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Comprehensive care program for elderly patients over 65 years with hip fracture
Rev Clin Esp. 2014;214(1):17---23
Revista Clínica Española www.elsevier.es/rce
ORIGINAL ARTICLE
Comprehensive care program for elderly patients over 65 years with hip fracture夽 A. Fernández-Moyanoa,∗ , R. Fernández-Ojedaa , V. Ruiz-Romerob , B. García-Benítezc , C. Palmero-Palmeroa , R. Aparicio-Santosa a
Servicio de Medicina Interna, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain Departamento de Calidad Asistencial, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain c Servicio de Traumatología y Ortopedia, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain b
Received 31 October 2012; accepted 21 January 2013 Available online 21 June 2013
KEYWORDS Hip fracture; Interdisciplinary care; Internal medicine; Mortality; Length of stay; Patient readmissions
Abstract Objectives: To report the health outcomes of a multidisciplinary care program for patients over 65 years with hip fracture. Patients and methods: We have developed a care coordination model for the comprehensive care of hip fracture patients. It establishes what, who, when, how and where orthopedists, internists, family physicians, emergency, intensive care, physiotherapists, anesthetists, nurses and workers social intervene. All elderly patients over 65 years admitted with the diagnosis of hip fracture (years 2006---2010) were retrospectively evaluated. Results: One thousand episodes of hip fracture, corresponding to 956 patients, were included. Mean age was 82 years and mean stay 6.7 days. This was reduced by 1.14 days during the 5 years of the program. A total of 85.1% were operated on before 72 yours, and 91.2% during the program. Incidence of surgical site infection was 1.5%. In-hospital mortality was 4.5% (24.2% at 12 months). Readmissions at one year was 14.9%. Independence for basic activity of daily living was achieved by 40% of the patients. Conclusions: This multidisciplinary care program for hip fracture patients is associated with positive health outcomes, with a high percentage of patients treated early (more than 90%), reduced mean stay (less than 7 days), incidence of surgical site infections, readmissions and inpatient mortality and at one year, as well as adequate functional recovery. © 2013 Elsevier Espa˜ na, S.L. All rights reserved.
DOI of original article: http://dx.doi.org/10.1016/j.rce.2013.01.011 Please cite this article as: Fernández-Moyano A, et al. Programa de atención integral a pacientes mayores de 65 a˜ nos con fractura de cadera. Rev Clin Esp. 2014;214:17---23. ∗ Corresponding author. E-mail address: [email protected] (A. Fernández-Moyano). 夽
2254-8874/$ – see front matter © 2013 Elsevier Espa˜ na, S.L. All rights reserved.
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PALABRAS CLAVE Fractura de cadera del anciano; Atención multidisciplinar; Medicina interna; Mortalidad; Estancia media; Reingresos
nos con fractura de cadera Programa de atención integral a pacientes mayores de 65 a˜ Resumen Objetivos: Presentamos los resultados en salud de un programa de asistencia multidisciplinar a pacientes con fractura de cadera mayores de 65 a˜ nos. Pacientes y métodos: Hemos desarrollado un modelo de coordinación asistencial para la atención integral del paciente con fractura de cadera, estableciendo qué, quién, cuándo, cómo y dónde intervienen traumatólogos, internistas, médicos de familia de urgencias, intensivistas, fisioterapeutas, anestesistas, enfermeros y trabajadores sociales. Se evaluaron retrospectivamente todos los pacientes mayores de 65 a˜ nos que ingresaron con diagnóstico de fractura de cadera (a˜ nos 2006 a 2010). Resultados: Se incluyen 1.000 episodios de fractura de cadera ocurridos en 956 pacientes. La edad media fue de 82 a˜ nos y la estancia media de 6,7 días, reduciéndose 1,14 días en los 5 a˜ nos del programa. Antes de las 72 h se intervinieron el 85,1%, y el 91,2% a lo largo del programa. La incidencia de infección quirúrgica fue del 1,5% y la mortalidad intrahospitalaria del 4,5% (24,2% a los 12 meses). Al cabo de un a˜ no reingresaron el 14,9%, y el 40% de los enfermos consiguieron ser independientes para las actividades básicas de su vida diaria. Conclusiones: Este programa de atención multidisciplinar al paciente con fractura de cadera se asoció a resultados beneficiosos en salud, con un elevado porcentaje de pacientes intervenidos precozmente (más del 90%), una reducida estancia media (menos de 7 días), incidencia de infecciones quirúrgicas, reingresos y mortalidad intrahospitalaria y al a˜ no de seguimiento, así como una adecuada recuperación funcional. © 2013 Elsevier Espa˜ na, S.L. Todos los derechos reservados.
Background One out of every 20 individuals will experience hospitalization due to a hip fracture over the course of their life. The rates among the various European countries are highly variable, ranging from 550,000 to 600,000 cases per year.1,2 It is estimated that, in the European Union and in the next 50 years, these fractures will increase by up to 135% and could reach 972,000 cases by 2050.3 Patients with hip fractures have long hospital stays and high mortality and, by the end of the process, experience a significant reduction in functionality and quality of life. Approximately 1 of every 15 patients with hip fractures dies during hospitalization and, of those who survive, 1---4 of every 10 die at 12 months.4 The mean length of stay, as an expression of morbidity, varies widely between 10 and 30 days.5 Once at home, only half of these patients will recover their prefracture mobility,6 without which their quality of life suffers.7 These patients also have orthopedic problems and considerable comorbidity (2.8 associated chronic diseases).8 There is also a relevant direct economic cost, calculated at approximately D8200---15,000 per patient for Spain.9,10 Interdisciplinary professional care improves health results11 and professional satisfaction12 and is recommended by the American Academy of Orthopedic Surgeons13 and by various clinical practice guidelines.14 Current organizational diversity15 accounts for the high variability of results reported worldwide.4,16 The orthogeriatric model is the most sophisticated, with a system that involves teamwork between orthopedic trauma surgeons, geriatricians, nurses, social workers and physiotherapists, starting from patient admission. The reported experiences from this model are limited, with limited numbers of patients and some performed in specific geriatric centers aimed primarily at caring
for patients with hip fractures.8,10,16---19 In this study, we present the health results of a coordinated, multidisciplinary healthcare program for patients over 65 years of age with hip fractures, implemented during the last 5 years in a general acute-care hospital.
Patients and methods Description of the model Our program implements an interim model between the so-called multidisciplinary healthcare team with a clinical pathways model and the orthogeriatric model. It establishes what, who, when, how and where the various activities should be implemented,20 following the grade IV architecture model of comprehensive healthcare processes,21 whose results are assessed annually and whose contents are updated periodically by the improvement and implementation group. In this model, health care is performed by trauma surgeons, internists, emergency physicians, physiotherapists, anesthesiologists, nurses and social workers who include this activity within their other healthcare activities of their specialty, which have been described previously.22 This care follows the following general principles of conduct: (1) the medical responsibility for patients from their arrival at the emergency department up to their discharge is shared between the trauma surgeon and the formal doctor (emergency physician or internist), daily and depending on the clinical condition that needs treating, with both parties reporting to the patient (or family members should they be authorized or in the event of disability); (2) the large majority of patients benefit from surgery as soon as possible and early mobilization after surgery, following a standardized
Comprehensive care program for elderly patients
What we know Hip fractures in the elderly usually result in long hospital stays and a high consumption of healthcare resources. Hip fractures require the participation of numerous healthcare professionals whose expertise is not always in line with patient needs. In this study, we assessed the health results over a 5-year period of a comprehensive healthcare program for patients with hip fractures.
What this article provides A total of 956 patients experienced 1000 episodes of hip fractures (mean age: 82 years). The overall results of the program (more than 90% of the patients were operated on within 72 h; the mean hospital stay was reduced to 6.7 days; mortality at 1 year was less than 25%; and the return to normal with complete autonomy at 12 months was 40%) suggest that the coordination of this condition by internists offers highly relevant benefits. The Editors
treatment protocol including nursing, hip fracture rehabilitation and management of related chronic diseases; (3) a proper home transfer should be carried out, with subsequent follow-up in the orthopedic trauma surgeon’s office at 1 month, 3 months and/or 6 months and according to the clinical evolution, up to at least 1 year after the procedure.
Population Our hospital treats the population of the Aljarafe region (Seville, Spain), with 244,031 inhabitants surveyed in 2006 and 272,759 in 2010. We retrospectively included all patients over 65 years of age with the diagnosis at discharge of hip fracture (ICD-9 820.00---820.9) from January 1, 2006 to December 31, 2010, with or without surgery. We excluded those with pathological fractures (defined as fractures due to a primary neoplastic or metastatic bone disease), periprosthetic fractures, reinterventions and ‘‘high-energy’’ or severe trauma fractures (defined as traffic accidents, accidents in high-risk sports and falls from considerable height).
Variables In addition to the typical demographic variables, we recorded the date of hospitalization (arrival at the emergency department), surgery and discharge, the type of surgical procedure and the length of stay (average, total and preoperative). An episode was considered a hospitalization due to hip fracture. Early intervention was considered surgery performed within 72 h after the patient arrived at the hospital, divided into 3 periods: within 24 h, within 48 h and within 72 h. The reason for not performing surgery, the onset of acute diseases, decompensation of chronic diseases
19 and surgical-site or prosthetic-material infection were identified through an audit conducted by an internal medicine specialist. The audit reviewed the information recorded in the progress assessments and discharge report of the digital medical histories by the doctors and nurses who treated the patient. The audit compared this information with the laboratory results and the treatment employed. Electrolyte disorders were only considered when corrective treatment was used. The diagnosis of de novo renal failure was considered, based on the laboratory analysis records, when there was a 50% increase in baseline creatinine values. An exacerbation of chronic renal failure was considered an increase of 1 mg/dl from baseline creatinine levels during hospitalization. For delirium, we used the DSM-IV-TR criteria, as well as the medical history records. Clinical comorbidity was assessed using the age-adjusted Charlson Comorbidity Index (aaCCI).23 Information on readmission at 1 month and at 1 year for any reason was obtained through the automatic record in the digital medical history. The reason for readmission was obtained based on the ICD-9 coding of the discharge report. The functional assessment was performed by the responsible hospitalization nurse based on the basic activities of daily living (BADL) measured with the Barthel index (BI) and considering the baseline score prior to the fracture and at 3, 6 and 12 months after discharge. For the functional recovery assessment, we excluded patients who had severe functional dependence, defined in this case as a BI < 40 points. All BI values were included in the mortality analysis. Complete independence for BADL was considered a BI ≥ 90. In-hospital mortality for any cause was obtained from the hospital registries generated from the computerized medical history, and mortality at 1 year for any cause was determined by consulting the Andalusian Institute of Statistics. For the identification of relevant medical complications and surgical wound or prosthetic infections, we extracted a representative sample of 259 and 122 episodes, respectively, taking into account a 95% CI and a 5% beta error on the expected 35% overall prevalence rate for medical complications and the expected 10% rate for surgical wound or prosthetic infections. To assess the incidence of prosthetic infection, we conducted a 12-month follow-up.
Statistical analysis To describe the quantitative variables, we presented the mean (when the distribution was symmetrical), with a 95% confidence interval for the mean or median (if asymmetrical) with quartiles 1 and 3. The qualitative variables were described using percentages. In the comparative analysis, we performed contrast tests of Student’s t-test, Mann---Whitney U test, chi-square, ANOVA and Kruskal---Wallis, depending on the variables being compared. The study used the SPSS® statistical package v 18.0.
Results A total of 1000 episodes were included in the study, which corresponded to 956 patients, 44 of whom presented 2 episodes. This represents an incidence of 729 episodes/100,000 patients over 65 years of age. The number of patients per year varied between 189 and 212, with
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Table 1 Clinical characteristics of 956 patients with 1000 episodes of hip fractures (2006---2010).a Variable
n (%)
Age, years Women Age-adjusted Charlson index Baseline Barthel indexb Complete independence for BADLb % Dementiaa , % Institutionalizeda , % Operated
82 (7.03) 804 (80.4) 5.9 (2.4) 82 (22.9) 48 35.4 12.7 935 (93.5)
Type of surgery Closed reduction with internal fixation Partial prosthetic Remainder
551 (58.9) 227 (24.2) 107 (16.9)
Table 3 Major medical complications during hospitalization in the context of a comprehensive healthcare program for patients over 65 years with hip fractures.a Medical complicationsa Delirium (hyperactive, hypoactive) Renal failure, de novo or exacerbation Sodium or potassium electrolyte disorders Atrial fibrillation (insufficient heart rate control) Decompensated heart failure Decompensated COPD Acute coronary syndrome Ileus Gastrointestinal hemorrhage Pneumonia Venous thromboembolic disease a
BADL, basic activities of daily life. a The results are expressed as mean (SD) or number of participants (%). b Recorded from January 2009 to December 2010 (n = 401 patients).
a total of 935 undergoing surgery (93.5% of episodes). The mean age was 82 years (SD: 7.03), ranging from 65 to 106 years of age, with 80.4% of the patients being female. The remaining baseline characteristics are shown in Table 1. The mean total stay was 6.7 days and decreased from the start of the program by 1.14 days (Table 2). The mean preoperative stay was 1.1 days. In the first 24 h, 426 patients (45.6%) underwent surgery; 654 (70.0%) were operated on within 48 h; and 796 (85.1%) were operated on in the first 72 h. By the end of the program, 91.2% of patients had undergone surgery within 72 h in 2010. Sixty-five patients (6.5%) did not undergo surgery; there were no differences in terms of age, gender or type of fracture between these patients and those that underwent surgery. The reasons for not operating were functional dependence (n = 53; 81.5%), advanced cognitive impairment (n = 10; 15.4%) and refusal by patient
Table 2 Results of comprehensive healthcare program for patients older than 65 years with hip fractures.a Variables
n (% or M ± SD)
Mean overall length of stay (days) Mean preoperative length of stay (days) Operated on within 24 h Operated on within 48 h Operated on within 72 h Readmitted at 1 month Readmitted at 1 year Intraepisode mortality Mortality at 1 year Functionality (% BI reduction at 12 months compared with baseline BI)b
6.7 (5.2; 8.8) 1.1 (0.8; 2.4) 426 (45.5) 654 (70.0) 796 (85.1) 52 (5.4) 143 (14.9) 45 (4.5) 231 (24.2) 78.5 vs. 82 (4%)
a The results are expressed as mean (interquartile range) or number of participants (%). b Recorded from January 2009 to December 2010 (n = 401 patients).
n (%) 48 28 19 16 13 10 10 8 5 3 1
(29.8) (17.4) (11.8) (9.9) (8.1) (6.2) (6.2) (5.0) (3.1) (1.9) (0.6)
Obtained from a representative sample of 259 patients.
(or their family if they could not make that decision) to undergo surgery (n = 2; 3.1%). The most common major medical complication was the onset of delirium (29.8%) (Table 3). About 1.5% of patients developed surgical infections (related to the surgical procedure). A total of 45 patients (4.5%) died during hospitalization, with the patients who were not operated on more likely to die (36 [3.85%] vs. 9 [0.65%]; p < .001). At 1 year of followup, 231 patients had died (24.2% of those discharged). Most of the patients who died were male (35.4% vs. 23.0%; p = 0.001) and elderly (84.5 years vs. 81.1 years; p = 0.001). Those who died were more likely to have developed delirium during hospitalization (40.0% vs. 21.2%; p = 0.023), had a tendency toward greater baseline functional dependence (Barthel index: 44 vs. 50; p = 0.58) and had no significant differences in the surgical delay (1.08; 0.75---2.3 days vs. 0.95; 0.72---2.5 days; p = 0.17). At follow-up, 52 patients (5.4% of those discharged) had been readmitted at 1 month, and 143 (14.9% of those discharged) had been readmitted at 1 year. Medical conditions represented 96.6% of the reasons for readmission at 1 year, with the most relevant being respiratory or urinary tract infections (20.3%); decompensated HF or acute coronary syndrome (18.6%); gastric, hepatobiliary or intestinal disease (12%); neurological disease (10.2%); and kidney disease (8.5%). A total of 32 patients (3.35% of those discharged) were readmitted at 1 year for a new fracture. The loss of functionality compared with the baseline condition was 46.0% at 3 months (Barthel index: 44.4; SD: 27.2), 21.9% at 6 months (Barthel index: 64.2; SD: 27.5) and 4.5% at 12 months (Barthel index: 78.5; SD: 18.8). The percentage of patients who achieved complete independence for BADL at 3, 6 and 12 months was 5.9%, 26.3% and 40.0%, respectively.
Discussion This study presents the health results of a comprehensive healthcare program for patients over 65 years of age with hip fractures. The results of the study are relevant because they demonstrate the effectiveness of the
Comprehensive care program for elderly patients program in terms of several health indicators such as mean length of stay, morbidity and mortality (both intraepisode and after 1 year), readmission and autonomy after 12 months. The baseline characteristics of our patients are similar to those described in other studies,4,8,10,24 although the patient institutionalization rate was significantly lower than that described in other studies.10,24 Most patients were operated on within 48 h. In Spain, the median delay to surgery is 3 days,25 and up to 64.9% of patients have to wait more than 48 h for surgery.24 These results may be attributed to the organizational changes made to promote the availability of operating rooms and develop the multidisciplinary program itself, which optimizes the care of medical diseases. The mean length of stay achieved was lower than that reported by other authors (between 14 and 25 days).4,26,27 The early discharge programs with home support28 and the hospital intervention programs with geriatric programs29 have positive results in reducing the mean length of stay. However, a recent study by Vidan et al.8 found no association with reduced hospital stay, possibly due to the Hawthorne effectd and by a sample size that was lower than required. Delirium was the most common medical complication and was within the range reported by other studies (9---30%).25,30 This amplitude may be due to the various patient characteristics studied, the delirium identification method, the diagnostic criteria used, the number of assessments performed over the course of the hospitalization and the evaluated healthcare model itself. Other major medical complications were within the broad range described in other studies,25 except for thromboembolic venous disease and pneumonia, whose incidence was lower. We had a surgical site infection rate lower than those reported in other studies.31 It is possible that adherence to safe practices by the practitioners (recognized by the ‘‘Manos Seguras’’ [Safe Hands] emblem granted by the Observatorio de Seguridad del Paciente [Patient Safety Observatory] in 2010) and the use of antibiotic prophylaxis (97%) with a surgical checklist have been able, at least in part, to bring about these results. Our program is associated with an intraepisode mortality of 4.5% (as compared to the 1.5---10% reported in other studies).4,5,24 Most studies have not shown a reduction of intraepisode mortality,32 except for the study by Vidan et al.,8 which had a rate of 0.6%. Mortality at the end of 1 year was 24.2%, with considerable variability in the published studies (10.4---45%).5,7,8 The independent factors associated with these variables include age, male gender, extended institutionalization, functional dependence, the presence of comorbidities, the development of delirium and surgical delay.25,33,34 The number of readmissions at 1 month and at 1 year were below those reported in other studies (between 18.3%35 and 34%36 at 1 month and up to 30.1%37
d This effect is a form of psychological reactivity by which the participants in an experiment show a change in some aspect of their behavior as a result of knowing they are being studied, and not in response to any type of handling considered in the experimental study.
21 at 1 year). These figures were higher in multidisciplinary intervention programs,38 such as the one implemented in this study. The implementation in our hospital since 2005 of a healthcare coordination program with primary care may have contributed to these results.22 In those patients who did not have severe functional dependence, we identified at 12 months a level of autonomy for BADL that was very similar to the level the patients had before the fracture. There are few studies that have assessed this health result, and those that have used various definitions, which hinders their comparison. The study most similar to ours by Vidan et al. showed similar results.8 The limitations of this study, as well as those of retrospective studies, include the lack of a control group, given that the measures adopted had already been implemented in patients with hip fractures since the opening of the hospital. In conclusion, the implementation of a multidisciplinary healthcare program for patients older than 65 years with hip fractures,39 developed by competent internists40,41 and integrated into the standard activity of a regional acutecare hospital, was associated over time with positive health results, a high percentage of patients undergoing early surgery, a shorter length of stay on average, a lower incidence of surgical site infections, fewer readmissions, lower mortality (intraepisode and at 1-year follow-up) and highly satisfactory functional recovery.
Conflict of interest The authors declare that they have no conflicts of interest.
Acknowledgments We would like to thank Blas García Vargas-Machuca and José Luis García Garmendia for their impetus from the management department to develop this healthcare program. We would also like to thank Dr. Francisco Varela, Fernando Baquero, Juan Prieto and Pilar Jimenez, emergency department heads of trauma, rehabilitation and anesthesia, respectively, for their participation in developing and implementing the program. Finally, we would like to thank all the healthcare professionals who perform their daily work with these patients.
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Comprehensive care program for elderly patients elderly patients with hip fractures: implementation results from Centre for Geriatric Traumatology, Almelo, The Netherlands. Ned Tijdschr Geneeskd. 2011;155:A3197. 39. Reyes-García R, Rozas-Moreno P, Mu˜ noz-Torres M. Enfermedad cardiovascular, osteoporosis y riesgo de fractura. Rev Clin Esp. 2012;212:188---92.
23 40. Losa JE, Zapatero A, Barba R, Marco J, Plaza S, Canora J. Encuesta SEMI sobre la oferta asistencial en los hospitales del sistema público de salud. Rev Clin Esp. 2011;211:223---32. 41. Porcel JM, Casademont J, Conthe P, Pinilla B, Pujol R, GarcíaAlegría J. Competencias básicas de la medicina interna. Rev Clin Esp. 2011;211:307---11.
Revista Clínica Española www.elsevier.es/rce
ORIGINAL ARTICLE
Comprehensive care program for elderly patients over 65 years with hip fracture夽 A. Fernández-Moyanoa,∗ , R. Fernández-Ojedaa , V. Ruiz-Romerob , B. García-Benítezc , C. Palmero-Palmeroa , R. Aparicio-Santosa a
Servicio de Medicina Interna, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain Departamento de Calidad Asistencial, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain c Servicio de Traumatología y Ortopedia, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain b
Received 31 October 2012; accepted 21 January 2013 Available online 21 June 2013
KEYWORDS Hip fracture; Interdisciplinary care; Internal medicine; Mortality; Length of stay; Patient readmissions
Abstract Objectives: To report the health outcomes of a multidisciplinary care program for patients over 65 years with hip fracture. Patients and methods: We have developed a care coordination model for the comprehensive care of hip fracture patients. It establishes what, who, when, how and where orthopedists, internists, family physicians, emergency, intensive care, physiotherapists, anesthetists, nurses and workers social intervene. All elderly patients over 65 years admitted with the diagnosis of hip fracture (years 2006---2010) were retrospectively evaluated. Results: One thousand episodes of hip fracture, corresponding to 956 patients, were included. Mean age was 82 years and mean stay 6.7 days. This was reduced by 1.14 days during the 5 years of the program. A total of 85.1% were operated on before 72 yours, and 91.2% during the program. Incidence of surgical site infection was 1.5%. In-hospital mortality was 4.5% (24.2% at 12 months). Readmissions at one year was 14.9%. Independence for basic activity of daily living was achieved by 40% of the patients. Conclusions: This multidisciplinary care program for hip fracture patients is associated with positive health outcomes, with a high percentage of patients treated early (more than 90%), reduced mean stay (less than 7 days), incidence of surgical site infections, readmissions and inpatient mortality and at one year, as well as adequate functional recovery. © 2013 Elsevier Espa˜ na, S.L. All rights reserved.
DOI of original article: http://dx.doi.org/10.1016/j.rce.2013.01.011 Please cite this article as: Fernández-Moyano A, et al. Programa de atención integral a pacientes mayores de 65 a˜ nos con fractura de cadera. Rev Clin Esp. 2014;214:17---23. ∗ Corresponding author. E-mail address: [email protected] (A. Fernández-Moyano). 夽
2254-8874/$ – see front matter © 2013 Elsevier Espa˜ na, S.L. All rights reserved.
18
A. Fernández-Moyano et al.
PALABRAS CLAVE Fractura de cadera del anciano; Atención multidisciplinar; Medicina interna; Mortalidad; Estancia media; Reingresos
nos con fractura de cadera Programa de atención integral a pacientes mayores de 65 a˜ Resumen Objetivos: Presentamos los resultados en salud de un programa de asistencia multidisciplinar a pacientes con fractura de cadera mayores de 65 a˜ nos. Pacientes y métodos: Hemos desarrollado un modelo de coordinación asistencial para la atención integral del paciente con fractura de cadera, estableciendo qué, quién, cuándo, cómo y dónde intervienen traumatólogos, internistas, médicos de familia de urgencias, intensivistas, fisioterapeutas, anestesistas, enfermeros y trabajadores sociales. Se evaluaron retrospectivamente todos los pacientes mayores de 65 a˜ nos que ingresaron con diagnóstico de fractura de cadera (a˜ nos 2006 a 2010). Resultados: Se incluyen 1.000 episodios de fractura de cadera ocurridos en 956 pacientes. La edad media fue de 82 a˜ nos y la estancia media de 6,7 días, reduciéndose 1,14 días en los 5 a˜ nos del programa. Antes de las 72 h se intervinieron el 85,1%, y el 91,2% a lo largo del programa. La incidencia de infección quirúrgica fue del 1,5% y la mortalidad intrahospitalaria del 4,5% (24,2% a los 12 meses). Al cabo de un a˜ no reingresaron el 14,9%, y el 40% de los enfermos consiguieron ser independientes para las actividades básicas de su vida diaria. Conclusiones: Este programa de atención multidisciplinar al paciente con fractura de cadera se asoció a resultados beneficiosos en salud, con un elevado porcentaje de pacientes intervenidos precozmente (más del 90%), una reducida estancia media (menos de 7 días), incidencia de infecciones quirúrgicas, reingresos y mortalidad intrahospitalaria y al a˜ no de seguimiento, así como una adecuada recuperación funcional. © 2013 Elsevier Espa˜ na, S.L. Todos los derechos reservados.
Background One out of every 20 individuals will experience hospitalization due to a hip fracture over the course of their life. The rates among the various European countries are highly variable, ranging from 550,000 to 600,000 cases per year.1,2 It is estimated that, in the European Union and in the next 50 years, these fractures will increase by up to 135% and could reach 972,000 cases by 2050.3 Patients with hip fractures have long hospital stays and high mortality and, by the end of the process, experience a significant reduction in functionality and quality of life. Approximately 1 of every 15 patients with hip fractures dies during hospitalization and, of those who survive, 1---4 of every 10 die at 12 months.4 The mean length of stay, as an expression of morbidity, varies widely between 10 and 30 days.5 Once at home, only half of these patients will recover their prefracture mobility,6 without which their quality of life suffers.7 These patients also have orthopedic problems and considerable comorbidity (2.8 associated chronic diseases).8 There is also a relevant direct economic cost, calculated at approximately D8200---15,000 per patient for Spain.9,10 Interdisciplinary professional care improves health results11 and professional satisfaction12 and is recommended by the American Academy of Orthopedic Surgeons13 and by various clinical practice guidelines.14 Current organizational diversity15 accounts for the high variability of results reported worldwide.4,16 The orthogeriatric model is the most sophisticated, with a system that involves teamwork between orthopedic trauma surgeons, geriatricians, nurses, social workers and physiotherapists, starting from patient admission. The reported experiences from this model are limited, with limited numbers of patients and some performed in specific geriatric centers aimed primarily at caring
for patients with hip fractures.8,10,16---19 In this study, we present the health results of a coordinated, multidisciplinary healthcare program for patients over 65 years of age with hip fractures, implemented during the last 5 years in a general acute-care hospital.
Patients and methods Description of the model Our program implements an interim model between the so-called multidisciplinary healthcare team with a clinical pathways model and the orthogeriatric model. It establishes what, who, when, how and where the various activities should be implemented,20 following the grade IV architecture model of comprehensive healthcare processes,21 whose results are assessed annually and whose contents are updated periodically by the improvement and implementation group. In this model, health care is performed by trauma surgeons, internists, emergency physicians, physiotherapists, anesthesiologists, nurses and social workers who include this activity within their other healthcare activities of their specialty, which have been described previously.22 This care follows the following general principles of conduct: (1) the medical responsibility for patients from their arrival at the emergency department up to their discharge is shared between the trauma surgeon and the formal doctor (emergency physician or internist), daily and depending on the clinical condition that needs treating, with both parties reporting to the patient (or family members should they be authorized or in the event of disability); (2) the large majority of patients benefit from surgery as soon as possible and early mobilization after surgery, following a standardized
Comprehensive care program for elderly patients
What we know Hip fractures in the elderly usually result in long hospital stays and a high consumption of healthcare resources. Hip fractures require the participation of numerous healthcare professionals whose expertise is not always in line with patient needs. In this study, we assessed the health results over a 5-year period of a comprehensive healthcare program for patients with hip fractures.
What this article provides A total of 956 patients experienced 1000 episodes of hip fractures (mean age: 82 years). The overall results of the program (more than 90% of the patients were operated on within 72 h; the mean hospital stay was reduced to 6.7 days; mortality at 1 year was less than 25%; and the return to normal with complete autonomy at 12 months was 40%) suggest that the coordination of this condition by internists offers highly relevant benefits. The Editors
treatment protocol including nursing, hip fracture rehabilitation and management of related chronic diseases; (3) a proper home transfer should be carried out, with subsequent follow-up in the orthopedic trauma surgeon’s office at 1 month, 3 months and/or 6 months and according to the clinical evolution, up to at least 1 year after the procedure.
Population Our hospital treats the population of the Aljarafe region (Seville, Spain), with 244,031 inhabitants surveyed in 2006 and 272,759 in 2010. We retrospectively included all patients over 65 years of age with the diagnosis at discharge of hip fracture (ICD-9 820.00---820.9) from January 1, 2006 to December 31, 2010, with or without surgery. We excluded those with pathological fractures (defined as fractures due to a primary neoplastic or metastatic bone disease), periprosthetic fractures, reinterventions and ‘‘high-energy’’ or severe trauma fractures (defined as traffic accidents, accidents in high-risk sports and falls from considerable height).
Variables In addition to the typical demographic variables, we recorded the date of hospitalization (arrival at the emergency department), surgery and discharge, the type of surgical procedure and the length of stay (average, total and preoperative). An episode was considered a hospitalization due to hip fracture. Early intervention was considered surgery performed within 72 h after the patient arrived at the hospital, divided into 3 periods: within 24 h, within 48 h and within 72 h. The reason for not performing surgery, the onset of acute diseases, decompensation of chronic diseases
19 and surgical-site or prosthetic-material infection were identified through an audit conducted by an internal medicine specialist. The audit reviewed the information recorded in the progress assessments and discharge report of the digital medical histories by the doctors and nurses who treated the patient. The audit compared this information with the laboratory results and the treatment employed. Electrolyte disorders were only considered when corrective treatment was used. The diagnosis of de novo renal failure was considered, based on the laboratory analysis records, when there was a 50% increase in baseline creatinine values. An exacerbation of chronic renal failure was considered an increase of 1 mg/dl from baseline creatinine levels during hospitalization. For delirium, we used the DSM-IV-TR criteria, as well as the medical history records. Clinical comorbidity was assessed using the age-adjusted Charlson Comorbidity Index (aaCCI).23 Information on readmission at 1 month and at 1 year for any reason was obtained through the automatic record in the digital medical history. The reason for readmission was obtained based on the ICD-9 coding of the discharge report. The functional assessment was performed by the responsible hospitalization nurse based on the basic activities of daily living (BADL) measured with the Barthel index (BI) and considering the baseline score prior to the fracture and at 3, 6 and 12 months after discharge. For the functional recovery assessment, we excluded patients who had severe functional dependence, defined in this case as a BI < 40 points. All BI values were included in the mortality analysis. Complete independence for BADL was considered a BI ≥ 90. In-hospital mortality for any cause was obtained from the hospital registries generated from the computerized medical history, and mortality at 1 year for any cause was determined by consulting the Andalusian Institute of Statistics. For the identification of relevant medical complications and surgical wound or prosthetic infections, we extracted a representative sample of 259 and 122 episodes, respectively, taking into account a 95% CI and a 5% beta error on the expected 35% overall prevalence rate for medical complications and the expected 10% rate for surgical wound or prosthetic infections. To assess the incidence of prosthetic infection, we conducted a 12-month follow-up.
Statistical analysis To describe the quantitative variables, we presented the mean (when the distribution was symmetrical), with a 95% confidence interval for the mean or median (if asymmetrical) with quartiles 1 and 3. The qualitative variables were described using percentages. In the comparative analysis, we performed contrast tests of Student’s t-test, Mann---Whitney U test, chi-square, ANOVA and Kruskal---Wallis, depending on the variables being compared. The study used the SPSS® statistical package v 18.0.
Results A total of 1000 episodes were included in the study, which corresponded to 956 patients, 44 of whom presented 2 episodes. This represents an incidence of 729 episodes/100,000 patients over 65 years of age. The number of patients per year varied between 189 and 212, with
20
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Table 1 Clinical characteristics of 956 patients with 1000 episodes of hip fractures (2006---2010).a Variable
n (%)
Age, years Women Age-adjusted Charlson index Baseline Barthel indexb Complete independence for BADLb % Dementiaa , % Institutionalizeda , % Operated
82 (7.03) 804 (80.4) 5.9 (2.4) 82 (22.9) 48 35.4 12.7 935 (93.5)
Type of surgery Closed reduction with internal fixation Partial prosthetic Remainder
551 (58.9) 227 (24.2) 107 (16.9)
Table 3 Major medical complications during hospitalization in the context of a comprehensive healthcare program for patients over 65 years with hip fractures.a Medical complicationsa Delirium (hyperactive, hypoactive) Renal failure, de novo or exacerbation Sodium or potassium electrolyte disorders Atrial fibrillation (insufficient heart rate control) Decompensated heart failure Decompensated COPD Acute coronary syndrome Ileus Gastrointestinal hemorrhage Pneumonia Venous thromboembolic disease a
BADL, basic activities of daily life. a The results are expressed as mean (SD) or number of participants (%). b Recorded from January 2009 to December 2010 (n = 401 patients).
a total of 935 undergoing surgery (93.5% of episodes). The mean age was 82 years (SD: 7.03), ranging from 65 to 106 years of age, with 80.4% of the patients being female. The remaining baseline characteristics are shown in Table 1. The mean total stay was 6.7 days and decreased from the start of the program by 1.14 days (Table 2). The mean preoperative stay was 1.1 days. In the first 24 h, 426 patients (45.6%) underwent surgery; 654 (70.0%) were operated on within 48 h; and 796 (85.1%) were operated on in the first 72 h. By the end of the program, 91.2% of patients had undergone surgery within 72 h in 2010. Sixty-five patients (6.5%) did not undergo surgery; there were no differences in terms of age, gender or type of fracture between these patients and those that underwent surgery. The reasons for not operating were functional dependence (n = 53; 81.5%), advanced cognitive impairment (n = 10; 15.4%) and refusal by patient
Table 2 Results of comprehensive healthcare program for patients older than 65 years with hip fractures.a Variables
n (% or M ± SD)
Mean overall length of stay (days) Mean preoperative length of stay (days) Operated on within 24 h Operated on within 48 h Operated on within 72 h Readmitted at 1 month Readmitted at 1 year Intraepisode mortality Mortality at 1 year Functionality (% BI reduction at 12 months compared with baseline BI)b
6.7 (5.2; 8.8) 1.1 (0.8; 2.4) 426 (45.5) 654 (70.0) 796 (85.1) 52 (5.4) 143 (14.9) 45 (4.5) 231 (24.2) 78.5 vs. 82 (4%)
a The results are expressed as mean (interquartile range) or number of participants (%). b Recorded from January 2009 to December 2010 (n = 401 patients).
n (%) 48 28 19 16 13 10 10 8 5 3 1
(29.8) (17.4) (11.8) (9.9) (8.1) (6.2) (6.2) (5.0) (3.1) (1.9) (0.6)
Obtained from a representative sample of 259 patients.
(or their family if they could not make that decision) to undergo surgery (n = 2; 3.1%). The most common major medical complication was the onset of delirium (29.8%) (Table 3). About 1.5% of patients developed surgical infections (related to the surgical procedure). A total of 45 patients (4.5%) died during hospitalization, with the patients who were not operated on more likely to die (36 [3.85%] vs. 9 [0.65%]; p < .001). At 1 year of followup, 231 patients had died (24.2% of those discharged). Most of the patients who died were male (35.4% vs. 23.0%; p = 0.001) and elderly (84.5 years vs. 81.1 years; p = 0.001). Those who died were more likely to have developed delirium during hospitalization (40.0% vs. 21.2%; p = 0.023), had a tendency toward greater baseline functional dependence (Barthel index: 44 vs. 50; p = 0.58) and had no significant differences in the surgical delay (1.08; 0.75---2.3 days vs. 0.95; 0.72---2.5 days; p = 0.17). At follow-up, 52 patients (5.4% of those discharged) had been readmitted at 1 month, and 143 (14.9% of those discharged) had been readmitted at 1 year. Medical conditions represented 96.6% of the reasons for readmission at 1 year, with the most relevant being respiratory or urinary tract infections (20.3%); decompensated HF or acute coronary syndrome (18.6%); gastric, hepatobiliary or intestinal disease (12%); neurological disease (10.2%); and kidney disease (8.5%). A total of 32 patients (3.35% of those discharged) were readmitted at 1 year for a new fracture. The loss of functionality compared with the baseline condition was 46.0% at 3 months (Barthel index: 44.4; SD: 27.2), 21.9% at 6 months (Barthel index: 64.2; SD: 27.5) and 4.5% at 12 months (Barthel index: 78.5; SD: 18.8). The percentage of patients who achieved complete independence for BADL at 3, 6 and 12 months was 5.9%, 26.3% and 40.0%, respectively.
Discussion This study presents the health results of a comprehensive healthcare program for patients over 65 years of age with hip fractures. The results of the study are relevant because they demonstrate the effectiveness of the
Comprehensive care program for elderly patients program in terms of several health indicators such as mean length of stay, morbidity and mortality (both intraepisode and after 1 year), readmission and autonomy after 12 months. The baseline characteristics of our patients are similar to those described in other studies,4,8,10,24 although the patient institutionalization rate was significantly lower than that described in other studies.10,24 Most patients were operated on within 48 h. In Spain, the median delay to surgery is 3 days,25 and up to 64.9% of patients have to wait more than 48 h for surgery.24 These results may be attributed to the organizational changes made to promote the availability of operating rooms and develop the multidisciplinary program itself, which optimizes the care of medical diseases. The mean length of stay achieved was lower than that reported by other authors (between 14 and 25 days).4,26,27 The early discharge programs with home support28 and the hospital intervention programs with geriatric programs29 have positive results in reducing the mean length of stay. However, a recent study by Vidan et al.8 found no association with reduced hospital stay, possibly due to the Hawthorne effectd and by a sample size that was lower than required. Delirium was the most common medical complication and was within the range reported by other studies (9---30%).25,30 This amplitude may be due to the various patient characteristics studied, the delirium identification method, the diagnostic criteria used, the number of assessments performed over the course of the hospitalization and the evaluated healthcare model itself. Other major medical complications were within the broad range described in other studies,25 except for thromboembolic venous disease and pneumonia, whose incidence was lower. We had a surgical site infection rate lower than those reported in other studies.31 It is possible that adherence to safe practices by the practitioners (recognized by the ‘‘Manos Seguras’’ [Safe Hands] emblem granted by the Observatorio de Seguridad del Paciente [Patient Safety Observatory] in 2010) and the use of antibiotic prophylaxis (97%) with a surgical checklist have been able, at least in part, to bring about these results. Our program is associated with an intraepisode mortality of 4.5% (as compared to the 1.5---10% reported in other studies).4,5,24 Most studies have not shown a reduction of intraepisode mortality,32 except for the study by Vidan et al.,8 which had a rate of 0.6%. Mortality at the end of 1 year was 24.2%, with considerable variability in the published studies (10.4---45%).5,7,8 The independent factors associated with these variables include age, male gender, extended institutionalization, functional dependence, the presence of comorbidities, the development of delirium and surgical delay.25,33,34 The number of readmissions at 1 month and at 1 year were below those reported in other studies (between 18.3%35 and 34%36 at 1 month and up to 30.1%37
d This effect is a form of psychological reactivity by which the participants in an experiment show a change in some aspect of their behavior as a result of knowing they are being studied, and not in response to any type of handling considered in the experimental study.
21 at 1 year). These figures were higher in multidisciplinary intervention programs,38 such as the one implemented in this study. The implementation in our hospital since 2005 of a healthcare coordination program with primary care may have contributed to these results.22 In those patients who did not have severe functional dependence, we identified at 12 months a level of autonomy for BADL that was very similar to the level the patients had before the fracture. There are few studies that have assessed this health result, and those that have used various definitions, which hinders their comparison. The study most similar to ours by Vidan et al. showed similar results.8 The limitations of this study, as well as those of retrospective studies, include the lack of a control group, given that the measures adopted had already been implemented in patients with hip fractures since the opening of the hospital. In conclusion, the implementation of a multidisciplinary healthcare program for patients older than 65 years with hip fractures,39 developed by competent internists40,41 and integrated into the standard activity of a regional acutecare hospital, was associated over time with positive health results, a high percentage of patients undergoing early surgery, a shorter length of stay on average, a lower incidence of surgical site infections, fewer readmissions, lower mortality (intraepisode and at 1-year follow-up) and highly satisfactory functional recovery.
Conflict of interest The authors declare that they have no conflicts of interest.
Acknowledgments We would like to thank Blas García Vargas-Machuca and José Luis García Garmendia for their impetus from the management department to develop this healthcare program. We would also like to thank Dr. Francisco Varela, Fernando Baquero, Juan Prieto and Pilar Jimenez, emergency department heads of trauma, rehabilitation and anesthesia, respectively, for their participation in developing and implementing the program. Finally, we would like to thank all the healthcare professionals who perform their daily work with these patients.
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