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Breda K, Keller MS, Gotanda H, Beland A, McKelvey K, Lin C, Rosen S. Geriatric fracture program centering age-friendly care associated with lower length of stay and lower direct costs. Health Serv Res 2023; 58 Suppl 1:100-110. [PMID: 36054014 PMCID: PMC9843078 DOI: 10.1111/1475-6773.14052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To evaluate outcomes associated with an integrated inpatient and outpatient program aimed at optimizing the care of geriatric fracture patients in a mixed community and academic health system setting. DATA SOURCES AND STUDY SETTING This study took place at a tertiary-care, 886-bed hospital system. The Geriatric Fracture Program (GFP) was designed in 2018 using the 4Ms Framework (What Matters, Medication, Mentation, and Mobility). Patients ≥65 years old with non-spine fractures managed by orthopedic faculty surgeons and participating hospitalist groups were included. A fracture liaison team educated patients regarding bone health and ensured ambulatory geriatrics follow-up. Outpatient geriatric visits focused on mobility, fall risk, bone health imaging, and medications. STUDY DESIGN We compared GFP-enrolled patients (n = 746) to patients seen by non-GFP-participating physicians (n = 852) and used a generalized estimating equations approach and Poisson models to analyze associations between participation in the GFP program and four inpatient outcomes (time to surgery, length of stay, Vizient length of stay index, and total direct costs). We examined outcomes across all fractures and also stratified them by fracture type (hip vs. non-hip). We descriptively examined post-discharge care outcomes: fall, gait, and balance assessments; bone health imaging; and medications. DATA COLLECTION/EXTRACTION METHODS We collected data through chart reviews/electronic health record extracts from July 2018 to June 2021. PRINCIPAL FINDINGS GFP-enrolled patients with all fracture types had a significantly lower length of stay (marginal effect [ME]: -2.12, 95%CI: -2.61, -1.63), length of stay index (ME: -0.33, 95%CI: -0.42, -0.25), and total direct costs (ME: -$5316, 95%CI: -$6806, -$3826); the magnitude of the effects was greater for non-hip fractures. There was no significant difference in time to surgery. Of 746 GFP patients, 170 (23%) had a post-discharge visit with a participating geriatrician ≥6 months. CONCLUSIONS A systematic approach to improving care for older adults with fractures improved length of stay and total direct costs.
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Affiliation(s)
- Kathleen Breda
- Department of OrthopedicsCedars‐Sinai Medical CenterBeverly HillsCaliforniaUSA
| | - Michelle S. Keller
- Division of General Internal Medicine, Department of MedicineCedars‐Sinai Medical CenterBeverly HillsCaliforniaUSA
- Division of Informatics, Department of Biomedical SciencesCedars‐Sinai Medical CenterBeverly HillsCaliforniaUSA
- Department of Health Policy and ManagementUniversity of California‐Los AngelesLos AngelesCaliforniaUSA
| | - Hiroshi Gotanda
- Division of General Internal Medicine, Department of MedicineCedars‐Sinai Medical CenterBeverly HillsCaliforniaUSA
- Section of Geriatric Medicine, Department of MedicineCedars‐Sinai Medical CenterBeverly HillsCaliforniaUSA
- Cedars‐Sinai Medical Care FoundationBeverly HillsCaliforniaUSA
| | | | - Karma McKelvey
- Department of OrthopedicsCedars‐Sinai Medical CenterBeverly HillsCaliforniaUSA
| | - Carol Lin
- Department of OrthopedicsCedars‐Sinai Medical CenterBeverly HillsCaliforniaUSA
| | - Sonja Rosen
- Section of Geriatric Medicine, Department of MedicineCedars‐Sinai Medical CenterBeverly HillsCaliforniaUSA
- Rocky Vista UniversityParkerColoradoUSA
- David Geffen UCLA School of MedicineUniversity of California‐Los AngelesLos AngelesCaliforniaUSA
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Gosch M, Kammerlander C, Fantin E, Jensen TG, Salazar AML, Olarte C, Bavatonavarech S, Medina C, Link BC, Cunningham M. Design and Evaluation of a Hospital-Based Educational Event on Fracture Care for Older Adult. Geriatr Orthop Surg Rehabil 2021; 12:21514593211003857. [PMID: 33868767 PMCID: PMC8020218 DOI: 10.1177/21514593211003857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Surgeons, internal medicine physicians, nurses, and other members of the
healthcare team managing older adults with a fracture all have barriers to
attending educational courses, including time away from practice and cost.
Our planning group decided to create and evaluate a hospital-based
educational event to address, meet, and improve the care of older adults
with a fracture. Materials and Methods: A committee of surgeons and geriatricians defined 3 learning objectives to
improve knowledge and attitudes in co-managed care. They designed a 1-day
educational event consisting of a departmental visit, a review of cases, a
planning session to identify gaps and plan changes, and presentations on
selected topics. Thirteen hospitals worldwide completed an 8-question online
application form, and 7 sites were selected for delivery over 3 years in
Denmark, Colombia, Thailand, Paraguay, Switzerland, and the Dominican
Republic. Results: Each event was conducted by 1 or more visiting surgeons and geriatricians,
and the local team leaders. The most common challenges reported in the
applications were preoperative assessment or optimization, delayed surgery,
lack of protocols, access to a geriatrician, teamwork, and specific aspects
of perioperative and postoperative care. In each department, 4 or 5 goals
and targets for implementation were agreed. The presentations section was
customized and attended by 20 to 50 team members. Discussion: Topics selected by a majority of departments were principles of co-managed
care (7), preoperative optimization (7), and management of delirium (4).
Follow up was conducted after 3 and 12 months to review the degree of
achievement of each planned change and to identify any barriers to complete
implementation. Conclusions: Hospital-based events with visiting and local faculty were effective to
engage a broader audience that might not attend external courses. A
performance improvement component with goal setting and follow up was
acceptable to all host departments.
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Affiliation(s)
| | | | - Emilio Fantin
- IMC Instituto Modelo de Cardiologia Cordoba, Argentina
| | | | | | | | | | - Claudia Medina
- IPS Universitaria Clínica León XIII, Envigado, Antioquia, Colombia
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Abstract
BACKGROUND Traditional care of patients with geriatric hip fracture has been fragmented with patients admitted under various specialty services and to different units within a hospital. This produces inconsistent care and leads to varying outcomes that can be associated with increased length of stay, delays in time from admission to surgery, and higher readmission rates. PURPOSE The purpose of this article is to describe the process taken to establish a successful geriatric hip fracture program (GFP) and the initial results observed in a single institution after its implementation. METHODS All patients 60 years or older, with an osteoporotic hip fracture sustained from a low energy mechanism (defined as a fall from 3-ft height or less), were included in our program. Fracture patterns include femoral neck, intertrochanteric, pertrochanteric, and subtrochanteric femur fractures including displaced, nondisplaced, and periprosthetic fractures. Preprogram data included all patients admitted from January 1, 2012, through December 31, 2014; postprogram data were collected on patients admitted between May 1, 2016, and May 1, 2018. RESULTS Demographic characteristics of the populations were similar. After the GFP was implemented, the proportion of patients who were treated surgically within 24 and 48 hours increased. The average number of hours between admission and surgery significantly reduced from 35.2 to 23.2 hours. Overall length of stay was decreased by 1.8 days and readmission within 30 days of discharge was lower. Reasons for readmission were similar in both timeframes. The rate of inpatient death was similar in the two groups. Mortality within 30 days of surgery appeared somewhat higher in the post-GFP period. CONCLUSION Our program found that, with the utilization of a multidisciplinary approach, we could positively influence the care of patients with geriatric hip fracture through the implementation of evidence-based practice guidelines. In the first 2 years after initiation of the GFP, our institution saw a decrease in time from admission to surgery, length of stay, and blood transfusion requirements.
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Abstract
The world's population is aging resulting in changes in the way we manage geriatric care. Furthermore, this population has a considerable risk of fragility fractures, most notably hip fractures. Hip fractures are associated with significant morbidity and mortality and have large economic consequences. It is due to these factors that the concept of an elderly trauma center was developed. These trauma centers utilize the expertise in orthopedic and geriatric disciplines to provide coordinated care to the elderly hip fracture patient. As a result, studies have demonstrated improvements in clinical outcomes within the hospital stay, a reduction in iatrogenic complications, and improvements in 1-year mortality rates compared to the usual care given at a similar facility. Furthermore, economic models have demonstrated that there is a role for regionalized hip fracture centers that can be both profitable and provide more efficient care to these patients.
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Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay. J Am Acad Orthop Surg 2019; 27:e293-e300. [PMID: 30358636 PMCID: PMC6411423 DOI: 10.5435/jaaos-d-17-00447] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway. METHODS A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016. RESULTS LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications. DISCUSSION Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program. LEVEL OF EVIDENCE III.
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Lim JY. Fragility Fracture Care: An Urgent Need to Implement the Integrated Model of Geriatric Care. Ann Geriatr Med Res 2019; 23:1-2. [PMID: 32743277 PMCID: PMC7387601 DOI: 10.4235/agmr.19.0011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/03/2022] Open
Affiliation(s)
- Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Marcantonio AJ, Pace M, Brabeck D, Nault KM, Trzaskos A, Anderson R. Team Approach: Management of Postoperative Delirium in the Elderly Patient with Femoral-Neck Fracture. JBJS Rev 2019; 5:e8. [PMID: 29064845 DOI: 10.2106/jbjs.rvw.17.00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew J Marcantonio
- Departments of Orthopaedics (A.J.M.), Anesthesiology (M.P.), Hospital Medicine (D.B.), and Rehabilitation Services (A.T.), and Surgical Critical Care Clinical Pharmacy (K.M.N. and R.A.), Lahey Hospital and Medical Center, Burlington, Massachusetts
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Recommended care received by geriatric hip fracture patients: where are we now and where are we heading? Arch Orthop Trauma Surg 2018; 138:1077-1087. [PMID: 29704045 DOI: 10.1007/s00402-018-2939-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Despite the availability of clinical guidelines on the prevention and treatment of geriatric hip fractures, the percentage of recommended care received by patients is low. We conducted an importance-performance analysis for prioritizing interventions to improve the in-hospital management of these patients. MATERIALS AND METHODS A secondary data analysis was conducted on the in-hospital treatment of 540 geriatric hip fracture patients in 34 hospitals in Belgium, Italy, and Portugal. First, we assessed the level of expert consensus on the process indicators composing international guidelines on hip fracture treatment. Second, guideline adherence on in-hospital care was evaluated within and across hospitals. Third, an importance-performance analysis was conducted, linking expert consensus to guideline adherence. RESULTS Level of expert consensus was high (above 75%) for 12 of 22 process indicators identified from the literature. There is large between and within hospital variation in guideline adherence for these indicators and for none of the 540 patients were all 22 process indicators adhered to. Importance-performance analysis demonstrated that three indicators that had a high level of expert consensus also had a high level of adherence (above 80%). Nine indicators, most of which have been previously linked to patient outcomes, had a high level of expert consensus but a consistently low level of adherence across hospitals and are identified as priority areas for improvement. CONCLUSIONS Guideline adherence for the treatment of geriatric hip fracture patients is remarkably suboptimal. Importance-performance analysis is a useful strategic approach to assist practitioners and healthcare managers to improve the quality of care.
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Pueyo-Sánchez MJ, Larrosa M, Surís X, Sánchez-Ferrin P, Bullich-Marin I, Frigola-Capell E, Ortún V. Association of orthogeriatric services with long-term mortality in patients with hip fracture. Eur Geriatr Med 2018; 9:175-181. [PMID: 34654256 DOI: 10.1007/s41999-018-0028-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/10/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE To assess the impact of the comprehensive orthogeriatric care model (OGM) on 2-year survival, length of stay (LOS), discharges to nursing homes, and antiosteoporotic treatment (AOT) in patients with hip fracture. METHODS Retrospective cohort study. Hospitals were classified as OGM if the patient was cared for in a comprehensive orthogeriatric unit. We included data from patients ≥ 65 years old discharged between 2012 and 2013. The main outcome was 12- and 24-month mortality. The variables collected were sex, type of fracture, comorbidities, AOT, LOS, and discharge to nursing homes. Survival analysis was performed with Kaplan-Meier method and comparison with Mantel-Haenszel test. Factors associated with death were determined by logistic regression. RESULTS First admissions in the 12 (out of 32) hospitals with OGM were 3580 of 9215 (38.8%). Patients in OGM had more comorbidities and discharges to nursing homes, shorter LOS, and less prescription of AOT. Two years after the admission the deceased patients were 3000 (32.6%). The survival was lower in males (p < 0.001), in the older age groups (p < 0.001), and in patients with Charlson > 1 (p < 0.001). Factors associated with increased risk of death at 12 and 24 months (logistic regression) were male gender, age and Charlson > 1, while care in the OGM decreased the risk. OGM benefited more patients > 80 years and those with Charlson < 1. CONCLUSIONS Patients admitted in OGM have shorter stays, more discharges to nursing homes, lower prescription of AOT, and better 12- and 24-month survival adjusted by sex, age, and comorbidities compared to non-OGM care.
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Affiliation(s)
- Maria-Jesús Pueyo-Sánchez
- Department of Health, Master Plan of Musculoskeletal Diseases, Travessera de les Corts 139-151, 08028, Barcelona, Spain. .,Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain.
| | - M Larrosa
- Department of Health, Master Plan of Musculoskeletal Diseases, Travessera de les Corts 139-151, 08028, Barcelona, Spain.,Rheumatology Department, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - X Surís
- Department of Health, Master Plan of Musculoskeletal Diseases, Travessera de les Corts 139-151, 08028, Barcelona, Spain.,Rheumatology Department, Hospital General de Granollers, Granollers, Spain.,School of Medicine and Health Sciences, International University of Catalonia, Sant Cugat del Vallès, Spain
| | - P Sánchez-Ferrin
- Department of Health, Master Plan of Social and Health Care, Barcelona, Spain
| | - I Bullich-Marin
- Department of Health, Master Plan of Social and Health Care, Barcelona, Spain
| | - E Frigola-Capell
- Department of Health, Master Plan of Musculoskeletal Diseases, Travessera de les Corts 139-151, 08028, Barcelona, Spain.,Jordi Gol Institute for Research in Primary Care, IDIAP Jordi Gol, Barcelona, Spain
| | - Vicente Ortún
- Department of Economics, Pompeu Fabra University, Barcelona, Spain
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Association of comprehensive geriatric assessment with quality-related care practices during implementation and development of an orthogeriatric hip fracture program. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Facilitators and barriers experienced by federal cross-sector partners during the implementation of a healthy eating campaign. Public Health Nutr 2017. [PMID: 28633687 DOI: 10.1017/s1368980017001264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To identify facilitators and barriers that Health Canada's (HC) cross-sector partners experienced while implementing the Eat Well Campaign: Food Skills (EWC; 2013-2014) and describe how these experiences might differ according to distinct partner types. DESIGN A qualitative study using hour-long semi-structured telephone interviews conducted with HC partners that were transcribed verbatim. Facilitators and barriers were identified inductively and analysed according partner types. SETTING Implementation of a national mass-media health education campaign. SUBJECTS Twenty-one of HC's cross-sector partners (food retailers, media and health organizations) engaged in the EWC. RESULTS Facilitators and barriers were grouped into seven major themes: operational elements, intervention factors, resources, collaborator traits, developer traits, partnership factors and target population factors. Four of these themes had dual roles as both facilitators and barriers (intervention factors, resources, collaborator traits and developer traits). Sub-themes identified as both facilitators and barriers illustrate the extent to which a facilitator can easily become a barrier. Partnership factors were unique facilitators, while operational and target population factors were unique barriers. Time was a barrier that was common to almost all partners regardless of partnership type. There appeared to be a greater degree of uniformity among facilitators, whereas barriers were more diverse and unique to the realities of specific types of partner. CONCLUSIONS Collaborative planning will help public health organizations anticipate barriers unique to the realities of specific types of organizations. It will also prevent facilitators from becoming barriers. Advanced planning will help organizations manage time constraints and integrate activities, facilitating implementation.
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Abstract
Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.
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Geriatric hip fracture management: keys to providing a successful program. Eur J Trauma Emerg Surg 2016; 42:565-569. [PMID: 27241865 DOI: 10.1007/s00068-016-0685-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hip fractures are a common event in older adults and are associated with significant morbidity, mortality and costs. This review examines the necessary elements required to implement a successful geriatric fracture program and identifies some of the barriers faced when implementing a successful program. INTERVENTION The Geriatric Fracture Center (GFC) is a treatment model that standardizes the approach to the geriatric fracture patient. It is based on five principles: surgical fracture management; early operative intervention; medical co-management with geriatricians; patient-centered, standard order sets to employ best practices; and early discharge planning with a focus on early functional rehabilitation. Implementing a geriatric fracture program begins with an assessment of the hospital's data on hip fractures and standard care metrics such as length of stay, complications, time to surgery, readmission rates and costs. Business planning is essential along with the medical planning process. CONCLUSION To successfully develop and implement such a program, strong physician leadership is necessary to articulate both a short- and long-term plan for implementation. Good communication is essential-those organizing a geriatric fracture program must be able to implement standardized plans of care working with all members of the healthcare team and must also be able to foster relationships both within the hospital and with other institutions in the community. Finally, a program of continual quality improvement must be undertaken to ensure that performance outcomes are improving patient care.
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[Anesthesiological care in orthogeriatric co-management. Perioperative treatment of geriatric trauma patients]. Z Gerontol Geriatr 2016; 49:237-55. [PMID: 27090913 DOI: 10.1007/s00391-016-1057-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/25/2016] [Accepted: 02/25/2016] [Indexed: 12/19/2022]
Abstract
Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.
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Singler K, Roth T, Beck S, Cunningham M, Gosch M. Development and initial evaluation of a point-of-care educational app on medical topics in orthogeriatrics. Arch Orthop Trauma Surg 2016; 136:65-73. [PMID: 26646844 PMCID: PMC4706575 DOI: 10.1007/s00402-015-2366-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Research by AOTrauma's orthogeriatrics education taskforce identified ongoing educational needs for surgeons and trainees worldwide regarding the medical management of older adults with a fracture. To address practicing surgeons' preference for increased use of mobile learning, a point-of-care educational app was planned by a committee of experienced faculty. The goals were to deliver the app to surgeons, trainees, and other healthcare professionals, to measure usage, and to evaluate the impact on patient care. MATERIALS AND METHODS The committee of geriatricians and surgeons designed and developed four modules on osteoporosis, delirium, anticoagulation, and pain based on published evidence and the content was programmed into mobile app formats. A registration form was integrated and a 14-question online evaluation survey was administered to users. RESULTS The AOTrauma Orthogeriatrics app was installed by 17,839 users worldwide between September 2014 and October 2015: Android smartphones (44%), iPhones (32%), iPads (15%), Android tablets (9%). 920 users registered and 100 completed the online evaluation: orthopedic/trauma surgeons (67%), residents/fellows (20%), and other professionals (13%). Ratings for all aspects were 4 or higher on a 1-5 Likert scale (5 = Excellent). 80% of evaluation respondents found the answer to their question or educational need on their last visit, and 26 of 55 respondents (47%) reported making a change in an aspect of their management of patients as a result of their learning from the app. CONCLUSION The orthogeriatrics app reached its intended audiences and was rated highly as a method of providing education to help improve patient care. Content input by experienced faculty and app improvements based on user feedback were key contributors to successful implementation.
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Affiliation(s)
- Katrin Singler
- />Department of Geriatrics, Klinikum Nürnberg, Paracelsus Private Medical University, Nürnberg, Germany , />Institute for Biomedicine of Ageing, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Germany
| | - Tobias Roth
- />Department of Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sacha Beck
- />Department of Geriatrics, Stadtspital Waid, Zurich, Switzerland
| | | | - Markus Gosch
- />Department of Geriatrics, Klinikum Nürnberg, Paracelsus Private Medical University, Nürnberg, Germany
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Abstract
The world's population is aging resulting in changes in the way we manage geriatric care. Furthermore, this population has a considerable risk of fragility fractures, most notably hip fractures. Hip fractures are associated with significant morbidity and mortality and have large economic consequences. It is due to these factors that the concept of an elderly trauma center was developed. These trauma centers utilize the expertise in orthopedic and geriatric disciplines to provide coordinated care to the elderly hip fracture patient. As a result, studies have demonstrated improvements in clinical outcomes within the hospital stay, a reduction in iatrogenic complications, and improvements in 1-year mortality rates compared to the usual care given at a similar facility. Furthermore, economic models have demonstrated that there is a role for regionalized hip fracture centers that can be both profitable and provide more efficient care to these patients.
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Affiliation(s)
- S L Kates
- Department of Orthopaedic Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, 14642, Box 665, Rochester, NY, USA.
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Dodd AC, Sethi MK. Editorial on "Comprehensive geriatric care for patients with hip fractures: a prospective, randomized, controlled trial" published in The Lancet on April 25(th), 2015. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:216. [PMID: 26488012 DOI: 10.3978/j.issn.2305-5839.2015.07.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Ashley C Dodd
- The Vanderbilt Orthopaedic Institute Center for Health Policy, Vanderbilt University, Nashville, TN 37232, USA
| | - Manish K Sethi
- The Vanderbilt Orthopaedic Institute Center for Health Policy, Vanderbilt University, Nashville, TN 37232, USA
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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. Med Care 2015; 53:686-91. [PMID: 26172938 PMCID: PMC4501693 DOI: 10.1097/mlr.0000000000000383] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Bernstein J. Not the Last Word: Geriatric Hip Fracture Centers: The Time Has Come. Clin Orthop Relat Res 2015; 473:2214-8. [PMID: 25845951 PMCID: PMC4457754 DOI: 10.1007/s11999-015-4289-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/26/2015] [Indexed: 01/31/2023]
Affiliation(s)
- Joseph Bernstein
- Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA 19104 USA
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Kates SL. Lean Business Model and Implementation of a Geriatric Fracture Center. Clin Geriatr Med 2014; 30:191-205. [DOI: 10.1016/j.cger.2014.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kammerlander C, Zegg M, Schmid R, Gosch M, Luger TJ, Blauth M. Fragility Fractures Requiring Special Consideration. Clin Geriatr Med 2014; 30:361-72. [DOI: 10.1016/j.cger.2014.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
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.
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Affiliation(s)
- Daniel Ari Mendelson
- Highland Hospital, Department of Medicine, 1000 South Avenue, Box 58, Rochester, NY 14620, USA.
| | - Susan M Friedman
- Highland Hospital, Department of Medicine, 1000 South Avenue, Box 58, Rochester, NY 14620, USA
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Cunningham M, Kates S, Blauth M. Using a commitment to change tool for evaluation and planning of a global competency-based curriculum in orthogeriatrics. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2014; 34:123-130. [PMID: 24939354 DOI: 10.1002/chp.21219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Measuring the outcomes of educational activities at the performance level is a challenge for all medical educators. This study reports retrospective outcomes data from the administration of a commitment to change (CTC) at orthogeriatrics courses and how the findings were used for curriculum improvement. METHODS During 2010-2012, a CTC questionnaire was administered at 8 educational courses attended by 513 orthopedic and trauma surgeons and medicine physicians in 5 countries. The CTC asked if physicians intended to change anything in their clinical practice as a result of participating and to list their specific changes. A 3-month follow-up was conducted to assess the status of intended changes and identify barriers to implementation. RESULTS Two hundred seventy-six (54%) of the 513 course participants and faculty reported at least 1 intended change in their clinical practice (485 specific changes overall). The intended changes were quantified and analyzed further based on 10 competencies for orthogeriatrics. Follow-up responses were received for N = 150 (31%) of the intended changes. Of these changes, 24% were fully implemented, 51% were partially implemented, and 25% were not implemented. The main barriers to implementation were categorized as "ongoing process (needs more time)" and "requires more discussion, collaboration, or support." DISCUSSION CTC is an effective tool for self-reported measurement of outcomes of educational activities at the performance level with orthopedic surgeons and an interprofessional audience. Analysis based on a framework of competencies enables curriculum improvement by identifying content that could be adjusted and new materials to address the issues and barriers that were reported.
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Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium. Wien Med Wochenschr 2013; 163:448-54. [PMID: 23949565 DOI: 10.1007/s10354-013-0228-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 07/04/2013] [Indexed: 02/05/2023]
Abstract
The course of older patients with hip fractures is often complicated by infections and delirium. Accurate care and high suspicion for these complications are essential, since these conditions are associated with an increase in mortality, length of hospital stay and nursing home placement, poorer mobility, and functional decline. Because of immunosenescence and higher infection rates, older patients need specific care, immediate diagnosis, and treatment of infections. Numerous guidelines of various medical societies outline the management of nosocomial infections, but there is a need of an individualized treatment plan because of comorbidities and polypharmacy. Hygiene measures have first priority to reduce the rate of infections. Treatment of geriatric syndromes like malnutrition, exsiccosis, gait disorders, falls, delirium, urine incontinence, and organ insufficiency are as important as immunization against pneumococci and influenza. Advanced age, cognitive impairment, hearing loss, peripheral vascular disease, prior delirium episodes, sight disorders, and polypharmacy are established risk factors for delirium; thus, older people with several chronic diseases are prone to delirium. A multifactorial approach, comprising standardized screening, oxygen support, intravenous fluid administration and augmented nutrition, monitoring of vital signs, pain treatment, optimized medication, and modification in perioperative management, significantly reduces delirium incidence during hospitalization for hip fracture. An interdisciplinary approach between surgeons and geriatricians may warrant optimized satisfaction of patients' needs.
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