ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Disclosure presenter
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
The effectiveness of integratedorthogeriatric treatment on 1-year outcome in frail elderly
with hip fracture
E. Folbert, MANP, PhD Hospital Group Twente, Almelo-Hengelo
Rotterdam, 2018 august 27
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Geriatric TraumatologyPhD thesis
Finished 27 march 2017
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Elderly patients and fracture
Its a challenge to treat them well!
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
The GFC treatment model
From an international perspective
Ø Awareness that these patients need special attention
Ø Different models of care
Ø No clear evidence which model is most effective*
* Kammerlander et al, Osteoporos Int 2010
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Aim study
Evaluate the effectiviness of an orthogeriatric treatment model in elderly patients with a hip fracture on 1-year mortality and to identify associated
risk factors*
* Folbert et al, Osteoporos Int 2017
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Design
Prospective cohort with historical controls
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
PatientsInclusionØ Acute admission hip fractureØ Age 70 yrs. or olderØ Treated by traumasurgeon
ExclusionØ Pathological or periprosthetic fracture Ø Indication total hip artroplasty
PeriodsØ 2008 - 2013: n=850 GFCØ 2002 - 2008: n=535 usual care
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Data collectionVariables & outcome measures
GFC UC Sociodemografic variables Sociodemografic variables
Frailty score
Dementia diagnosed
ASA ASA
History of osteoporosis, previous osteopotic fracture
Type of fracture Type of fracture
Barthelindex and Parker Mobility score
Prefracture living
Charlson comorbidity Score
Length of stay on the ED
Time to surgery Time to surgery
Type of operation; conservative or operative treatment
Type of operation; conservative or operative treatment
Length of hospital stay Length of hospital stay
Incidence of postoperative surgical and medical complications Complicated course or not
Mortality rate (in hospital, 30 days, 1 year) Mortality rate (in hospital, 30 days, 1 year)
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
BaselineGFC n=850 UC n=535 P value
♀: ♂, % 74:26 71:29 0.361Age 83 82 0.015ASA* ≥ 3, % 78 53 <0.001Independent: Institutionalized; %
84:16 90:10 0.019
Ref. * https://www.asahq.org/
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
GFC patients n=850VMS Frailty score; % delirium falls < 6mnd. malnutrition (SNAQ) physical limitations (KATZ)
mean (IQR)
289819702.0 (2.0-3.0)
Dementia, % 21CCI-score* ≥3 29Barthel**-before: Barthel-after 16:10 (-6)PMS***-before: PMS-after 6:2 (-4)
Ref.* Charlson (1987), ** Mahoney (1965), *** Parker (1993)
GFC cohort
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
GFC n=850 UC n=535 P value
ED, min, mean (SD) 102 (50.0) No priority
Time till surgery from admission, %<24 hrs. >24 hrs.
7624
7822
0.259
Conservative treatment, % 2 0 <0.001Length of hospital stay, daysmediaan (IQR)
9 (6-13) 10 (7-17) <0.001
Logistics treatment process
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TwenteLocatie Almelo
GFC n=850 UC n=535 P value
Patients with a complicatedcourse; %
53.4 66.9 <0.001
In hospital mortality; % 4.4 6.2 0.133
Mortality ≤ 30 days; % 7.5 10.3 0.075
Mortality ≤ 365 days; % 23.2 35.1 <0.001
Complications and mortality
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Kaplan-meier survival curve
GFC group
Usual care group
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OR 95% BI P valueMale 1.68 1.13-2.45 0.011
Age in years 1.06 1.02-1.09 0.001
VMS Frailty score physical limitations 2.35 1.32-4.20 0.004
VMS Frailty malnutrition 2.01 1.34-3.02 <0.001
ASA 3 2.43 1.25-4.74 0.009
ASA 4-5 7.05 3.20-15.52 <0.001
CCI 5 of > 2.71 1.23-5.93 0.013
Barthel Index preop 0.96 0.92-1.01 0.091
Independent risk factors 1 year mortality
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TwenteLocatie Almelo
Strenght and limitations
+ First study in the Netherlands
+ Fittest patients excluded, overestimating seems unlikely
+ Good description of case mix
+ Use of specifically defined measuring instruments and outcome measures
- Use of historical control group instead of randomized study design
- Q of life not analyzed
- No insight in performance during geriatric rehab in nursing homes
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Conclusion
Ø After integrated care, a significant decrease in the 1-year mortality rate in frail elderly patients compared to historical controls treated with standard care.
Ø Gender, increasing age, malnutrition, physical limitations and medical conditions were independent risk factors for 1–year mortality .
Ø Awareness of the RF can be usefull in an attempt to optimize care and outcomes.
Ø Due to the multidimensional needs orthogeriatric treatment should be the standard.
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Our future goals
Ø The development and implementation of a clinical path way and a Q auditing system withour stakeholders in the geriatric rehabilitation nursing homes
Ø Monitoring recovery during rehab with health wearables
Ø To improve Q of care it would be a challenge to collaborate with international GFC’s forresearch purposes.
ChirurgieZiekenhuisgroep
TwenteLocatie Almelo
Thank you for your attention
Questions?