Mortality and institutionalization following hip fracture

OBJECTIVES

To identify determinants of mortality and institutionalization after hip fracture and to identify those older hip fracture patients at high risk of death or institutionalization after hip fracture.

DESIGN

Population-based prospective inception cohort study of hip fracture patients; patients were assessed in the hospital and at 3 months following the hip fracture.

SETTING

Edmonton area hip fracture patients admitted to one of two Edmonton, Alberta, Canada, acute care centers between July 10, 1996, and August 31, 1997.

PARTICIPANTS

Patients were residents of the Edmonton area and over the age of 64. Those who had previously fractured the same hip within the past 5 years or had some pathological condition underlying the hip fracture were excluded. Of 610 eligible patients, 558 contributed some baseline information and were included in the mortality analysis; the institutionalization analysis was restricted to the 338 patients who lived in the community before fracture, survived the 3-month period postfracture, and had completed a 3-month follow-up interview.

MEASUREMENTS

The baseline interview was done in the hospital to assess mental status, prefracture physical function, prefracture health perception, and prefracture social support. The 3-month follow-up interview was done by phone to assess physical function, health perception, and social support 3 months postfracture. Demographic and comorbidity information was collected from medical records.

RESULTS

Low mental status in hospital was found to increase the chances of mortality and institutionalization, and male gender was found to increase mortality risk fourfold. Each additional 10 years of age increased the risk of institutionalization approximately 2.5 times. Patients with lower postfracture physical function had at least five times the risk of institutionalization compared to patients with high postfracture physical function.

CONCLUSIONS

Cognitive impairment, older age, and gender were associated with increased risk of poor outcome following hip fracture. The socioeconomic variables--social support and health perception--did not contribute significant additional information in explaining mortality or institutionalization risk. While demographic factors cannot be modified, physical function 3 months postfracture may be amenable to intervention and may reduce the risk of institutionalization. Intervening to increase postfracture physical function may be particularly beneficial to older patients, or to those who are cognitively impaired.

Comparison of physician and artificial intelligence-based symptom checker diagnostic accuracy

Symptom checkers are increasingly used to assess new symptoms and navigate the health care system. The aim of this study was to compare the accuracy of an artificial intelligence (AI)-based symptom checker (Ada) and physicians regarding the presence/absence of an inflammatory rheumatic disease (IRD). In this survey study, German-speaking physicians with prior rheumatology working experience were asked to determine IRD presence/absence and suggest diagnoses for 20 different real-world patient vignettes, which included only basic health and symptom-related medical history. IRD detection rate and suggested diagnoses of participants and Ada were compared to the gold standard, the final rheumatologists’ diagnosis, reported on the discharge summary report. A total of 132 vignettes were completed by 33 physicians (mean rheumatology working experience 8.8 (SD 7.1) years). Ada’s diagnostic accuracy (IRD) was significantly higher compared to physicians (70 vs 54%, p = 0.002) according to top diagnosis. Ada listed the correct diagnosis more often compared to physicians (54 vs 32%, p < 0.001) as top diagnosis as well as among the top 3 diagnoses (59 vs 42%, p < 0.001). Work experience was not related to suggesting the correct diagnosis or IRD status. Confined to basic health and symptom-related medical history, the diagnostic accuracy of physicians was lower compared to an AI-based symptom checker. These results highlight the potential of using symptom checkers early during the patient journey and importance of access to complete and sufficient patient information to establish a correct diagnosis.

Digitally-supported patient-centered asynchronous outpatient follow-up in rheumatoid arthritis - an explorative qualitative study

OBJECTIVE

A steadily increasing demand and decreasing number of rheumatologists push current rheumatology care to its limits. Long travel times and poor accessibility of rheumatologists present particular challenges for patients. Need-adapted, digitally supported, patient-centered and flexible models of care could contribute to maintaining high-quality patient care. This qualitative study was embedded in a randomized controlled trial (TELERA) investigating a new model of care consisting of the use of a medical app for ePRO (electronic patient-reported outcomes), a self-administered CRP (C-reactive protein) test, and joint self-examination in rheumatoid arthritis (RA) patients. The qualitative study aimed to explore experiences of RA patients and rheumatology staff regarding (1) current care and (2) the new care model.

METHODS

The study included qualitative interviews with RA patients (n = 15), a focus group with patient representatives (n = 1), rheumatology nurses (n = 2), ambulatory rheumatologists (n = 2) and hospital-based rheumatologists (n = 3). Data was analyzed by qualitative content analysis.

RESULTS

Participants described current follow-up care as burdensome. Patients in remission have to travel long distances. Despite pre-scheduled visits physicians lack questionnaire results and laboratory results to make informed shared decisions during face-to-face visits. Patients reported that using all study components (medical app for ePRO, self-performed CRP test and joint self-examination) was easy and helped them to better assess their disease condition. Parts of the validated questionnaire used in the trial (routine assessment of patient index data 3; RAPID3) seemed outdated or not clear enough for many patients. Patients wanted to be automatically contacted in case of abnormalities or at least have an app feature to request a call-back or chat. Financial and psychological barriers were identified among rheumatologists preventing them to stop automatically scheduling new appointments for patients in remission. Rheumatology nurses pointed to the potential lack of personal contact, which may limit the holistic care of RA-patients.

CONCLUSION

The new care model enables more patient autonomy, allowing patients more control and flexibility at the same time. All components were well accepted and easy to carry out for patients. To ensure success, the model needs to be more responsive and allow seamless integration of education material.

TRIAL REGISTRATION

The study was prospectively registered on 2021/04/09 at the German Registry for Clinical Trials (DRKS00024928).

"The Simpler, the Better." A Qualitative Study on Digital Health Transformation in Early Adopter Rheumatology Outpatient Clinics

Workforce shortage and the increasing burden of rheumatic and musculoskeletal diseases lead to extreme time constraints in rheumatology outpatient care. Digital services promise to facilitate care by relieving employees and unleash new capacities. This study aims to explore the perspectives of early adopter health care professionals (HCP) on digital transformation in outpatient rheumatology. In-depth qualitative interviews were conducted with rheumatology nurses and physicians in 3 German rheumatology outpatient clinics, each characterized by an advanced level of digital adaption. Qualitative data were subsequently analyzed using deductive-inductive qualitative content analysis. Interviews with 11 rheumatology nurses and 5 rheumatologists were completed. Three key themes emerged from the qualitative analysis: (i) Digital transformation of care; (ii) impact of digital transformation on health care delivery; and (iii) perceived drivers of successful digitalization. The interviews revealed that digital technologies are widely used throughout the complete patient pathway. Digitalization enables more continuity and flexibility in rheumatology care. Patient information can be electronically obtained in a standardized manner prior to planned visits, enabling an informed consultation and more time for in-depth patient discussion. Although digitalization restructures work, it can also increase the current workload. Improved accessibility for patient calls leads to more work for HCP. Important drivers of successful digital technology implementation are low-threshold and interoperable services, a medical team that is interested and educated in eHealth, and comprehensive patient information and onboarding. Digital transformation is increasingly redefining rheumatology care. While accelerating communication and workflows, improved service accessibility leads to more work for HCP.

Digital Transformation of Rheumatology Care in Germany: Cross-Sectional National Survey

BACKGROUND

In recent years, health care has undergone a rapid and unprecedented digital transformation. In many fields of specialty care, such as rheumatology, this shift is driven by the growing number of patients and limited resources, leading to increased use of digital health technologies (DHTs) to maintain high-quality clinical care. Previous studies examined user acceptance of individual DHTs in rheumatology, such as telemedicine, video consultations, and mHealth. However, it is essential to conduct cross-technology and continuous analyses of user acceptance and DHT use to maximize the benefits for all relevant stakeholders.

OBJECTIVE

This study aimed to explore the current acceptance, use, and preferences regarding DHTs among patients in rheumatology care in Germany.

METHODS

Rheumatology patients from 3 clinics in Germany were surveyed to understand their perspectives on DHTs. The survey included main themes, including acceptance, preferences, COVID-19's impact, potential, and barriers related to DHTs. The data were analyzed using descriptive statistics and correlation analysis.

RESULTS

Out of 337 participants, 53% (179/337) reported using DHTs. Specific technologies included wearables (72/337, 21%), mHealth apps (71/337, 21%), digital therapeutics (32/337, 9%), electronic prescriptions (30/337, 9%), video consultations (15/337, 4%), and at-home blood self-sampling (3/337, 1%). Nearly two-thirds (220/337, 65%) found DHTs useful, and 69% (233/337) held a generally positive attitude toward DHTs. Attitudes shifted positively during the COVID-19 pandemic for 40% (135/337) of participants. Higher education was more prevalent among DHT users (114/179, 63.7%) compared with nonusers (42/151, 27.8%; P=.02). The main potential benefits identified were location-independent use (244/337, 72%) and time-independent use (216/337, 64%). Key barriers included insufficient user knowledge (165/337, 49%) and limited information on DHTs (134/337, 40%).

CONCLUSIONS

Patient acceptance and use of DHTs in rheumatology is increasing in Germany. A prospective, standardized monitoring of digital transformation in rheumatology care is highly needed.