Postoperative Admission to a Dedicated Geriatric Unit Decreases Mortality in Elderly Patients with Hip Fracture

Abstract

BackgroundElderly patients with hip fracture have a 5 to 8 fold increased risk of death during the months following surgery. We tested the hypothesis that early geriatric management of these patients focused on co-morbidities and rehabilitation improved long term mortality.Methods and FindingsIn a cohort study over a 6 year period, we compared patients aged >70 years with hip fracture admitted to orthopedic versus geriatric departments in a time series analysis corresponding to the creation of a dedicated geriatric unit. Co-morbidities were assessed using the Cumulative Illness Rating Scale (CIRS). Each cohort was compared to matched cohorts extracted from a national registry (n = 51,275) to validate the observed results. Main outcome measure was 6-month mortality. We included 131 patients in the orthopedic cohort and 203 in the geriatric cohort. Co-morbidities were more frequent in the geriatric cohort (median CIRS: 8 vs 5, P<0.001). In the geriatric cohort, the proportion of patients who never walked again decreased (6% versus 22%, P<0.001). At 6 months, re-admission (14% versus 29%, P = 0.007) and mortality (15% versus 24%, P = 0.04) were decreased. When co-morbidities were taken into account, the risk ratio of death at 6 months was reduced (0·43, 95%CI 0·25 to 0·73, P = 0.002). Using matched cohorts, the average treatment effects on the treated associated to early geriatric management indicated a reduction in hospital mortality (−63%; 95% CI: −92% to −6%, P = 0.006).ConclusionsEarly admission to a dedicated geriatric unit improved 6-month mortality and morbidity in elderly patients with hip fracture.

Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis

“…One study was a level 1 prospective randomized control trial [70], and the remaining seven were level 3 studies with historical controls [5,17,24,28,39,40,52]. Results of our metaanalysis showed an average reduction in length of stay by 2.28 days (95% CI, 2.00-2.56 days) (Fig.…”

“…Additionally, although a few studies have reported improved readmission rates with comanagement [5,39], others have reported no change [17,24,28,52]. We chose not to include a decreased readmission rate in our analysis, although a decreased rate would decrease the costs seen in the comanagement strategy and make it even more favorable.…”

“…Of the more successful models, two of the common features are (1) a shift in focus where both physicians act as a patient's primary caregiver as opposed to the traditional model of admission to a single service with the other service acting as a consultant, and (2) a shared goal that common medical and surgical complications should be anticipated rather than treated after their occurrence. This approach has decreased complication rates [5,17,22,45,64], time from injury until the operating room [4,24,52], hospital length of stay [5,17,24,28,39,40,52,70], and has improved osteoporosis treatment [22,28].…”

“…Highquality economic studies have evaluated the benefits of directing resources toward the focused goal of reducing time to the operating room [19] and the benefits of early initiation of osteoporosis treatment [31,32,35]. Additionally, numerous studies have identified important predictors of perioperative complications, costs, and mortality [5,13,18,41,46,49,53,54,65], suggesting that different patient populations may have different predisposing risk factors, and thus experience different degrees of benefit from a comanagement system. Although the financial issues associated with comanagement programs have been explored [14,19,37], to our knowledge no formal economic analysis based on decision analysis principles-which can be used to synthesize results over multiple studies and create generalizable conclusions-has been performed.…”

The status of intensive care medicine research and a future agenda for very old patients in the ICU

“…However, specific geriatric ICUs are scarce [17], and most VOPs are never visited by a geriatrician. Geriatricians' involvement is an advantage that recently has been found to provide a survival benefit in many other groups [18]. This benefit may reflect the more holistic approach a geriatrician may have to the VOP, leading to better decision-making.…”