JAMDA 15 (2014) 232e233
JAMDA journal homepage: www.jamda.com
Editorial
Innovations in Hip Fracture Care: A Comparison of Geriatric Fracture Centers Rani Ramason MBChB, MRCP, FAMS a, *, Mei Sian Chong MBBS, FRCP, FAMS a, William Chan MBBS, FACRM, FAFRM (RACP), FAMS b, Ganesan Naidu Rajamoney MBBS, FRCS, FAMS c a b c
Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
Hip fractures are common in the elderly and are associated with significant morbidity and mortality.1 Recently, geriatric fracture centers (GFCs) have been set up worldwide to try to improve care of frail elderly patients with hip fracture.2e5 The key strategy for GFCs is ortho-geriatric comanaged care. Comanaged care is defined by interdisciplinary involvement and integration of orthopedic surgeons, geriatricians, anesthetists, rehabilitation physicians, nurses, physiotherapists, occupational therapists, care managers, social workers, and dieticians working together with shared ownership and equal responsibilities. As good care involves a multidisciplinary, interprofessional approach, it is imperative to have patient-centered protocoldriven standardized care. The key elements of good care for patients with fragility fracture are described well in the Blue Book6,7 and have been used as the goals of care for these GFCs. The advantages include shorter time to surgery, and reduction of hospital complications, length of stay (LOS), readmission rates, and mortality. Positive outcomes have been published for GFCs developed at the University of Rochester Medical Center, New York, and in Austria thus far.2e5 The population is aging, especially rapidly in Asia. In Singapore, the prevalence of adults older than 65 years is set to rise from 9.9% in 2012 to 19.0% in 2030.8 The International Osteoporosis Foundation’s 2009 Asian Audit Report states that the incidence of hip fractures in Singapore is set to rise from 1300 in 1998 to 9000 per annum by 2050.9 In support of this, the Ministry of Health in Singapore awarded Tan Tock Seng Hospital $5.7 million for a Health Services Development Project to develop a 5-year program (October 2011 to September 2016) to improve the quality of hip fracture care for older persons. The objectives of this program were to optimize patients’ clinical and functional outcomes, and reduce inpatient LOS, unplanned readmissions, and morbidity. The strategies adopted include prompt admission from the emergency department to orthopedic wards, comanagement between orthopedics and geriatric medicine with interdisciplinary team involvement, and standardized care bundles (carepath), together with patient and family education using
The authors declare no conflicts of interest. * Address correspondence to Rani Ramason, MBBS, MRCP, Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, S308433 Singapore. E-mail address: [email protected] (R. Ramason).
a “hip fracture booklet.” Additionally, there was care coordination, whereby frail older persons transfer from the acute care to rehabilitation centers and subsequently postdischarge community services, enabling integrated, holistic hip fracture care. This was provided by the integrated care manager who additionally helps to (1) educate, coordinate, and improve compliance and follow-up care; (2) devise a “Fitness for Op Criteria” to expedite surgery within 48 hours of admission; (3) extend rehabilitation beyond discharge; and (4) initiate an interdisciplinary hip fracture clinic to standardize care and improve osteoporosis treatment and falls assessment and prevention. Ethics approval was obtained from the National Healthcare Group Domain Specific Research Board. We compared the results of our hip fracture program (October 2011 to September 2012) with the published results of various international GFCs in terms of time to surgery, LOS, and various morbidity and mortality data (Table 1). Our time to surgery within 48 hours was 77% (from baseline of 35%). Although it is an improvement from our baseline of 35% (results not shown), this is still low compared with the other centers. Compared with the other hip fracture programs, it was noted that the LOS varied between 4.2 and 15.8 days. The reason for this could be the different models of step-down care available in the different countries and the efficiency and availability of step-down care or rehabilitation beds. In Rochester, where the LOS is shortest, at 4.2 days, patients with hip fracture are transitioned over from their acute hospital bed to their associated nursing facility rehabilitation beds by the third postoperative day. In most other centers, including Singapore, the patients with hip fracture have to wait for an available bed in a geriatric rehabilitation hospital. Our 30-day admission rates were low at 1.3% as we tracked readmissions back only to the orthopedic department in our study compared to the other centers that tracked all readmissions to the hospital. We had comparable hip fracture inpatient mortality rates (1.4%) to the Rochester center, despite having a longer LOS. Albeit a longer time to surgery and LOS, our 1year mortality rate was one of the lowest at 12.1% (Table 1). These good postoperative results are evidence of good hip fracture care through this integrated program, despite a longer LOS (likely contributed by different countries’ model of step-down care availability and setup) and longer time to surgery. Further quality
1525-8610/$ - see front matter Ó 2014 - American Medical Directors Association, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jamda.2014.01.005
Editorial / JAMDA 15 (2014) 232e233
233
Table 1 Comparison of Length of Stay, Time to Surgery, Morbidity, and Mortality Data of Various Geriatric Hip Fracture Programs
Surgery within 48 h, % Length of stay, d 30-d readmission Hospital mortality rates, % 1-year mortality, %
Rochester Model2e4
Innsbruck Model5
Usual Care10
National Hip Fracture Database (UK)12
Hong Kong Model15
Singapore Model
93.3 4.2 9.8 1.6 21.2
95.7 11.3 5.2 3.1 Not available
86.0 5.7e23.2 13.2 2.5e5.8 18.8e39.511
86.0 15.8 11.813 8.2 19.314
86.0 6.4 15 1.25 16.4e22.416
77.0 10.9 1.3 1.4 12.1*
*Mortality data obtained from the National Death Registry.
improvement projects are under way to try to improve these processes. In summary, comanaged interdisciplinary care involving the geriatrician has been shown to improve outcomes for elderly patients with hip fracture and is fast becoming the standard of good elderly hip fracture care around the world.
References 1. Zuckerman JD. Hip fracture. N Engl J Med 1996;334:1519e1525. 2. Kates SL, Mendelson DA, Friedman SM. Co-managed care for fragility hip fractures (Rochester model). Osteoporos Int 2010;21:S621eS625. 3. Friedman SM, Mendelson DA, Bingham KW, et al. Impact of a comanaged geriatric fracture centre on short-term hip fracture outcomes. Arch Intern Med 2009;169:1712e1717. 4. Friedman SM, Mendelson DA, Kates SL, et al. Geriatric co-management of proximal femur fractures: Total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatric Soc 2008; 56:1349e1356. 5. Kammerlander C, Gosch M, Blauth M, et al. The Tyrolean Geriatric Fracture Center: an orthogeriatric co-management model. Z Gerontol Geriatr 2011;44: 363e367. 6. British Orthopaedic Association. BOA/BGS Blue Book: Care of patients with fragility fractures. London, UK: British Orthopaedic Association; 2007.
7. British Association Standards for Trauma (BOAST) 1 version 2: all patients sustaining a fragility hip fracture. London, UK: British Orthopaedic Association; 2012. 8. Singapore Department of Statistics. Population and population structure. Available at: http://www.singstat.gov.sg/statistics/browse_by_theme/popula tion.html. Accessed December 1, 2013. 9. Mithal A, Dhingra V, Lau E. The Asian Audit: Epidemiology, Costs and Burden of Osteoporosis in Asia 2009. Switzerland: International Osteoporosis Foundation; 2009. p. 1e60. 10. Kates SL, Blake D, Bingham KW, et al. Comparison of an organized geriatric fracture program to United States government data. Geriatr Orthop Surg Rehabil 2010;1:15e21. 11. Schnell S, Friedman SM, Mendelson DA, et al. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil 2010; 1:6e14. 12. Health Quality Improvement Partnership. National Hip Fracture Database. National Report 2013. Available at: http://www.hqip.org.uk/assets/NCAPOPLibrary/NCAPOP-2013-14/NHFD-National-Report-2013.pdf. Accessed January 26, 2014. 13. Khan MA, Hossain FS, Dashti Z, et al. Causes and predictors of early re-admission after surgery for a fracture of the hip. J Bone Joint Surg Br 2012;94:690e697. 14. Wiles MD, Moran CG, Sahota O, et al. Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur. Br J Anaesth 2011;106:501e504. 15. Lau TW, Leung F, Siu D, et al. Geriatric hip fracture clinical pathway: The Hong Kong experience. Osteoporos Int 2010;21:627e636. 16. Chau PH, Wong M, Lee A, et al. Trends in hip fracture incidence and mortality in Chinese population from Hong Kong 2001e09. Age Ageing 2013;42: 229e233.
JAMDA journal homepage: www.jamda.com
Editorial
Innovations in Hip Fracture Care: A Comparison of Geriatric Fracture Centers Rani Ramason MBChB, MRCP, FAMS a, *, Mei Sian Chong MBBS, FRCP, FAMS a, William Chan MBBS, FACRM, FAFRM (RACP), FAMS b, Ganesan Naidu Rajamoney MBBS, FRCS, FAMS c a b c
Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
Hip fractures are common in the elderly and are associated with significant morbidity and mortality.1 Recently, geriatric fracture centers (GFCs) have been set up worldwide to try to improve care of frail elderly patients with hip fracture.2e5 The key strategy for GFCs is ortho-geriatric comanaged care. Comanaged care is defined by interdisciplinary involvement and integration of orthopedic surgeons, geriatricians, anesthetists, rehabilitation physicians, nurses, physiotherapists, occupational therapists, care managers, social workers, and dieticians working together with shared ownership and equal responsibilities. As good care involves a multidisciplinary, interprofessional approach, it is imperative to have patient-centered protocoldriven standardized care. The key elements of good care for patients with fragility fracture are described well in the Blue Book6,7 and have been used as the goals of care for these GFCs. The advantages include shorter time to surgery, and reduction of hospital complications, length of stay (LOS), readmission rates, and mortality. Positive outcomes have been published for GFCs developed at the University of Rochester Medical Center, New York, and in Austria thus far.2e5 The population is aging, especially rapidly in Asia. In Singapore, the prevalence of adults older than 65 years is set to rise from 9.9% in 2012 to 19.0% in 2030.8 The International Osteoporosis Foundation’s 2009 Asian Audit Report states that the incidence of hip fractures in Singapore is set to rise from 1300 in 1998 to 9000 per annum by 2050.9 In support of this, the Ministry of Health in Singapore awarded Tan Tock Seng Hospital $5.7 million for a Health Services Development Project to develop a 5-year program (October 2011 to September 2016) to improve the quality of hip fracture care for older persons. The objectives of this program were to optimize patients’ clinical and functional outcomes, and reduce inpatient LOS, unplanned readmissions, and morbidity. The strategies adopted include prompt admission from the emergency department to orthopedic wards, comanagement between orthopedics and geriatric medicine with interdisciplinary team involvement, and standardized care bundles (carepath), together with patient and family education using
The authors declare no conflicts of interest. * Address correspondence to Rani Ramason, MBBS, MRCP, Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, S308433 Singapore. E-mail address: [email protected] (R. Ramason).
a “hip fracture booklet.” Additionally, there was care coordination, whereby frail older persons transfer from the acute care to rehabilitation centers and subsequently postdischarge community services, enabling integrated, holistic hip fracture care. This was provided by the integrated care manager who additionally helps to (1) educate, coordinate, and improve compliance and follow-up care; (2) devise a “Fitness for Op Criteria” to expedite surgery within 48 hours of admission; (3) extend rehabilitation beyond discharge; and (4) initiate an interdisciplinary hip fracture clinic to standardize care and improve osteoporosis treatment and falls assessment and prevention. Ethics approval was obtained from the National Healthcare Group Domain Specific Research Board. We compared the results of our hip fracture program (October 2011 to September 2012) with the published results of various international GFCs in terms of time to surgery, LOS, and various morbidity and mortality data (Table 1). Our time to surgery within 48 hours was 77% (from baseline of 35%). Although it is an improvement from our baseline of 35% (results not shown), this is still low compared with the other centers. Compared with the other hip fracture programs, it was noted that the LOS varied between 4.2 and 15.8 days. The reason for this could be the different models of step-down care available in the different countries and the efficiency and availability of step-down care or rehabilitation beds. In Rochester, where the LOS is shortest, at 4.2 days, patients with hip fracture are transitioned over from their acute hospital bed to their associated nursing facility rehabilitation beds by the third postoperative day. In most other centers, including Singapore, the patients with hip fracture have to wait for an available bed in a geriatric rehabilitation hospital. Our 30-day admission rates were low at 1.3% as we tracked readmissions back only to the orthopedic department in our study compared to the other centers that tracked all readmissions to the hospital. We had comparable hip fracture inpatient mortality rates (1.4%) to the Rochester center, despite having a longer LOS. Albeit a longer time to surgery and LOS, our 1year mortality rate was one of the lowest at 12.1% (Table 1). These good postoperative results are evidence of good hip fracture care through this integrated program, despite a longer LOS (likely contributed by different countries’ model of step-down care availability and setup) and longer time to surgery. Further quality
1525-8610/$ - see front matter Ó 2014 - American Medical Directors Association, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jamda.2014.01.005
Editorial / JAMDA 15 (2014) 232e233
233
Table 1 Comparison of Length of Stay, Time to Surgery, Morbidity, and Mortality Data of Various Geriatric Hip Fracture Programs
Surgery within 48 h, % Length of stay, d 30-d readmission Hospital mortality rates, % 1-year mortality, %
Rochester Model2e4
Innsbruck Model5
Usual Care10
National Hip Fracture Database (UK)12
Hong Kong Model15
Singapore Model
93.3 4.2 9.8 1.6 21.2
95.7 11.3 5.2 3.1 Not available
86.0 5.7e23.2 13.2 2.5e5.8 18.8e39.511
86.0 15.8 11.813 8.2 19.314
86.0 6.4 15 1.25 16.4e22.416
77.0 10.9 1.3 1.4 12.1*
*Mortality data obtained from the National Death Registry.
improvement projects are under way to try to improve these processes. In summary, comanaged interdisciplinary care involving the geriatrician has been shown to improve outcomes for elderly patients with hip fracture and is fast becoming the standard of good elderly hip fracture care around the world.
References 1. Zuckerman JD. Hip fracture. N Engl J Med 1996;334:1519e1525. 2. Kates SL, Mendelson DA, Friedman SM. Co-managed care for fragility hip fractures (Rochester model). Osteoporos Int 2010;21:S621eS625. 3. Friedman SM, Mendelson DA, Bingham KW, et al. Impact of a comanaged geriatric fracture centre on short-term hip fracture outcomes. Arch Intern Med 2009;169:1712e1717. 4. Friedman SM, Mendelson DA, Kates SL, et al. Geriatric co-management of proximal femur fractures: Total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatric Soc 2008; 56:1349e1356. 5. Kammerlander C, Gosch M, Blauth M, et al. The Tyrolean Geriatric Fracture Center: an orthogeriatric co-management model. Z Gerontol Geriatr 2011;44: 363e367. 6. British Orthopaedic Association. BOA/BGS Blue Book: Care of patients with fragility fractures. London, UK: British Orthopaedic Association; 2007.
7. British Association Standards for Trauma (BOAST) 1 version 2: all patients sustaining a fragility hip fracture. London, UK: British Orthopaedic Association; 2012. 8. Singapore Department of Statistics. Population and population structure. Available at: http://www.singstat.gov.sg/statistics/browse_by_theme/popula tion.html. Accessed December 1, 2013. 9. Mithal A, Dhingra V, Lau E. The Asian Audit: Epidemiology, Costs and Burden of Osteoporosis in Asia 2009. Switzerland: International Osteoporosis Foundation; 2009. p. 1e60. 10. Kates SL, Blake D, Bingham KW, et al. Comparison of an organized geriatric fracture program to United States government data. Geriatr Orthop Surg Rehabil 2010;1:15e21. 11. Schnell S, Friedman SM, Mendelson DA, et al. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil 2010; 1:6e14. 12. Health Quality Improvement Partnership. National Hip Fracture Database. National Report 2013. Available at: http://www.hqip.org.uk/assets/NCAPOPLibrary/NCAPOP-2013-14/NHFD-National-Report-2013.pdf. Accessed January 26, 2014. 13. Khan MA, Hossain FS, Dashti Z, et al. Causes and predictors of early re-admission after surgery for a fracture of the hip. J Bone Joint Surg Br 2012;94:690e697. 14. Wiles MD, Moran CG, Sahota O, et al. Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur. Br J Anaesth 2011;106:501e504. 15. Lau TW, Leung F, Siu D, et al. Geriatric hip fracture clinical pathway: The Hong Kong experience. Osteoporos Int 2010;21:627e636. 16. Chau PH, Wong M, Lee A, et al. Trends in hip fracture incidence and mortality in Chinese population from Hong Kong 2001e09. Age Ageing 2013;42: 229e233.
