Integrated Fragility Hip Fracture Program: A Model for High Quality Care

A 10-Year Experience of an Integrated Geriatric Hip Fracture Treatment Protocol: Outcomes at a Minimum 2-Year Follow-Up

Introduction

Increasing incidence of fragility fractures has spurred development of protocols, largely focused on peri-operative care, with numerous proven benefits. The purpose of this investigation was to evaluate outcomes of our hip fracture treatment program regarding successful protocol implementation, compliance, effect on subsequent fracture rates, and mortality during the first decade of adoption.

Methods

A retrospective review identified patients >65 years old with fragility hip fractures between 2010 and 2022. The HiROC (+) cohort consisted of patients who received a "High-Risk Osteoporosis Clinic" (HiROC) referral for bone health evaluation and bisphosphonate initiation as indicated. Additional fracture rates and mortality at 3 years were calculated. Protocol implementation and compliance over the first 10 years was analyzed in the four identified cohorts.

Results

A total of 1671 fragility hip fractures were identified, with 386 excluded due to insufficient follow-up, with an average age of 81.6 years and a median follow-up of 36.4 months. Of the 1280 included cases, 56% (n = 717) had a HiROC referral placed. HiROC(+) groups had lower subsequent fracture rates at two years, compared to those without referral (28% vs 13%, P < 0.0001) and those completing more steps of the protocol had lower subsequent fracture rates (28% vs 15% vs 13% vs 5%, P < 0.0001). No statistically significant difference was observed between the cohorts for anatomic site of subsequent fractures.

Discussion

Greater than half of all eligible patients were successfully captured by the protocol. Patients completing more steps of the protocol had lower subsequent fracture rates. Captured patients demonstrated reduced mortality rates when compared to current literature.

Conclusion

Successful implementation of this geriatric hip fracture protocol was associated with reduced additional fractures and mortality rates. Identifying steps of process failures in the protocol can provide opportunities for increased compliance and reduction in future fracture occurrences.

Improving morbidity and mortality in hip fragility fractures

PURPOSE OF REVIEW

Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system.

RECENT FINDINGS

There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality.

SUMMARY

HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

Implementation and operationalization of Integrated People-Centred Health Services delivery strategies in integrated osteoporosis care (IOC) initiatives: a systematic review

Integrated Osteoporosis Care (IOC) has been emerging over the past decade. To support integrated care initiatives, the World Health Organisation (WHO) has developed the Integrated People Centred Health Services (IPCHS) framework, which consists of five interdependent strategies. Five electronic databases (PubMed, Embase, World of Science, CINAHL, and Scopus) were searched for relevant studies published from January 1, 2010 to December 2022. Initiatives implementing collaborative practices and at least two IPCHS strategies were included. Quality assessment was performed using the Effective Public Health Practice Project checklist. Seventy-six publications describing 69 implementations met the inclusion criteria; 90% of them were implemented at the hospital level, and over half focused on secondary fracture prevention. Three implementations captured all five IPCHS strategies, and half applied three. Substrategies targeting individuals as beneficiaries were frequently employed. Substrategies requiring fundamental shifts (e.g., systemic coordination and updating) were seldomly implemented. Substantive heterogeneity in substrategy operationalization was observed. Patient education, standardized care, team-based care, care coordinators, and health care provider training were commonly pursued. IOC interventions have focused mainly on secondary fracture prevention in a hospital setting and have been narrowly operationalized. Future implementation should: employ all five IPCHS strategies; better align programmes, providers, and regulatory frameworks, while adapting funding mechanisms; and operationalize broader and more innovative substrategies.Registration: This review has been registered at the international prospective register of systematic reviews PROSPERO (CRD42021250244).

Outcomes on an inpatient oncology service after the introduction of hospitalist comanagement

BACKGROUND

Smilow Cancer Hospital (SCH) introduced hospitalist comanagement to the inpatient oncology service to address long lengths of stay and oncologist burnout.

OBJECTIVE

To determine the impact of hospitalists on inpatient quality outcomes and oncologist experience.

INTERVENTIONS

Hospitalists were introduced to one of two inpatient oncology services at SCH. Patients were assigned to teams equally based on capacity. Outcomes on the oncologist-led, traditional service (TS) were compared with outcomes on the hospitalist service (HS) 6 months after program implementation.

MAIN OUTCOMES AND MEASURES

Outcomes included patient volume, length of stay (LOS), early discharge, discharge time, and 30-day readmission rate. Mixed linear or Poisson models that accounted for multiple admissions during the study duration were used. Oncologist experience was measured by survey.

RESULTS

During the study period, there were 713 discharges, 400 from the HS and 313 from the TS (p = .0003). There was no difference in demographics or severity of illness (SOI) between services. Following adjustment for age, sex, race/ethnicity, cancer type, and discharge disposition, the average LOS was 4.71 on the HS and 5.47 on the TS (p = .01). Adjusted early discharge rate was 6.22% on the HS and 2.06% on the TS (p = .01). Adjusted mean discharge time was 3:45 p.m. on HS and 4:16 p.m. on TS (p = .009). There was no difference in readmission rates. Oncologists reported less stress (p = .001) and a better ability to manage competing responsibilities (p < .0001) while working on the HS.

CONCLUSIONS

Hospitalist comanagement significantly improved LOS, early discharge, time of discharge, and oncologist experience without an increase in 30-day readmissions.

Exploring Barriers to, and Enablers of, Evidence-Informed Hip Fracture Care in Five Low- Middle-Income Countries: China, India, Thailand, the Philippines and Vietnam

Globally, populations are ageing and the estimated number of hip fractures will increase from 1.7 million in 1990 to more than 6 million in 2050. The greatest increase in hip fractures is predicted in Low- and Middle‑Income Countries (LMICs), largely in the Asia-Pacific region where direct costs are expected to exceed $US15 billion by 2050. The aims of this qualitative study are to identify barriers to, and enablers of, evidence informed hip fracture care in LMICs, and to determine if the Blue Book standards, developed by the British Orthopaedic Association and British Geriatrics Society to facilitate evidence informed care of patients with fragility fractures, are applicable to these settings. This study utilised semi-structured interviews with clinical and administrative hospital staff to explore current hip fracture care in LMICs. Transcribed interviews were imported into NVivo 12 and analysed thematically. Interviews were conducted with 35 participants from eleven hospitals in five countries. We identified five themes-costs of care and the capacity of patients to pay, timely hospital presentation, competing demands on limited resources, delegation and defined responsibility, and utilisation of available data-and within each theme, barriers and enablers were distinguished. We found a mismatch between patient needs and provision of recommended hip fracture care, which in LMICs must commence at the time of injury. This study describes clinician and administrator perspectives of the barriers to, and enablers of, high quality hip fracture care in LMICs; results indicate that initiatives to overcome barriers (in particular, delays to definitive treatment) are required. While the Blue Book offers a starting point for clinicians and administrators looking to provide high quality hip fracture care to older people in LMICs, locally developed interventions are likely to provide the most successful solutions to improving hip fracture care.

High-Quality Nursing Care for the Elderly in the Department of Otolaryngology

ENT patients have different types of diseases and clinical symptoms, and generally, patients have a low level of understanding of their professional knowledge about their ENT diseases. In this paper, quality nursing interventions in otorhinolaryngology require nursing staff to implement relevant nursing interventions in the process of implementing relevant nursing care, which should be based on patients' needs, and guide patients to perform rehabilitation exercises according to their individual conditions, in addition to establishing continuous nursing interventions with patients at the time of discharge with the help of modern technology. By comparing the nursing satisfaction of patients in the observation group and the control group, it was found that the nursing satisfaction of patients in the observation group who received humanistic nursing was higher, and the difference was statistically significant compared with that of the control group (P < 0.05). The SCL-90 scale scores of patients in both groups were not significantly different on the day of admission as verified by t values, and the SCL-90 scale scores of patients in both groups changed to a certain extent after hospitalization. The difference between the two groups was verified by t value.

A Simple Physical Therapy Algorithm Is Successful in Decreasing Skilled Nursing Facility Length of Stay and Increasing Cost Savings After Hip Fracture With No Increase in Adverse Events

Introduction:

Shorter length of stays (LOS) at a Skilled Nursing Facility (SNF) after hip fracture surgery would be expected to lead to costs savings for the healthcare system. Evidence also suggests that shorter SNF stays also leads to improved 30-day outcomes, thus compounding this value proposition. Our Integrated Fragility Hip Fracture Program created a simple algorithm at discharge to provide each post-operative hip fracture patient with an expected SNF LOS. We studied whether this intervention produced a shorter SNF LOS and other observable short-term outcomes.

Methods:

We retrospectively reviewed all original Medicare hip fracture patients treated with operative fixation who were admitted to our hospital in 2015, 2017 and 2018. We selected patients who were discharged to a single SNF following hospitalization, and excluded patients with incomplete records. The algorithm for the expected LOS recommendation was based on the degree of assistance the patient needed for ambulation: 7 days (“0-person assist”), 14 days (“1-person assist”), or 21 days (“2-person assist”). We compare the SNF LOS of our hip fracture patient population between those discharged to a program participant, those SNF that agreed to this algorithm, and those discharged to a non-program participant SNF.

Results:

We identified 246 patients meeting our selection criteria. 69 were discharged to a program participant SNF. Patients discharged to a participant SNF had similar baseline demographics and ASA distributions to those discharged to a non-participant provider. There was a statistically significant difference in length of stay between the groups, with program participant patients spending an average of 23 days at the SNF while the control group spent an average of 31 days. (p < 0.001). Program participant discharges were also associated with additional cost savings. There was no significant difference in ED visits within 90 days of discharge.

Discussion:

SNF LOS for geriatric hip fractures can be decreased with implementation of a simple physical therapy driven algorithm based on the patient’s ambulatory independence at hospital discharge. Conclusion: This is a simple, yet completely unique program that seems to have increased the value of healthcare provided.

Preventive strategy for the clinical treatment of hip fractures in the elderly during the COVID-19 outbreak: Wuhan's experience

Hip fractures in the elderly account for more than half of osteoporotic fractures and represent a substantial economic and social burden. Novel coronavirus pneumonia (COVID-19), which began to spread in December 2019, has created challenges in the management of elderly hip fracture patients, not only by influencing the choice of operation and postoperative rehabilitation methods, but also by generating new risks for the medical staff. During this period, our infection and orthopedic treatment unit in the center of the epidemic area effectively treated 82 elderly patients with hip fracture, and no cross-infection occurred. Therefore, our experience in prevention and treatment is worth recommending to frontline anti-epidemic personnel.