended length of hospital stay (eLOS) in the geriatric hip fracture population. In addition, a statistical model was created to predict the probability of eLOS in a geriatric hip fracture patient.

Methods:

The National Surgical Quality Improvement Program database (2005 to 2018) was searched for patients aged ≥65 years who underwent hip fracture surgery. Patients with a hospital stay greater than or equal to 14 days were considered to have an eLOS. A multivariate logistic regression model using 24 patient characteristics from two-thirds of the study population was created to determine independent risk factors predictive of having an eLOS; the remaining one-third of the population was used for internal model validation. Regression analyses were performed to determine preoperative and postoperative risk factors for having an eLOS.

Results:

A total of 77,144 patients were included in the study. Preoperatively, male sex, dyspnea, ventilator use, chronic obstructive pulmonary disease, American Society of Anesthesiologist class 3 and 4, and increased admission-to-operation time were among the factors associated with higher odds of having an eLOS (all P < 0.001). Postoperatively, patients with acute renal failure had the highest likelihood of eLOS (odds ratio [OR] 7.664), followed by ventilator use >48 hours (OR 4.784) and pneumonia (OR 4.332).

Discussion:

Among geriatric hip fracture patients, particular efforts should be directed toward optimizing those with preoperative risk factors for eLOS. Preemptive measures to target the postoperative complications with the strongest eLOS association may be beneficial for both the patient and the healthcare system as a whole.

Implementing a Geriatric Fracture Program in a Mixed Practice Environment Reduces Total Cost and Length of Stay

Introduction:

Geriatric-orthopaedic co-management models can improve patient outcomes. However, prior reports have been at large academic centers with “closed” systems and an inpatient geriatric service. Here we describe a Geriatric Fracture Program (GFP) in a mixed practice “pluralistic” environment that includes employed academic faculty, private practice physicians, and multiple private hospitalist groups. We hypothesized GFP enrollment would reduce length of stay (LOS), time to surgery (TTS), and total hospital costs compared to non-GFP patients.

Materials and Methods:

A multidisciplinary team was created around a geriatric Nurse Practitioner (NP) and consulting geriatrician. Standardized geriatric focused training programs and electronic tools were developed based on best practice guidelines. Fracture patients >65 years old were prospectively enrolled from July 2018 – June 2019. A trained biostatistician performed all statistical analyses. A p < 0.05 was considered significant.

Results:

564 operative and nonoperative fractures in patients over 65 were prospectively followed with 153 (27%) enrolled in the GFP and 411 (73%) admitted to other hospitalists or their primary care provider (non-GFP). Patients enrolled in the GFP had a significantly shorter median LOS of 4 days, compared to 5 days in non-GFP patients (P < 0.001). There was a strong trend towards a shorter median TTS in the GFP group (21.5 hours v 25 hours, p = 0.066). Mean total costs were significantly lower in the GFP group ($25,323 v $29085, p = 0.022)

Discussion:

Our data shows that a geriatric-orthopaedic co-management model can be successfully implemented without an inpatient geriatric service, utilizing the pre-existing resources in a complex environment. The program can be expanded to include additional groups to improve care for entire geriatric fracture population with significant anticipated cost savings.

Conclusions:

With close multidisciplinary team work, a successful geriatric-orthopaedic comanagement model for geriatric fractures can be implemented in even a mixed practice environment without an inpatient geriatrics service.

High- Versus Low-Energy Acetabular Fracture Outcomes in the Geriatric Population

Introduction:

High-energy mechanisms of acetabular fracture in the geriatric population are becoming increasingly common as older adults remain active later in life. This study compared outcomes for high- versus low-energy acetabular fractures in older adults.

Materials and Methods:

We studied outcomes of 22 older adults with acetabular fracture who were treated at a level-I trauma center over a 4-year period. Fourteen patients were categorized as low-energy mechanism of injury, and 8 were identified as a high-energy mechanism. We analyzed patient demographics with univariate logistic regressions performed to assess differences in high- and low-energy group as well as patient characteristics compared with surgical outcomes.

Results:

Most high-energy mechanisms were caused by motor vehicle collision (n = 4, 50.0%), with most having posterior wall fractures (50.0%). Among patient characteristics, the mechanism of injury, hip dislocation, fracture types, and fracture gap had the largest differences between energy groups effect size (ES: 2.45, 1.43, 1.36, and 0.83, respectively). The high-energy group was more likely to require surgery (odds ratio [OR] = 2.80, 95% CI: 0.26-30.70), develop heterotopic bone (OR = 4.33, 95% CI: 0.33-57.65), develop arthritis (OR = 3.60, 95% CI: 0.45-28.56), and had longer time to surgery (mean = 4.8 days, standard deviation [SD] = 5.8 days) compared to low-energy group (mean = 2.5 days, SD = 2.3 days).

Discussion:

The results of this case series confirm previous findings that patients with high-energy acetabular fractures are predominantly male, younger, and have fewer comorbidities than those who sustained low-energy fractures. Our results demonstrate that the majority of the high-energy fracture patients also suffered a concurrent hip dislocation with posterior wall fracture and experienced a longer time to surgery than the low-energy group.

Conclusion:

Geriatric patients who sustained high-energy acetabular fractures tend to have higher overall rates of complications, including infection, traumatic arthritis, and heterotopic bone formation when compared with patients with a low-energy fracture mechanism.

Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society

BACKGROUND

The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities.

METHODOLOGY

A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS.

RESULTS/CONCLUSION

A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study

BACKGROUND/OBJECTIVES

For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture.

DESIGN

Retrospective chart review.

SETTING

Seven hospitals (three tertiary, four community) within a large health system.

PARTICIPANTS

Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married).

MEASUREMENTS

Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality.

RESULTS

Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE.

CONCLUSION

This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690-1697, 2020.

The "Hip Fracture" Bundle-Experiences, Challenges, and Opportunities

Introduction:

With growing popularity and success of alternative-payment models (APMs) in elective total joint arthroplasties, there has been recent discussion on the probability of implementing APMs for geriatric hip fractures as well.

Significance:

Despite the growing interest, little is known about the drawbacks and challenges that will be faced in a stipulated “hip fracture” bundle.

Results:

Given the varying intricacies and complexities of hip fractures, a “one-size-fits-all” bundled payment may not be an amenable way of ensuring equitable reimbursement for participating physicians and hospitals.

Conclusions:

Health-policy makers need to advocate for better risk-adjustment methods to prevent the creation of financial disincentives for hospitals taking care of complex, sicker patients. Hospitals participating in bundled care also need to voice concerns regarding the grouping of hip fractures undergoing total hip arthroplasty to ensure that trauma centers are not unfairly penalized due to higher readmission rates associated with hip fractures skewing quality metrics. Physicians also need to consider the launch of better risk-stratification protocols and promote geriatric comanagement of these patients to prevent occurrences of costly adverse events.

Prevalence of Postoperative Periprosthetic Femur Fractures Between Two Different Femoral Component Designs Used in Direct Anterior Total Hip Arthroplasty

BACKGROUND

Periprosthetic femur fractures are a well-documented complication following direct anterior uncemented total hip arthroplasty. The purpose of this study is to compare the prevalence of postoperative periprosthetic femur fractures between 2 different femoral component designs used in direct anterior total hip arthroplasty.

METHODS

Beginning in February 2015, a single fellowship-trained adult reconstruction surgeon performed 361 consecutive direct anterior total hip replacements using a flat, single-taper, wedged femoral implant. In June 2016, that same surgeon, using the exact same surgical technique and postoperative weight-bearing protocol, began using a dual-taper, hydroxyapatite-coated implant for 789 consecutive hips. The patients were carefully monitored for 3 months after surgery to identify the frequency of periprosthetic femur fractures. A Fisher's exact test was used to determine if the prevalence of periprosthetic femur fractures differed between the 2 implant designs.

RESULTS

Five of 361 (1.4%) patients sustained proximal femur fractures at an average of 19.6 days postoperatively in the first group, all demonstrating a Vancouver type B2 periprosthetic fracture and requiring femoral revision. No patients (0/789, 0%) in the second cohort sustained a postoperative, periprosthetic fracture (P = .006).

CONCLUSION

In this comparison of 2 consecutive cohorts, the dual-taper, hydroxyapatite-coated implant had a statistically significant lower postoperative periprosthetic fracture rate than a flat, single-taper, wedged design.

The impact of an orthogeriatric intervention in patients with fragility fractures: a cohort study

Background

While orthogeriatric care to patients with hip fractures is established, the impact of similar intervention in patients with fragility fractures in general is lacking. Therefore, we aimed to assess the impact of an orthogeriatric intervention on postoperative complications and readmissions among patients admitted due to and surgically treated for fragility fractures.

Methods

A prospective observational cohort study with a retrospective control was designed. A new orthogeriatric unit for acute patients of sixty-five years or older with fragility fractures in terms of hip, vertebral or appendicular fractures was opened on March 1, 2014. Patients were excluded if the fracture was cancer-related or caused by high-energy trauma, if the patient was operated on at another hospital, treated conservatively with no operation, or had been readmitted within the last month due to fracture-related complications.

Results

We included 591 patients; 170 in the historical cohort and 421 in the orthogeriatric cohort. No significant differences were found between the two cohorts with regard to the proportion of participants experiencing complications (24.5% versus 28.3%, p = 0.36) or readmission within 30 days after discharge (14.1% vs 12.1%, p = 0.5). With both cohorts collapsed and adjusting for age, gender and CCI, the odds of having postoperative complications as a hip fracture patient was 4.45, compared to patients with an appendicular fracture (p <  0.001). Furthermore, patients with complications during admission were at a higher risk of readmission within 30 days than were patients without complications (22.3% vs 9.5%, p <  0.001).

Conclusions

In older patients admitted with fragility fractures, our model of orthogeriatric care showed no significant differences regarding postoperative complications or readmissions compared to the traditional care. However, we found significantly higher odds of having postoperative complications among patients admitted with a hip fracture compared to other fragility fractures. Additionally, our study reveals an increased risk of being readmitted within 30 days for patients with postoperative complications.

Hip fracture co-management in the elderly in a tertiary referral hospital: A cohorts study

INTRODUCTION

Hip fracture in the elderly is one of the most prevalent diagnoses in Orthopedic Surgery Departments. It has a great impact in medical, economic and social terms. Our objective is to analyze clinical impact of a co-management care model between orthopedic surgery and internal medicine departments for elderly patients admitted with hip fracture in a tertiary referral hospital.

MATERIAL AND METHODS

Retrospective cohort study of patients older than 65 years old admitted with hip fracture between January 2005-August 2006 (HIST cohort) without a co-management care model, and between January 2008-August 2010 (COFRAC cohort) with a co-manEdadment care model. Analysis of demographic, clinical and surgery characteristics, complications incidence and mortality and re-admissions at 30 days was made.

RESULTS

A total of 701 patients were included (471 HIST, 230 COFRAC). There were no differences in sex, gender, time to surgery, type of anesthesia and surgery, length of stay, ambulation at discharge and 30-days emergency room consultation, readmissions or mortality at 30 days. There were differences in identification of polypatological patients (16.8 vs. 24.4%, P=0.02), presence of osteoporosis (3.9 vs. 7.6%, P=0.03), motor deficit (3.5 vs. 8.8%, P=0.03), number of chronic drugs (3.7±2.5 vs. 4.3±3.2, P<0.01), diagnosis of delirium (15.6 vs. 20.9%, P=0.048), constipation (80.3 vs. 74.7%, p<0.001), monitoring of anemia (83.3 vs. 97.1%, P>0.01) and renal failure at discharge (44.5 vs. 97.3%, P<0.01) and hospital mortality (4.6 vs. 1.3%, P=0.02).

CONCLUSIONS

Co-management for elderly patients admitted with hip fracture provides a better information about previously chronic conditions, a higher control of hospital complications and decreases hospital mortality.

Standardized Hospital-Based Care Programs Improve Geriatric Hip Fracture Outcomes: An Analysis of the ACS NSQIP Targeted Hip Fracture Series

OBJECTIVE

To determine relative complication rates and outcome measures in patients treated under a standardized hip fracture program (SHFP).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who underwent operative fixation of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures in 2016. Cohorts of patients who were and were not treated under a documented SHFP were identified. Relevant perioperative clinical and outcomes data were collected. Multivariate regression was used to assess risk-adjusted complication rates and outcomes for patients treated in SHFPs.

RESULTS

A total of 9360 hip fracture patients were identified of whom 5070 (54.2%) were treated under a documented SHFP. Median age was 84 years, and 69.9% of patients were women. Patients in an SHFP had a lower risk-adjusted incidence of postoperative deep vein thrombosis [odds ratio (OR) 0.48 (0.32-0.72), P < 0.001]. Rates of other medical and surgical complications and 30-day mortality were statistically comparable. Risk-adjusted evaluation showed that SHFP patients were less likely to be discharged to an inpatient facility versus home [OR 0.72 (0.63-0.81), P < 0.001] and had a lower 30-day readmission rate [OR 0.83 (0.71-0.97), P = 0.023]. Furthermore, the SHFP patients had higher rates of immediate postoperative weight-bearing as tolerated [OR 1.23 (1.10-1.37), P < 0.001], adherence to deep vein thrombosis prophylaxis at 28 days [OR 1.27 (1.16-1.38), P < 0.001], and initiation of bone protective medications [OR 1.79 (1.64-1.96), P < 0.001].

CONCLUSIONS

Care in a modern hospital-based SHFP is associated with improved short-term outcome measures. Further development and widespread implementation of organized, multidisciplinary orthogeriatric hip fracture protocols is recommended.

LEVEL OF EVIDENCE

Therapeutic Level III.

A Comparison of Geriatric Hip Fracture Databases

INTRODUCTION

The National Surgical Quality Improvement Project (NSQIP) and the Trauma Quality Improvement Project (TQIP) collect data on geriatric hip fractures (GHFs) that could be used to generate risk-adjusted metrics for care of these patients. We examined differences between GHFs reported by our own trauma center to the NSQIP and TQIP and those vetted through an internal GHF list.

METHODS

We reviewed charts of GHFs treated between January 1 and December 31, 2015, and compared patients in an internal GHF database and/or reported to the NSQIP and/or TQIP and determined differences between databases.

RESULTS

We identified 89 "true" GHFs, of which 96% were identified by our institutional database, 70% by NSQIP, and 9% by the TQIP. No differences were found in outcomes and total costs. The net revenue/patient in the NSQIP database was $24,373 more than those in the institutional database.

CONCLUSION

Caution should be taken when using NSQIP/TQIP databases to evaluate the care of GHFs.

LEVEL OF EVIDENCE

Level III.

High prevalence of deep vein thrombosis in elderly hip fracture patients with delayed hospital admission

PURPOSE

Deep vein thrombosis (DVT) is a common complication in hip fracture patients, associated with significant morbidity and mortality. Research has focused on postoperative DVT, with scant reports on preoperative prevalence. The aim of this study was to describe the prevalence of preoperative DVT in patients accessing medical care ≥ 48 h after a hip fracture.

METHODS

We included elderly patients admitted ≥ 48 h after sustaining a hip fracture, between September 2015 and October 2017. Patients with a previous episode of DVT, undergoing anticoagulation therapy, with pathologic fractures or undergoing cancer treatment were excluded. Of 273 patients, 59 were admitted at least 48 h after the fracture. DVT screening by Doppler ultrasound of both lower extremities was carried upon hospital admission. We recorded age, sex, Charlson comorbidity index and ASA score, fracture type, time since injury, time from admission to surgery and total length of hospital stay.

RESULTS

We studied 41 patients, 79 (± 10.34) years old. The delay from injury to admission was 120 h (48-696 h). Seven patients (17.1%) had a DVT upon admission. There were no significant differences between patients with and without DVT, regarding time from admission to surgery or the total length of the hospital stay.

CONCLUSIONS

The prevalence of DVT in patients admitted ≥ 48 h after a hip fracture was 17.1%. The diagnosis and management of DVT did not increase time to surgery or hospital stay. Our results suggest routine screening for DVT in patients consulting emergency services ≥ 48 h after injury.

ValuedCare program: a population health model for the delivery of evidence-based care across care continuum for hip fracture patients in Eastern Singapore

BACKGROUND

To test a population health program which could, through the application of process redesign, implement multiple evidence-based practices across the continuum of care in a functionally integrated health delivery system and deliver highly reliable and consistent evidence-based surgical care for patients with fragility hip fractures in an acute tertiary general hospital.

METHODS

The ValuedCare (VC) program was developed in three distinct phases as an ongoing collaboration between the Geisinger Health System (GHS), USA, and Changi General Hospital (CGH), Singapore, modelled after the GHS ProvenCare® Fragile Hip Fracture Program. Clinical outcome data on consecutive hip fracture patients seen in 12 months pre-intervention were then compared with the post-intervention group. Both pre- and post-intervention groups were followed up across the continuum of care for a period of 12 months.

RESULTS

VC patients showed significant improvement in median time to surgery (97 to 50.5 h), as well as proportion of patients operated within 48 h from hospital admission (48% from 18.8%) as compared to baseline pre-intervention data. These patients also had significant reduction (p value < 0.001) of acute inpatient complications such as delirium, pneumonia, urinary tract infections, and pressure sores. VC program has shown significant reduction in median length of stay for acute hospital (13 to 9 days) as well as median combined length of stay for acute and sub-acute rehabilitation hospital (46 to 39 days), thus reducing the total duration of hospitalization and saving total hospital bed days. Operative and inpatient mortality, together with readmission rates, remained low and comparable to international Geriatric Fracture Centers (GFCs).

CONCLUSION

The implementation of VC methodology has enabled consistent delivery of high-quality, reliable and comprehensive evidence-based care for hip fracture patients at Changi General Hospital. This has also reflected successful change management and interdisciplinary collaboration within the organization through the program. There is potential for testing this methodology as a quality improvement framework replicable to other disease groups in a functionally integrated healthcare system.

Cost-effectiveness of Open Reduction and Internal Fixation Compared With Hemiarthroplasty in the Management of Complex Proximal Humerus Fractures

Objectives

To determine if open reduction and internal fixation (ORIF) is more cost-effective than hemiarthroplasty (HA) in the management of proximal humerus fracture.

Design

Retrospective cohort study with cost-effectiveness analysis.

Setting

Tertiary referral center in Rochester, NY.

Patients/participants

The records of 459 consecutive patients in whom a proximal humerus fracture was treated surgically at our institution between the years 2002 and 2012 were studied retrospectively. We identified 30 consecutive patients with a mean follow-up of 60.3 months (13.6–134.5 months) of which 15 patients underwent primary ORIF and another 15 underwent primary HA for the management of head-splitting fracture or fracture-dislocation of the proximal humerus.

Intervention

HA or ORIF for the management of proximal humerus fracture.

Main outcome measurements

SF-36 scores were converted to utility weights, and a cost-effectiveness model was designed to evaluated ORIF and HA.

Results

Given the baseline assumptions, ORIF was slightly more costly but also more effective (0.75 quality-adjusted life years [QALY] vs 0.67 QALY) than HA. The incremental cost-effectiveness ratio (ICER) was $5319/QALY for ORIF compared to HA, which is less than the cost-effectiveness standard utilized based on a willingness to pay of $50,000/QALY.

Conclusions

Compared to HA, ORIF is the more cost-effective approach for the surgical management of complex proximal humerus fractures. These data are limited by patient selection which would impact the relative utility scores. These results suggest that ORIF should be considered the preferable surgical approach given payer and patient perspectives. Level of Evidence: This is a Level III retrospective, cohort therapeutic study.

Nutritional markers may identify patients with greater risk of re-admission after geriatric hip fractures

PURPOSE

Osteoporotic hip fractures are increasing in prevalence with the growing elderly population. Morbidity and mortality remain high following osteoporotic hip fractures despite advances in medical and surgical treatments. The associated costs and medical burdens are increased with a re-admission following hip fracture treatment. This study sought to identify demographic and clinical values that may be a predictive model for 30-day re-admission risk following operative management of an isolated hip fracture.

METHODS

Between January 1, 2013 and April 30, 2015 all patients admitted to a single academic medical centre for treatment of a hip fracture were reviewed. Candidate variables included standard demographics, common laboratory values, and markers of comorbid conditions and nutrition status. A 30-day, all-cause re-admission model was created utilizing multivariate logistic regression.

RESULTS

A total of 607 patients with hip fractures were identified and met the inclusion criteria; of those patients, 67 were re-admitted within 30 days. Univariate analysis indicates that the re-admission group had more comorbidities (p < 0.001) and lower albumin (p = 0.038) and prealbumin (p < 0.001). The final, reduced model contained 12 variables and incorporated four out of five nutritional makers with an internally, cross-validated C-statistic of 0.811 (95% CI: 0.754, 0.867).

CONCLUSION

Our results indicate that specific nutritional laboratory markers at the index admission may identify patients that have a greater risk of re-admission after hip fracture. This model identifies potentially modifiable risk factors and may allow orthogeriatricians to better educate patients and better treat post-operative nutritional status and care.

Using a Comanagement Model to Develop a Hip Fracture Integrated Care Pathway

EXECUTIVE SUMMARY

Hip fracture care represents a service line that profoundly affects patients' quality of life. As hospitals and physicians are motivated to improve quality, reduce costs, and maximize efficiency of care, several alignment models have been proposed under new healthcare legislation. Evaluation of such models as they pertain to hip fracture care warrants further investigation. In this article, we identify the current model of operations present in large healthcare organizations, examine the reasoning behind hospital-physician alignment, and describe specific comanagement principles that are common in healthcare settings. Furthermore, the effects of a comanagement model on a hip fracture integrated care pathway will be demonstrated through a case study. A comanagement team was formed at a Level I academic trauma center to create an integrated care pathway for the hip fracture service line. An internal data review of hip fracture cases before and after implementation of the pathway was undertaken to assess the impact of this model in terms of postoperative outcomes and resource utilization. The postimplementation group displayed more observant care while consuming fewer resources. Thus, the comanagement model described in this article serves as a powerful tool, allowing hospitals and physicians to improve the quality of care. This study provides recommendations based on our success in the hip fracture setting that may be extrapolated to improve service lines and healthcare efficiency nationally.

Costs Associated With Geriatric Ankle Fractures

INTRODUCTION

Ankle fractures are the third most common orthopaedic injury seen in the geriatric patient. Studies have identified mortality benefits with operative management, but treatment must be considered on a case-by-case basis. In the era of value-based analysis, a thorough of understanding of outcomes and costs of treatment is required. The purpose of this study was to analyze the inpatient and readmission costs associated with operative and nonoperative management of geriatric ankle fractures.

METHODS

Patients were identified using diagnosis codes for ankle fractures from all 2008 Part A Medicare claims. Patients younger than 65 years and those who sustained an ankle fracture during the previous year were excluded. Operative patients were then identified by ICD-9 procedure codes. Other variables collected included age, comorbidities, and the incidence of hospital readmissions. Inpatient costs were determined using Medicare reimbursement data.

RESULTS

A total of 19 648 patients with ankle fractures were identified. Of these, 15 193 (77.3%) underwent operative intervention. The mean cost for initial fracture admission was $5097.20 for nonoperative management compared with $8798.10 for operative management (  P < .05). The mean inpatient costs associated with readmission for nonoperative intervention was $5161.50 and for operative treatment, it was $5071.40 (  P > .05). The reimbursement for hospital readmissions for both groups combined for approximately $29.7 million. The total cost of initial treatment plus readmission for both treatment groups combined was approximately $185 million.

DISCUSSION

The total expenditure estimate of $185 million in this study has likely increased given the steady growth of the geriatric population. Expenditures associated with these readmissions was approximately $30 million-nearly a sixth of total costs. Future work must focus on determining which patients will benefit from operative intervention and optimizing care to decrease readmissions and their associated cost in this growing cohort of patients.

LEVELS OF EVIDENCE

Therapeutic, Level III: Retrospective study.

An Orthopedic-Hospitalist Comanaged Hip Fracture Service Reduces Inpatient Length of Stay

Introduction:

Hip fractures are common in the elderly patients with an incidence of 320 000 fractures/year in the United States, representing a health-care cost of US$9 to 20 billion. Hip fracture incidence is projected to increase dramatically. Hospitals must modify clinical models to accommodate this growing burden. Comanagement strategies are reported in the literature, but few have addressed orthopedic-hospitalist models. An orthopedic-hospitalist comanagement (OHC) service was established at our hospital to manage hip fracture patients. We sought to determine whether the OHC (1) improves the efficiency of hip fracture management as measured by inpatient length of stay (LOS) and time to surgery (TTS) and (2) whether our results are comparable to those reported in hip fracture comanagement literature.

Methods:

A comparative retrospective–prospective cohort study of patients older than 60 years with an admitting diagnosis of hip fracture was conducted to compare inpatient LOS and TTS for hip fracture patients admitted 10 months before (n = 45) and 10 months after implementation (n = 54) of the OHC at a single academic hospital. Secondary outcome measures included percentage of patients taken to surgery within 24 or 48 hours, 30-day readmission rates, and mortality. Outcomes were compared to comanagement study results published in MEDLINE-indexed journals.

Results:

Patient cohort demographics and comorbidities were similar. Inpatient LOS was reduced by 1.6 days after implementation of the OHC (P = .01) without an increase in 30-day readmission rates or mortality. Time to surgery was insignificantly reduced from 27.4 to 21.9 hours (P = .27) and surgery within 48 hours increased from 86% to 96% (P = .15).

Discussion:

The OHC has improved efficiency of hip fracture management as judged by significant reductions in LOS with a trend toward reduced TTS at our institution.

Conclusion:

Orthopedic-hospitalist comanagement may represent an effective strategy to improve hip fracture management in the setting of a rapidly expanding patient population.

Cost Drivers After Surgical Management of Proximal Humerus Fractures in Medicare Patients

OBJECTIVES

This comparative effectiveness study sought to determine the impact of complications, readmission, and procedure choice on in-hospital and total 90-day costs for surgical management of proximal humerus fractures.

METHODS

Medicare claims data from the Upstate New York area (2008-2009) were evaluated. The study included all patients treated with open reduction and internal fixation (ORIF) or hemiarthroplasty for proximal humerus fracture identified by ICD-9 codes. The primary end points included in-hospital costs and total health care costs within 90 days after the index operation. Multivariable generalized linear models with negative binomial distributions and log link function were used for cost analysis.

RESULTS

ORIF was performed in 52 cases and hemiarthroplasty in 57 cases, total n = 109. On univariate analysis, readmission increased in-hospital cost by $54,345 and total 90-day costs by $63,104, whereas complications increased in-hospital cost by $23,300 and total 90-day costs by $30,237. On multivariable analysis, ORIF was associated with 29% lower in-hospital cost compared with hemiarthroplasty [Odds Ratio 0.71; 95% Confidence Interval (CI), 0.54-0.92; P = 0.01], and readmission was associated with a 5.68-fold in-hospital cost increase (Odds Ratio 5.68; CI, 3.57-9.03; P < 0.0001).

CONCLUSIONS

Complications and hospital readmission continue to drive cost upward underscoring the need for best practice. The acute inpatient period costs may be decreased with ORIF in appropriately selected patients with proximal humerus fractures in comparison with hemiarthroplasty. This study provides real world cost estimates with the cost implications of complications, readmissions, and procedure choice.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of osteoporosis risk and initiation of a nurse practitioner intervention program in an orthopedic practice

The purpose of this study was to assess whether education and referral by a nurse practitioner could improve treatment adherence in patients with low bone mineral density in the orthopedic office. Our customized project did show some improvement but resistance to care continues in this unique population of patients.

INTRODUCTION

Osteoporosis and osteopenia are significant clinical problems. Nearly 50% of adults over the age of 50 are osteopenic (Looker et al. in Osteoporos Int 22:541-549, 2011). Many patients with osteoporosis are not taking calcium or vitamin D, or any active treatment, even after dual energy X-ray absorptiometry (DXA) and demonstration of low bone mineral density (Dell et al. in J Bone Joint Surg Am 91(Suppl 6):79-86, 2009). One hypothesis to explain low adherence with osteoporosis treatment is lack of patient education. This study was designed to compare a control group with an education-intervention group (receiving patient education from a nurse practitioner) to determine any effect of education on treatment adherence.

METHODS

A total of 242 females and 105 males were studied as a control: a total of 292 females and 155 male were studied in the education group. Patients in the education group received educational materials and were counseled by a single nurse practitioner. Patients had a DXA performed and patients with osteoporosis or osteopenia were followed to assess treatment. At 12 months, patients received follow-up phone calls to determine patient use of calcium, vitamin D, and/or an active treatment. Results between the groups were compared.

RESULTS

Significantly more patients began calcium and vitamin D after education (p = 0.04); significantly more patients were taking or were recommended for an active treatment after education (p = 0.03). Thirty percent of patients either did not follow up or refused active treatment for osteoporosis. Approximately 50% of patients with osteoporosis were not taking an FDA-approved pharmacologic agent for osteoporosis treatment, despite education.

CONCLUSION

After patient education and referral to endocrinology, significantly more patients began calcium and vitamin D supplementation. However, up to 50% of patients with osteoporosis would not complete follow-up visits and/or did not adhere to treatment recommendations for osteoporosis.

Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis

BACKGROUND

Osteoporotic hip fractures are common injuries typically occurring in patients who are older and medically frail. Studies have suggested that creation of a multidisciplinary team including orthopaedic surgeons, internal medicine physicians, social workers, and specialized physical therapists, to comanage these patients can decrease complication rates, improve time to surgery, and reduce hospital length of stay; however, they have yet to achieve widespread implementation, partly owing to concerns regarding resource requirements necessary for a comanagement program.

QUESTIONS/PURPOSES

We performed an economic analysis to determine whether implementation of a comanagement model of care for geriatric patients with osteoporotic hip fractures would be a cost-effective intervention at hospitals with moderate volume. We also calculated what annual volume of cases would be needed for a comanagement program to "break even", and finally we evaluated whether universal or risk-stratified comanagement was more cost effective.

METHODS

Decision analysis techniques were used to model the effect of implementing a systems-based strategy to improve inpatient perioperative care. Costs were obtained from best-available literature and included salary to support personnel and resources to expedite time to the operating room. The major economic benefit was decreased initial hospital length of stay, which was determined via literature review and meta-analysis, and a health benefit was improvement in perioperative mortality owing to expedited preoperative evaluation based on previously conducted meta-analyses. A break-even analysis was conducted to determine the annual case volume necessary for comanagement to be either (1) cost effective (improve health-related quality of life enough to be worth additional expenses) or (2) result in cost savings (actually result in decreased total expenses). This calculation assumed the scenario in which a hospital could hire only one hospitalist (and therapist and social worker) on a full-time basis. Additionally, we evaluated the scenario where the necessary staff was already employed at the hospital and could be dedicated to a comanagement service on a part-time basis, and explored the effect of triaging only patients considered high risk to a comanagement service versus comanaging all geriatric patients. Finally, probabilistic sensitivity analysis was conducted on all critical variables, with broad ranges used for values around which there was higher uncertainty.

RESULTS

For the base case, universal comanagement was more cost effective than traditional care and risk-stratified comanagement (incremental cost effectiveness ratios of USD 41,100 per quality-adjusted life-year and USD 81,900 per quality-adjusted life-year, respectively). Comanagement was more cost effective than traditional management as long as the case volume was more than 54 patients annually (range, 41-68 patients based on sensitivity analysis) and resulted in cost savings when there were more than 318 patients annually (range, 238-397 patients). In a scenario where staff could be partially dedicated to a comanagement service, universal comanagement was more cost effective than risk-stratified comanagement (incremental cost effectiveness of USD 2300 per quality-adjusted life-year), and both comanagement programs had lower costs and better outcomes compared with traditional management. Sensitivity analysis was conducted and showed that the level of uncertainty in key variables was not high enough to change the core conclusions of the model.

CONCLUSIONS

Implementation of a systems-based comanagement strategy using a dedicated team to improve perioperative medical care and expedite preoperative evaluation is cost effective in hospitals with moderate volume and can result in cost savings at higher-volume centers. The optimum patient population for a comanagement strategy is still being defined.

LEVEL OF EVIDENCE

Level 1, Economic and Decision Analysis.

Operative Mortality After Arthroplasty for Femoral Neck Fracture and Hospital Volume

Background:

The purpose of the present study is to use a statewide, population-based data set to identify mortality rates at 30-day and 1-year postoperatively following total hip arthroplasty (THA) and hemiarthroplasty (HA) for displaced femoral neck fractures. The secondary aim of the study is to determine whether arthroplasty volume confers a protective effect on the mortality rate following femoral neck fracture treatment.

Methods:

New York’s Statewide Planning and Research Cooperative System was used to identify 45 749 patients older than 60 years of age with a discharge diagnosis of femoral neck fracture undergoing THA or HA from 2000 through 2010. Comorbidities were identified using the Charlson comorbidity index. Mortality risk was modeled using Cox proportional hazards models while controlling for demographic and comorbid characteristics. High-volume THA centers were defined as those in the top quartile of arthroplasty volume, while low-volume centers were defined as the bottom quartile.

Results:

Patients undergoing THA for femoral neck fracture rather than HA were younger (79 vs 83 years, P < .001), more likely to have rheumatoid disease, and less likely to have heart disease, dementia, cancer, or diabetes (all P < .05). Thirty-day mortality after HA was higher (8.4% vs 5.7%; P < .001) as was 1-year mortality (25.9% vs 17.8%; P < .001). After controlling for age, gender, ethnicity, and comorbidities, risk of mortality following THA was 21% lower (hazard ratio [HR] 0.79; P = .003) at 30 days and 22% lower (HR 0.78; P < .001) at 1 year than HA. Patients undergoing THA at high-volume arthroplasty centers had improved 1-year mortality when compared to those undergoing THA at low-volume hospitals (HR 0.55; P = .008).

Conclusions:

Based on this large, population-based study, there is no basis to assume THA carries a greater mortality risk after hip fracture than does standard HA, even when accounting for institutional volume of hip arthroplasty.

Editorial on "Comprehensive geriatric care for patients with hip fractures: a prospective, randomized, controlled trial" published in The Lancet on April 25(th), 2015

A third of elderly adults fall every year, many leading to hip fractures with a 24% mortality rate just within the first year. As a growing number of the US population approaches old age, these hip fractures are expected to cost the US over 25 billion annually. In the near future, physicians will need to not only improve the treatment for a larger patient population but also reduce the medical costs associated. The authors in this paper sought to determine whether specialized geriatric care positively impacted patient outcome compared to standard orthopaedic care for hip fractures. The study found that geriatric care significantly increased patient mobility within 4 months after hip fracture and will likely reduce overall medical costs. Similar studies have shown promising results as well. Moving forward, geriatric fracture programs need more prospective randomized trials to determine the effectiveness of these programs to increase patient quality while also reducing overall medical costs. This study in correlation with others further demonstrates the importance and need of specialized geriatric programs in the US.

The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: an external evaluation using time trends in non-audit data

BACKGROUND

Hip fracture is the most common serious injury of older people. The UK National Hip Fracture Database (NHFD) was launched in 2007 as a national collaborative, clinician-led audit initiative to improve the quality of hip fracture care, but has not yet been externally evaluated.

METHODS

We used routinely collected data on 471,590 older people (aged 60 years and older) admitted with a hip fracture to National Health Service (NHS) hospitals in England between 2003 and 2011. The main variables of interest were the use of early surgery (on day of admission, or day after) and mortality at 30 days from admission. We compared time trends in the periods 2003-2007 and 2007-2011 (before and after the launch of the NHFD), using Poisson regression models to adjust for demographic changes.

FINDINGS

The number of hospitals participating in the NHFD increased from 11 in 2007 to 175 in 2011. From 2007 to 2011, the rate of early surgery increased from 54.5% to 71.3%, whereas the rate had remained stable over the period 2003-2007. Thirty-day mortality fell from 10.9% to 8.5%, compared with a small reduction from 11.5% to 10.9% previously. The annual relative reduction in adjusted 30-day mortality was 1.8% per year in the period 2003-2007, compared with 7.6% per year over 2007-2011 (P<0.001 for the difference).

INTERPRETATION

The launch of a national clinician-led audit initiative was associated with substantial improvements in care and survival of older people with hip fracture in England.

Osteoporotic Hip and Spine Fractures: A Current Review

Hip and spine fractures represent just a portion of the burden of osteoporosis; however, these fractures require treatment and often represent a major change in lifestyle for the patient and their family. The orthopedic surgeon plays a crucial role, not only in the treatment of these injuries but also providing guidance in prevention of future osteoporotic fractures. This review provides a brief epidemiology of the fractures, details the surgical techniques, and outlines the current treatment guidelines for orthopedic surgeons.

Mortality and Financial Burden of Periprosthetic Fractures of the Femur

Objective:

This study examines patient factors to identify risks of 12-month mortality following periprosthetic femur fractures. Hospital charges were analyzed to quantify the financial burden for treatment modalities.

Methods:

Data were retrospectively analyzed from a prospective database at a university hospital setting. One-hundred and thirteen patients with a periprosthetic fracture of the proximal or distal femur were identified. Risk factors for 12-month mortality were analyzed, and financial data were compared between the various treatment modalities.

Results:

In all, 14% of patients died (16 of 113) within 3 months and the 1-year mortality was 17.7% (20 of 113). Patients who died within 1 year had higher hospital charges (US$33 880 ± 25 051 vs US$22 886 ± 16 841; P = .01) and were older (87.6 ± 8.5 vs 81.5 ± 8.6; P = .004). Logistic regression analysis revealed age was the only significant predictor of 1-year mortality (P = .029, odds ratio 1.1). Analysis of financial data revealed 4 distinct groups (P < .05 between groups). Distal femoral revision arthroplasty (RA-DF) generated the highest hospital charges of US$91 035 ± 25 579 (n = 3). The second most highly charged group included proximal femoral fractures treated with revision arthroplasty (US$34 078 ± 17 832; n = 20) and hemi/total hip arthroplasty (THA; US$41 556 ± 23 651; n = 8). The third most charged group underwent open reduction internal fixation of the proximal (US$18 706 ± 6829; n = 35) and distal (US$22 381 ± 10 835; n = 35) femur. Nonoperative treatment generated the lowest charges (US$6426 ± 2899; n = 11). On average, the hospital lost money treating patients with RA-DF (US$−19 080 ± 2022 per patient) and hemi/THA (US$−6594 ± 9305 per patient), while all other treatment groups were profitable.

Conclusion:

One-year mortality after periprosthetic femur fractures was 17.7%, is mostly influenced by age, and 80% of deaths occur within 3 months. Patients treated with primary/revision arthroplasty generate more hospital charges than internal fixation. The average patient treated with revision arthroplasty of the distal femur or hemi/THA for a periprosthetic femur fractures resulted in net financial losses for the hospital.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

Fragility fracture programs: are they effective and what is the surgeon's role?

Fragility fractures are occurring at an ever-increasing rate, creating an enormous economic and societal impact. Outpatient-based fragility fracture programs have been developed to identify at-risk patients, initiate effective treatment of metabolic bone disease, and improve coordination between members of the patient's care team with the goal of reducing future fractures. Inpatient programs focus on effective, efficient management of patients presenting with acute fractures. Both have proven successful in reducing the impact of fragility fractures, but many challenges exist. The orthopedic surgeon, as part of an integrated team of providers, is integral in identifying at-risk patients, ensuring appropriate care of acute fractures, and initiating treatment protocols to reduce the risk of further injuries.

Revision rates and cumulative financial burden in patients treated with hemiarthroplasty compared to cannulated screws after femoral neck fractures

INTRODUCTION

This study compares re-operation rates and financial burden following the treatment of femoral neck fractures treated with hemiarthroplasty compared to non-displaced femoral neck fractures treated with cannulated screws.

METHODS

Data was retrospectively analyzed from a prospective database at a university hospital setting on patients undergoing hemiarthroplasty after femoral neck fractures and those with non-displaced femoral neck fractures treated with cannulated screws over a 7-year period. Re-operation rates were determined and financial data was analyzed. Charges refer to amounts billed by the hospital to insurance carriers, while costs refer to financial burden carried by the hospital during treatment.

RESULTS

There were 491 femoral neck fractures (475 patients) that underwent hemiarthroplasty (HA) and 120 non-displaced fractures (119 patients) treated with cannulated screw (CannS) fixation. Both groups had similar age, sex, Charlson co-morbidity scores, pre-operative Parker mobility scores, and 12-month mortality. There were 29 (5.9 %) reoperations in the HA group and 16 (13.3 %) in the CannS group (P = 0.007). The majority of re-operations occurred within 12 months for both groups [21/29 (72 %) HA group; 15/16 (94 %) CannS group; P = 0.13]. Average hospital charges per patient for the index procedure were higher in the HA group ($17,880 ± 745) compared to the CannS group ($14,104 ± 5,047; P < 0.001). After accounting for additional procedures related to their initial surgical fixation, average hospital charges and costs remained higher in the HA group.

CONCLUSION

Patients treated with hemiarthroplasty for femoral neck fractures have lower re-operation rates than patients treated with cannulated screws for non-displaced femoral neck fractures, with 80 % of re-operations occurring in the first 12 months. Hospital charges and costs to the hospital for treating patients undergoing hemiarthroplasty were higher than patients treated with cannulated screws for the index procedure alone, and after accounting for re-operations.

Principles of comanagement and the geriatric fracture center

This article describes the principles of comanagement in an optimized geriatric fracture center. This is a collaborative model of care that uses patient-centered, protocol-driven care to standardize the care for most patient fragility fractures. This model also uses shared decision making and frequent communication to improve clinically relevant outcomes. The orthopedic and medical teams are equally responsible from admission to discharge and are responsible for daily evaluation and clinical management of the patient.

Economic viability of geriatric hip fracture centers

Management of geriatric hip fractures in a protocol-driven center can improve outcomes and reduce costs. Nonetheless, this approach has not spread as broadly as the effectiveness data would imply. One possible explanation is that operating such a center is not perceived as financially worthwhile. To assess the economic viability of dedicated hip fracture centers, the authors built a financial model to estimate profit as a function of costs, reimbursement, and patient volume in 3 settings: an average US hip fracture program, a highly efficient center, and an academic hospital without a specific hip fracture program. Results were tested with sensitivity analysis. A local market analysis was conducted to assess the feasibility of supporting profitable hip fracture centers. The results demonstrate that hip fracture treatment only becomes profitable when the annual caseload exceeds approximately 72, assuming costs characteristic of a typical US hip fracture program. The threshold of profitability is 49 cases per year for high-efficiency hip fracture centers and 151 for the urban academic hospital under review. The largest determinant of profit is reimbursement, followed by costs and volume. In the authors’ home market, 168 hospitals offer hip fracture care, yet 85% fall below the 72-case threshold. Hip fracture centers can be highly profitable through low costs and, especially, high revenues. However, most hospitals likely lose money by offering hip fracture care due to inadequate volume. Thus, both large and small facilities would benefit financially from the consolidation of hip fracture care at dedicated hip fracture centers. Typical US cities have adequate volume to support several such centers.

Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures

BACKGROUND AND PURPOSE

Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Different models of orthogeriatric co-management are currently in use worldwide. These models differ for instance by the health-care professional who has the responsibility for care in the acute and early rehabilitation phases. There is no international consensus regarding the best model of care and which outcome parameters should be used to evaluate these models. The goal of this project was to identify which outcome parameters and assessment tools should be used to measure and compare outcome changes that can be made by the implementation of orthogeriatric co-management models and to develop recommendations about how and when these outcome parameters should be measured. It was not the purpose of this study to describe items that might have an impact on the outcome but cannot be influenced such as age, co-morbidities and cognitive impairment at admission.

METHODS

Based on a review of the literature on existing orthogeriatric co-management evaluation studies, 14 outcome parameters were evaluated and discussed in a 2-day meeting with panellists. These panellists were selected based on research and/or clinical expertise in hip fracture management and a common interest in measuring outcome in hip fracture care.

RESULTS

We defined 12 objective and subjective outcome parameters and how they should be measured: mortality, length of stay, time to surgery, complications, re-admission rate, mobility, quality of life, pain, activities of daily living, medication use, place of residence and costs. We could not recommend an appropriate tool to measure patients' satisfaction and falls. We defined the time points at which these outcome parameters should be collected to be at admission and discharge, 30 days, 90 days and 1 year after admission.

CONCLUSION

Twelve objective and patient-reported outcome parameters were selected to form a standard set for the measurement of influenceable outcome of patients treated in different models of orthogeriatric co-managed care.

Geriatric fracture center: a multidisciplinary treatment approach for older patients with a hip fracture improved quality of clinical care and short-term treatment outcomes

OBJECTIVE

Since April 1, 2008, patients aged ≥65 years presenting with a hip fracture at Ziekenhuisgroep Twente, Almelo (ZGT-A), The Netherlands, have been admitted to the geriatric fracture center (GFC) and treated according to the multidisciplinary treatment approach. The objective of this study was to evaluate how implementation of the treatment approach has influenced the quality of care given to older patients with hip fracture.

DESIGN

Prospective cohort study with historical control group.

METHOD

Two groups of patients with hip fracture were compared, 1 group was treated according to the new multidisciplinary treatment approach in 2009-2010, and the other group received the usual treatment in 2007-2008. The number of readmissions within 30 days after discharge was compared, and an analysis was carried out regarding the number of complications, the number of consultations with various specialists and with the geriatrician, and the duration of hospital stay.

RESULTS

In all, 140 patients from 2009 to 2010 group and 90 patients from 2007 to 2008 group were included. In 2009-2010 group, the number of readmissions within 30 days dropped by 11 percentage points (P = .001). The incidence of the number of complications decreased with a median of 1 compared with 2007-2008 (P = .017) group. Delirium was diagnosed to be 6 percentage points more frequent. The median number of consultations with various specialists per patient decreased by 1 percentage point as a result of geriatrician cotreatment (P = .002). The median duration of hospital stay was 1 day shorter than that in 2007-2008 group.

CONCLUSION

The use of the multidisciplinary treatment approach led to a significant reduction in the number of readmissions within 30 days after discharge. It appears to be associated with improved short-term treatment outcomes for older patients with a hip fracture.

Barriers to implementation of an organized geriatric fracture program

INTRODUCTION

There has been a recent increase in interest in implementing organized geriatric fracture programs for care of older adults with fragility fractures in order to improve both the quality and costs of care. Because such programs are relatively new, there are no standardized methods for implementation and no published descriptions of barriers to implementation.

MATERIALS AND METHODS

An online survey tool was sent to 185 surgeons and physicians practicing in the United States, who are involved with geriatric fracture care. Sixty-eight responses were received and evaluated.

RESULTS

Barriers identified included lack of medical and surgical leadership, need for a clinical case manager, lack of anesthesia department support, lack of hospital administration support, operating room time availability, and difficulty with cardiac clearance for surgery. Other issues important to implementation included quality improvement, cost reductions, cost to the hospital, infection prevention, readmission prevention, and dealing with competing interest groups and competing projects mandated by the government. Physicians and surgeons felt that a site visit to a functioning program was most important when considering implementing a hip fracture program.

CONCLUSIONS

This study provides useful insights into barriers to implementing an organized hip fracture program. The authors offer suggestions on ways to mitigate or overcome these barriers.

Hip fracture management, before and beyond surgery and medication: a synthesis of the evidence

INTRODUCTION

The geriatrician and orthopedic surgeon's roles are well defined in hip fracture management, yet other health-care providers contribute significantly toward care, as well as maximizing rehabilitation potential and decreasing readmissions. We examine evidence concerning pre-hospital care, pain management, multidisciplinary rehabilitation and secondary prevention strategies.

METHODS

Cochrane reviews and randomized controlled trials were identified through PubMed to synthesize current evidence in the role of multidisciplinary management of the patient with a hip fracture from injury to secondary prevention. The well-recognized roles of the geriatrician, anesthetist and orthopedic surgeon were not evaluated for the purpose of this review.

RESULTS

Transport of patients with a hip fracture can be eased through non-pharmaceutical simple, inexpensive techniques. Nerve blockade appears effective and easily administered in the emergency department. In-hospital multidisciplinary rehabilitation programs are effective in both earlier discharge and reducing falls, morbidity and mortality. Fall prevention programs are effective in nursing home patients, but not community dwellers. Osteoporosis prevention is primarily a medical endeavor; however, exercise and education may contribute to increased bone mineral density, compliance and better results of treatment.

CONCLUSION

Multidisciplinary medical management of patients with hip fractures is being improved within the hospital environment resulting in earlier discharge with decreased morbidity. There is evidence to show the benefits to patients with hip fractures from peripheral modalities within the hospital; however unless resident in a facility, multidisciplinary management is not clearly of benefit.

Co-managed care for fragility hip fractures (Rochester model)

Hip fractures in older adults are a common event with a high risk of morbidity and mortality. Patients who sustain a hip fracture often present with multiple co-morbid conditions that can benefit from co-management by orthopedic surgeons and geriatricians. This manuscript describes a co-managed model of care for patients with hip fractures. This model of care will be explained, and the benefits and results will be described. Retrospective review of the care of all native non-pathological hip fracture patients aged 60 years and older admitted between April 2005 and March 2009 to a 261-bed community teaching hospital. The outcome measures include patient characteristics, length of stay, mortality, 30-day readmission, re-operation, and costs of care. Seven hundred fifty-eight patients were identified with an average age of 84.8 (SD 8.4); 77.8% of the patients were female, 94.7% Caucasian, and 37.3% from nursing homes, and the mean Charlson score is 2.9 (SD 2.1). The length of stay was 4.3 days, 30-day readmission rate was 10.4%, 17-month re-operation rate was 1.9%, and costs of care to the system were $15,188. The 1-year mortality rate was 21.2%. This model of care resulted in improvements in all measures studied. Previous studies have shown reduction in in-hospital complications. Additional studies are needed to show if this model of care can be translated to other systems or to other surgical conditions. Wide application of this model care could substantially improve the quality of care and cost of caring for frail elders with hip fractures.