Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society.

BACKGROUND: The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities. METHODOLOGY: A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS. RESULTS/CONCLUSION: A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study.

BACKGROUND/OBJECTIVES: For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN: Retrospective chart review. SETTING: Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS: Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS: Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality. RESULTS: Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE. CONCLUSION: This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690-1697, 2020.

Quality indicators for in-hospital geriatric co-management programmes: a systematic literature review and international Delphi study.

OBJECTIVE: To find consensus on appropriate and feasible structure, process and outcome indicators for the evaluation of in-hospital geriatric co-management programmes. DESIGN: An international two-round Delphi study based on a systematic literature review (searching databases, reference lists, prospective citations and trial registers). SETTING: Western Europe and the USA. PARTICIPANTS: Thirty-three people with at least 2 years of clinical experience in geriatric co-management were recruited. Twenty-eight experts (16 from the USA and 12 from Europe) participated in both Delphi rounds (85% response rate). MEASURES: Participants rated the indicators on a nine-point scale for their (1) appropriateness and (2) feasibility to use the indicator for the evaluation of geriatric co-management programmes. Indicators were considered appropriate and feasible based on a median score of seven or higher. Consensus was based on the level of agreement using the RAND/UCLA Appropriateness Method. RESULTS: In the first round containing 37 indicators, there was consensus on 14 indicators. In the second round containing 44 indicators, there was consensus on 31 indicators (structure=8, process=7, outcome=16). Experts indicated that co-management should start within 24 hours of hospital admission using defined criteria for selecting appropriate patients. Programmes should focus on the prevention and management of geriatric syndromes and complications. Key areas for comprehensive geriatric assessment included cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers. Key outcomes for evaluating the programme included length of stay, time to surgery and the incidence of complications. CONCLUSION: The indicators can be used to assess the performance of geriatric co-management programmes and identify areas for improvement. Furthermore, the indicators can be used to monitor the implementation and effect of these programmes.

Hospital readmission after hip fracture.

INTRODUCTION: Readmission to the hospital following a hip fracture is common, often involves an adverse event, and strains an already overburdened health care system. OBJECTIVES: To assess the rate of 30-day readmission to the hospital after discharge for care of hip fracture. A secondary objective was measurement of the 30-day mortality rate for those patients readmitted versus those patients not readmitted to the hospital after discharge. MATERIALS AND METHODS: Study design was a retrospective review of registry data comparing readmitted patients to those not readmitted after hip fracture. Setting was a university affiliated level 3 trauma center. PARTICIPANTS: 1,081 patients aged 65 and older. MEASUREMENTS: rate of readmission, rate of mortality, predictors of readmission. RESULTS: 129 patients (11.9 %) were readmitted to the hospital within 30 days of their initial discharge date. The primary causes of readmission were surgical in nature for 24/129 (18.6 %) patients and 105/129 (81.4 %) were readmitted for medical or other reasons. Twenty-four (18.6 %) patients who were readmitted died during readmission. The one-year mortality rate for patients readmitted within 30 days was 56.2 vs. a 21.8 % 1-year mortality rate for those patients not readmitted (p < 0.0001). Independent predictors of readmission were age >85 (OR = 1.52; p = 0.03), time to surgery >24 h (OR = 1.50; p = 0.05), Charlson score ≥4 (OR = 1.70; p = 0.04), delirium (OR = 1.65; p = 0.01), dementia (OR = 1.61; p = 0.01), history of arrhythmia with pacemaker placement (OR = 1.75; p = 0.02), and presence of a pre-op arrhythmia (OR = 1.62; p = 0.02). CONCLUSION: Readmission after hip fracture is harmful and undesirable-18.6 % of readmitted patients died during their readmission and the average length of stay was 8.7 days. Approximately one of every six readmissions was identified as potentially preventable with interventions.

Anticoagulation management in individuals with hip fracture.

OBJECTIVES: To determine the interventions taken to lower international normalized ratio (INR) in individuals with hip fracture using warfarin before admission for hip fracture surgery in a geriatric fracture center (GFC) and compare outcomes with those of individuals not taking warfarin. DESIGN: Cohort study using retrospective chart review. SETTING: University-affiliated community teaching hospital. PARTICIPANTS: Individuals aged 60 and older admitted to a GFC for surgical repair of a nonpathological, nonperiprosthetic hip fracture between April 2006 and April 2012. MEASUREMENTS: Descriptive data collected from a quality improvement registry with additional information for individuals taking warfarin obtained from chart review. RESULTS: Of the 1,080 individuals included in the analysis, 84 (7.8%) were taking warfarin on admission. Participants using warfarin had a higher average Charlson Comorbidity Index (3.8 vs 3.1, P < .001). Atrial fibrillation was the most common indication for anticoagulation (83.3%). Average INR before surgery was 1.7 (range 1.2-3.6). Vitamin K, fresh frozen plasma, or both were given to 100% of those taking warfarin with an admission INR of 2.0 or greater. There was a trend toward longer time to surgery in those taking warfarin than in those not taking warfarin (28.9 vs 21.7 hours, P = .05). Length of stay was longer for those taking warfarin than those not taking warfarin (4.8 vs 4.2 days, P = .04). Neither time to surgery nor length of stay were significantly different after adjustment for baseline comorbidity. Participants taking warfarin were not found to have any significant differences in thromboembolic event rates, bleeding complications rates, mortality, or 30-day readmission after surgery than those not taking warfarin on admission. CONCLUSION: Active management in a GFC model to reverse anticoagulation before surgery may facilitate earlier surgery without increasing observed complications.

Barriers to implementation of an organized geriatric fracture program.

INTRODUCTION: There has been a recent increase in interest in implementing organized geriatric fracture programs for care of older adults with fragility fractures in order to improve both the quality and costs of care. Because such programs are relatively new, there are no standardized methods for implementation and no published descriptions of barriers to implementation. MATERIALS AND METHODS: An online survey tool was sent to 185 surgeons and physicians practicing in the United States, who are involved with geriatric fracture care. Sixty-eight responses were received and evaluated. RESULTS: Barriers identified included lack of medical and surgical leadership, need for a clinical case manager, lack of anesthesia department support, lack of hospital administration support, operating room time availability, and difficulty with cardiac clearance for surgery. Other issues important to implementation included quality improvement, cost reductions, cost to the hospital, infection prevention, readmission prevention, and dealing with competing interest groups and competing projects mandated by the government. Physicians and surgeons felt that a site visit to a functioning program was most important when considering implementing a hip fracture program. CONCLUSIONS: This study provides useful insights into barriers to implementing an organized hip fracture program. The authors offer suggestions on ways to mitigate or overcome these barriers.

Diagnosis and treatment of osteoporosis in high-risk patients prior to hip fracture.

PURPOSE: Hip fractures in older adults are common and serious events. Patients who sustain fragility hip fractures are defined as having osteoporosis. Patients with dementia or a history of a prior fragility fracture are at increased risk of a future fracture. This study assesses prefracture osteoporosis diagnosis and treatment in high-risk groups. METHODS: A case-control analysis of a database of all patients age ≥60 years admitted for surgical repair of nonpathological, low-impact femur fracture between May 2005 and October 2010 was performed. RESULTS: Of 1070 patients, 511 (47.8%) had dementia and 435 (40.7%) had been diagnosed with osteoporosis prior to admission. Patients with dementia were more likely to have a diagnosis of osteoporosis prior to their fracture than those without dementia (43.8% vs 37.7%, P < .05). Twenty-five percent of the total study population had been treated with calcium and vitamin D (Cal+D) prior to admission, and 12% with other osteoporosis medications. There was a trend toward patients with dementia being more likely to have been on Cal+D prior to admission (27.6% vs 22.5%, P = .06), but no difference in treatment with other agents (10.8% vs 13.1%, P = .25). Patients with prior fragility fractures were more likely to be on Cal+D (32.3% vs 25.0%, P < .02); however, there was no difference in the use of other osteoporosis medications (12.3% vs 12%, P = .90). CONCLUSION: Fewer than half of patients that presented with hip fractures were diagnosed with osteoporosis prior to fracture and primary preventative treatment rates were low. Although patients with dementia are more likely to be diagnosed with osteoporosis, they were not more likely to be treated, despite having a greater risk. Additionally, those with prior fragility fractures are often not on preventative treatment. This may represent a missed opportunity for prevention and room for improvement in order to reduce osteoporotic hip fractures.

The impact of comorbidity on perioperative outcomes of hip fractures in a geriatric fracture model.

BACKGROUND: Older adults who sustain hip fractures usually have multiple coexisting medical problems that may impact their treatment and outcomes. The geriatric fracture center (GFC) provides a model of care that standardizes treatment and optimizes outcomes. The purpose of this study is to determine whether GFC patients with a higher burden of comorbidity or specific comorbidities are at risk for worsened perioperative outcomes, such as increased time to surgery (TTS), postoperative complications, and longer length of hospital stay (LOS). METHOD: A total of 1077 patients aged 60 years and older who underwent surgery for a proximal femur fracture between April 15, 2005, and September 30, 2010, were evaluated. Comorbidities measured in the Charlson Comorbidity index were abstracted through chart review. Outcomes were TTS, postoperative complications, and LOS. RESULTS: Most patients were white, with an average age of 85. One half lived in either a nursing home or an assisted living facility. The mean Charlson score was 3.06 and the nursing home residents had a significantly higher score compared to community dwellers (3.4 vs 2.8; P < .0001). Dementia was the most common comorbidity. There was no difference in the LOS or TTS based on Charlson score. The overall complication rate was 44% with delirium being the most common postoperative complication. Peripheral vascular disease, history of solid tumor, and peptic ulcer disease predicted delirium incidence. Charlson score predicted complication risk, with an odds ratio of 1.12 for each point increase. CONCLUSION: Frailty and comorbidity put this hip fracture population at high risk for adverse perioperative outcomes. This study shows that in the GFC model of care the comorbidity burden did not impact the TTS and LOS but did predict postoperative complication rate.

The value of an organized fracture program for the elderly: early results.

OBJECTIVES: To describe the early financial results of an organized hip fracture program for older adults. DESIGN: Retrospective evaluation of financial data for a 1-year period on a hip fracture program for older adults. SETTING: University medical center. PATIENTS: All 193 adults older than age 60 with a native, nonpathologic hip fracture admitted to the hospital and surgically treated from May 2005 to April 2006 were included as subjects in this study. INTERVENTION: The comanaged, protocol-driven fracture management program was used as the specific intervention for treating all patients with hip fractures. MAIN OUTCOME MEASURE: The primary outcome was profit or loss resulting from treatment of patients. Key quality measures studied included length of hospital stay, mortality rates, complication rates, and hospital readmission rates. RESULTS: With use of an organized program, substantial savings in nearly all areas of expenditure is demonstrated. Adjusting for patient characteristics, costs are demonstrated to be 66.7% of the expected costs nationally. The length of stay, mortality, complication rates, and readmission rates were all noted to be below national averages. CONCLUSIONS: The improved quality measures suggest that better quality of patient care is associated with reduced costs.

Comparison of an organized geriatric fracture program to United States government data.

OBJECTIVE: This study describes the financial impact of an organized hip fracture program for elderly patients age 65 years and older. METHODS: This is a retrospective study of 797 fractures in 776 consecutive patients over a 50-month period (May 2005 to July 2009) treated in an organized hip fracture program for the elderly identified from a quality management database. Financial, demographic, and quality-of-care data were collected. The length of hospital stay, in-hospital complications, and Charlson comorbidity scores were collected from patient records, and all data were evaluated using standard statistical methods. SETTING: 261-bed community-based, university-affiliated teaching hospital in an urban setting with a catchment area of approximately 1 million persons. This is a level 3 trauma center. RESULTS: The average total net revenue per hip fracture was $12 159, with an average total cost to hospital of $8264. Physicians' fees consisted of fees collected by surgeons, anesthesiologists, medical specialty consultants, and consulting geriatricians and averaged $2024 per case. Thus, the average hospital charge to payers was $15 188. Compared to Agency for Healthcare Research and Quality average inpatient hospital costs in 2005 of $33 693, a savings of more than $18 000 was realized per patient. The average length of stay was 4.6 days, markedly less than the national average of 6.2 days. CONCLUSIONS: This organized geriatric fracture care model with geriatrics comanagement resulted in significant cost savings over a 50-month period, with associated increased quality. With an estimated 330 000 hip fractures annually in the United States, a large cost savings could potentially be realized if this model were more widely applied.

The 1-year mortality of patients treated in a hip fracture program for elders.

Comanagement of geriatric hip fracture patients with standardized protocols has been shown to improve short-term outcomes after surgery. A standardized, patient-centered, comanaged Hip Fracture Program for Elders is examined for 1-year mortality. Patients ≥60 years of age who were treated in the Hip Fracture Program for Elders were comanaged by orthopaedic surgeons and geriatricians. Data including age, place of origin, procedure, length of stay, 1-year mortality, Charlson score, and activities of daily living (ADLs) were retrospectively collected. A total of 758 patients ≥60 years of age with hip fractures between April 15, 2005, and March 1, 2009, were included. Their data were analyzed, and the Social Security Death Index and the hospital data system were searched for mortality data. Seventy-eight percent were female, with a mean age of 84.8 years. The mean Charlson score was 3. Fifty percent were admitted from an institutional setting. The overall 1-year mortality was 21.2%. Age (odds ratio [OR] = 1.03, 95% confidence interval [CI] = 1.00-1.05; P = .02), male gender (OR = 1.55, 95% CI = 1.01-2.36; P = .04), low Parker mobility score (OR = 2.94, 95% CI = 1.31-6.57; P = .01), and a Charlson score of 4 or greater (OR = 2.15, 95% CI = 1.30-3.55; P = .002) were predictive of 1-year mortality. ADL dependence was a borderline predictor, as was medium Parker mobility score. Prefracture residence and moderate comorbidity (Charlson score of 2-3) were not independently predictive of mortality at 1 year after adjusting for other characteristics. A comprehensive comanaged hip fracture program for elders not only improves the short-term outcomes but also demonstrates a low 1-year mortality rate, particularly in patients from nursing facilities.

Dementia and hip fractures: development of a pathogenic framework for understanding and studying risk.

Dementia and hip fractures are 2 conditions that are seen primarily in older adults, and both are associated with substantial morbidity and mortality. An individual with dementia is up to 3 times more likely than a cognitively intact older adult to sustain a hip fracture. This may occur via several mechanisms, including (1) risk factors that are common to both outcomes; (2) the presence of dementia increasing hip fracture incidence via intermediate risk factors, such as falls, osteoporosis, and vitamin D; and (3) treatment of dementia causing side effects that increase hip fracture risk. We describe a model that applies these 3 mechanisms to explain the relationship between dementia and hip fractures. Comprehensive understanding of these pathways and their relative influence on the outcome of hip fracture will guide the development of effective interventions and potentially improve prevention efforts.

Prevention and clinical management of hip fractures in patients with dementia.

Hip fractures and dementia increase exponentially with age, and patients who are afflicted by both conditions suffer significant morbidity and mortality. The aging of our population heightens the need to recognize the interaction of these conditions in order to improve our efforts to prevent hip fractures, provide acute care that improves outcomes, and provide secondary prevention and rehabilitation that returns patients to their previous level of functioning. Identification and treatment of vitamin D deficiency and osteoporosis and assessment and interventions to reduce falls in patients with dementia can significantly impact the incidence of first and subsequent hip fractures. Acute management of hip fractures that focuses on comanagement by orthopedic surgeons and geriatricians and uses protocol-driven geriatric-focused care has been shown to decrease mortality, length of hospitalization, readmission rates, and complications including delirium. Patients with mild-to-moderate dementia benefit from intensive geriatric rehabilitation to avoid nursing home placement. Recognizing the need to optimize primary and secondary prevention of hip fractures in patients with dementia and educating providers and families will lead to improved quality of life for patients affected by dementia and hip fractures.

Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes.

BACKGROUND: Hip fractures are associated with substantial morbidity and mortality for older adults. Patients sustaining hip fractures usually have comorbid conditions that may benefit from comanagement by geriatricians and orthopedic surgeons. METHODS: The Geriatric Fracture Center (GFC) is part of a community teaching hospital. Patients are comanaged daily by a geriatrician and orthopedic surgeon, emphasizing total quality management, timely treatment, and standardized care. We reviewed medical records to compare process and outcome measures in the GFC with a local institution that did not have a fracture management service. Patients 60 years or older admitted for a proximal femur fracture from May 1, 2005, to April 30, 2006, were included; pathological, recurrent, high-energy, periprosthetic, and nonoperative fractures were excluded. RESULTS: Geriatric Fracture Center patients (n = 193) were significantly older, were less likely to reside in the community, and had more comorbid conditions and dementia than usual care patients (n = 121). Despite baseline differences, GFC patients, compared with usual care patients, had shorter times to surgery (24.1 vs 37.4 hours), fewer postoperative infections (2.3% vs 19.8%), fewer complications overall (30.6% vs 46.3%), and shorter length of stay (4.6 vs 8.3 days). Compared with GFC patients, physical restraint use was significantly higher in usual care patients (0% vs 14.1%). After we adjusted for baseline characteristics, patients treated in the GFC had shorter times to surgery, shorter length of stay, fewer cardiac complications, and fewer cases of thromboembolism, delirium, and infection. There was no difference in in-hospital mortality or 30-day readmission rate. CONCLUSION: Comanagement by geriatricians and orthopedic surgeons, combined with standardized care, leads to improved processes and outcomes for patients with hip fractures.

Hazards of hospitalization: residence prior to admission predicts outcomes.

PURPOSE: Previous studies investigating adverse outcomes of hospitalized elders have focused on community-dwelling patients. Given the rapid growth of populations living in other settings, such as assisted living facilities, it is important to understand whether these patients are at higher risk of experiencing specific adverse outcomes during hospitalization, so that interventions can be developed to reduce risk. METHODS: This is a prospective, observational study of 212 sequential patients admitted during a 1-month period in 2006 to a 38-bed Acute Care for Elders unit in Rochester, New York and followed until discharge. We categorized the patients by residence prior to admission (i.e., community, assisted living, and nursing home). Our outcome categories were: worsening function, delirium, depression, falls, pressure sores, and nursing home admission. RESULTS: After adjusting for multiple characteristics, we found that patients admitted from assisted living facilities were at substantially higher risk than those admitted from the community for functional decline and falls. Patients from nursing homes had a trend toward increased risk for these outcomes, but the trend did not reach statistical significance. More than three fourths of assisted living facility residents were discharged to a nursing home after hospitalization, with a relative risk of 9.41 (p <.001) versus community-dwellers for this outcome. IMPLICATIONS: People who are admitted to the hospital from assisted living facilities are at high risk for falls and functional decline during hospitalization. Assisted living residents are at a particularly high risk of nursing home admission following hospitalization. Targeted preventive programs should be developed with a goal of reducing risk in this vulnerable population.

Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population.

Hip fractures in older adults are a common event, leading to substantial morbidity and mortality. Hip fractures have been previously described as a "geriatric, rather than orthopedic disease." Patients with this condition have a high prevalence of comorbidity and a high risk of complications from surgery, and for this reason, geriatricians may be well suited to improve outcomes of care. Co-management of hip fracture patients by orthopedic surgeons and geriatricians has led to better outcomes in other countries but has rarely been described in the United States. This article describes a co-managed Geriatric Fracture Center program that has resulted in lower-than-predicted length of stay and readmission rates, with short time to surgery, low complication rates, and low mortality. This program is based on the principles of early evaluation of patients, ongoing co-management, protocol-driven geriatric-focused care, and early discharge planning. This is a potentially replicable model of care that uses the expertise of geriatricians to optimize the management of a common and serious condition.

Advances in the medical management of osteoporosis.

Osteoporosis is a skeletal disorder characterised by compromised bone strength predisposing to increased risk of fracture, which is rapidly reaching epidemic proportions as the population ages. Many patients presenting with a fracture caused by a fall from standing height or less are not on any kind of therapy and many patients who sustain these fragility fractures are not started on therapy by their orthopaedic surgeon. In 2004, the United States Surgeon General released a report on osteoporosis recommending that physicians adopt a pyramidal approach to therapy. The base of the pyramid includes calcium, vitamin D, physical therapy and fall prevention. The second level calls for management or elimination of secondary causes of osteoporosis. The third level consists of treatment with either anti-resorptive or anabolic medications. The orthopaedic surgeon is in an ideal position to diagnose fragility fractures and suggest treatment in the hope of preventing future fractures. Anti-resorptive and anabolic therapies currently available are discussed.