Analysis of the experience of the geriatric fracture program in two institutions in Colombia: a reproducible model?

Background: hip fracture is the major cause of morbidity and mortality. Geriatric fracture programs promise to improve the quality of care, health outcomes and reduce costs. Objective: To describe the results related to the Geriatric fracture programs implementation in two Colombian institutions. These results could then be compared to other published experiences to assess reproducibility of the program. Methods: A retrospective descriptive study of the patients treated under the Geriatric fracture programs in two institutions in Colombia was carried out. The information of each institution was collected from the initial year of program implementation until 2018. Demographic characteristics, length of stay, hospitalization complications, readmissions and mortality were described. Consumption of healthcare resources was defined using base cases determined with local experts and costs were estimated using standard methods. Results: 475 patients were included in the Geriatric fracture programs in two institutions. We observed an increase in the number of patients during the Geriatric fracture programs. The length of stay decreased between 8.5% and 26.1% as did the proportion of total complications, with delirium having the greatest reduction. A similar situation was seen for first year mortality (from 10.9% to 4.7% in one institution and form 11.4% to 5.1% in the other), in-hospital deaths and readmissions. Estimates of costs of stay and complications showed reductions in all scenarios, varying between 22% and 68.3% depending on the sensitivity scenario. Conclusions: The present study presents the experience of two institutions that implemented the Geriatric fracture programs with increase in the number of patients treated and reductions in the time of hospital stay, the proportion of complications, readmissions, mortality, and estimated costs. These are similar between both institutions and with other published implementations. This could hint that geriatric fracture program may be implemented with reproducible results.

A Record-based Analysis of Profile, Pattern and Outcomes of Geriatric Fractures in a Tertiary CareHospital, Chandigarh

Introduction: Older people with diseased conditions are more prone to fracture irrespective of gender. Osteoporosis is the most common cause of elderly fractures. Objectives: 1) To ascertain the profile and pattern of geriatric fracture cases reporting a tertiary care institution, 2) To ascertain the extent of mortality and complications in geriatric fracture cases, and 3) To ascertain the functional outcomes of geriatric fracture cases discharged from the tertiary care institute. Methodology: A list of geriatric fracture inpatients of an institution was made for 2014 - 2018. The data on the profile of patients, type of fracture, treatment received, the lag time between the reporting and the surgery, comorbidities, past medical history, cause/ place of fracture, length of stay, and status at the time of the phone-based interview were analysed through SPSS software. Results: The highest range of the age for fracture occurrence was 60-70 years. Female patients were more than the male ones. Femur fracture was the most common. The most common direct cause of the fracture was fall (indoor). Open reduction, internal fixation and arthroplasty were the commonest treatment performed. The lag time between the patient arrival to the health care and surgery was 0-5 days. The highest length of stay by the patients in the hospital was 0-10 days. Conclusion: The possible direct causes of the fracture reported in the study were falls, roadside accidents, trauma etc.

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study

ObjectiveThe aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes.DesignCohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year.SettingInternational (six countries, three continents) multicentre study.Participants281 patients aged ≥70 with operatively treated proximal femur fractures.InterventionsTreatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy.Outcome measuresPrimary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life.ResultsPatients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002).ConclusionsContrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement.Trial registration numberClinicalTrials.gov: NCT02297581.

Multi-Component Care Bundle in Geriatric Fracture Hip for Reducing Post-Operative Delirium

Background: Delirium in elderly orthopaedic patients poses an enormous medical, social and financial burden to the healthcare system, and causes significant distress to patients and their caregivers. We examined whether a Multi-component Care Bundle (MCB) could reduce the incidence of post-operative delirium (POD) in fractured hip patients. Methods: An observational study was conducted, analyzing 154 patients (mean age ± SD, 85 ± 7.8, 68% women) admitted to Queen Mary Hospital with hip fracture. Half of the patients were cared for in the control group before MCB was introduced, which included installation of orientation aids, introduction of a Caregiver Empowerment Program, and incorporation of ultrasound-guided Fascia Iliaca Block (FIB) into the analgesia protocol. Results: There were fewer patients with POD in the MCB group, compared with the control group (18/76, 23.4% v 34/76, 44.2%, p = 0.006). Patients in MCB group consumed less opioid ( 4/77 v 13/77, p = 0.048), experienced less post-operative dizziness (2/77, 2.6% v 13/77, 16.9%, p = 0.003) and had a shorter median day to start walking post-operatively (day 1 [IQR 1-2] vs day 2 [IQR 2-3]; p = 0.001) than the control group. Length of stay was not affected. Conclusion: MCB effectively reduces POD, postoperative dizziness, opioid consumption, and days to start mobilization postoperatively.

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.

Commentary on “Multi-Component Care Bundle in Geriatric Fracture Hip for Reducing Postoperative Delirium”

The letter to the editor suggested several questions regarding the methodology of the recent article by Lam et al who determined effect of multicomponent care bundle on the development of postoperative delirium. This article is published in Geriatric Orthopaedic Surgery & Rehabilitation . 2021; 12:21514593211004530. Our concerns included the incomplete preoperative assessment, possible influences of anaesthetic and intraoperative managements on the development of postoperative delirium, bias effect of postoperative analgesia on the primary and secondary findings, and real clinical value of multicomponent care bundle to decrease the risk of postoperative delirium. We believe that clarifying these issues would improve the transparency of this study and interpretation of findings.