Komorbiditet og ortopædkirugi - erfaringer og viden. Benn Rønnow Duus, Ledende overlæge, Ortopædkirurgisk afdeling Bispebjerg Hospital

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1 Komorbiditet og ortopædkirugi - erfaringer og viden Benn Rønnow Duus, Ledende overlæge, Ortopædkirurgisk afdeling Bispebjerg Hospital Kræft og komorbiditet alle skal have del i de gode resultater 1 Kræftens Bekæmpelse 6. marts 2013

2 Diclosures None relevant for this presentation No relation to industry 2

3 The talk Demographics Comorbidity Change in pathways hip fx. patients Our results Different models of care Orthogeriatrics Our experiences and results 3

4 Demographics in Denmark National statistic bureau, Denmark 4

5 Challenges in general Fall-related Hospital admissions

6 Age standardized hip fx rate (women) SY Cheng et al; Osteoporosis int

7 The burden of hip fractures Xia WB et al, J Bone Miner Res 2011 Beijing, China Figures from and Age specific rates of hip fracture > 50 years 2.7 fold increase in women and 1.6 in men >70 years 3.8 fold increase in women and 2.0 fold in men 7

8 Comorbidity and mortality in hip fx patients Kannegaard et al, Age and Ageing

9 Mortality predicted by dementia, delirium and Barthel score 1.00 Gentofte n= 645, Age 84.7, Sex ratio f/m 0.73/ No dementia Dementia P < No delirium Delirium P = Barthel Barthel < 50 P =

10 Change of adresses and admittances to nursing homes number year average average + 2 SD nursing home admittances total change of adresses Cohort of 1397 patients sustaining a hip fracture Petersen MB et al, Injury

11 Pathway of Hip Fx Patients E.R Acute bed ward X-ray Operation theater E:R 1 of 4 bed wards 11

12 Optimized hip fracture program Bispebjerg Hospital, Univ CPH Aim: Reduce complications Pedersen SJ, J Am Geriatr Soc 2008 Reduce waiting routines Develop a Hip fracture room in the Emergency Department Early anaesthesiological evalutation, before the orthopedic surgeon Pain killers immediately (paracetamol) Reduce thirst periods nutrition and soft drinks orally immediately after admission Pre og postop.: Femoral nerve catheter og non-opioid pain treatment Operation: Spinal anaesthesia, femoral, ischiadicus and sacral block Training center in the bed ward Defined patient care, multimodal team function Personal physio, nurse and physician Systematic schematic hip fracture medical record Intracutaneous suture 12

13 Optimized Program Hip Fx Unit RUN BY ORTHOPAEDIC SURGEONS E.R. X-ray Hip Fracture Unit Operation theater 13

14 14 Femoral nerve catheter VAS score postop in a hip fracture patient Pedersen SJ, J Am Geriatr Soc 2008 Effective pain relief Immediate effect on pain at rest Mobilisation is possible

15 15 Urinary tract infection Optimized Hip Fracture Program Controls 357 Opt Prg 178 Pedersen SJ et al, J Am Geriatr Soc % % P = UVI 5.1 % controls Intervention

16 Pneumonia Optimized Hip Fracture Program Controls 357 Opt Prg 178 Pedersen SJ et al, J Am Geriatr Soc 2008 % 10.6 % P = % controls Intervention 2 0

17 17 Mean Hospital Stay Following Hip Fracture Hospital stay - days Pedersen SJ et al, J Am Geriatr Soc I / C 178 / Control Opt prg Intervention 9.7 d Controls 15.8 d T-test p < 0.05

18 Mortality & place of residence Optimized hip fx programme Pedersen SJ et al, J Am Geriatr Soc 2008 Community dwelling p=0.02 Nursing home Controls Optimised pathway p= N(C)=260 & N(I)=116 N(C)=97 & N(I)=62 Days 18

19 The Challenge for a hip fx unit - run by Orthopaedic Surgeons The care of hip fx patients are demanding Old patients with high comorbidity High percentage of polypharmacy Heavy social problems Not the primary goal for orthopaedic surgeons after the first optimism! The unit had to be closed even though it was a huge succes! 19

20 Models of care Traditional orthopaedic care Hip Fracture unit run by orthopaedic surgeons Geriatric Orthopaedic Rehabilitation Unit Orthogeriatric liaison and Hip Fracture Nurse Combined Orthogeriatric care 20

21 BOA BGS Blue Book Statements 2007 Care and rehabilitation of patients with hip fracture is the central challenge for trauma services; and those that can provide good care for these patients will cope well with the range of other fragility fractures Looking after hip fracture patients well - is a lot cheaper than looking after them badly. 21

22 Multidisciplinary rehabilitation for older people with hip fractures (2009) Handoll HHG, Cameron ID, Mak JCS, Finnegan TP Authors conclusions While there was a tendency to a better overall result in patients receiving multidisciplinary inpatient rehabilitation, these results were not statistically significant. Future trials of multidisciplinary rehabilitation should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than evaluate its components. 22

23 Combined orthogeriatric care A H-C Leung et al, Trauma

24 Comprehensive care Pioli G, et al Eur J Phys Rehabil Med 2011 The implementation of a comprehensive and multidisciplinary co-care model in an orthopedic unit is a difficult task because it is necessary to change cultural attitudes related to traditional model of care 24

25 Our department 89 beds 5 different wards 20 specialists 36 younger doctors 185 nurses and nurse asistents 5600 operations/year outpatient visits emergency visits 650 hip fracture patients 25

26 Challenges for our department 2008 patient evaluation 67 % > 65 years 75 % had significant medical comorbidity High percentage of polypharmacy Internal working group consisting of professionals 26

27 The hip fracture patient is not an orthopaedic patient with a medical comorbidity, but 27

28 Orthogeriatric ward 2009 Geriatrician daily leader of ward close cooperation with committed surgeons Patients with severe medical conditions regardless of fracture type 50% of all hip fracture patients Full geriatric assessment upon arrival Medical history, medication, comorbidity, osteoporosis Systematic and standardized monitoring and interventions Focus on delirium, infections, urinary retention, pain-assessment Early discharge planning 28

29 Data base population N=1274 Before After Orthogeriatrics Orthogeriatrics P-value N Sex (male % / female%) 28.7%/71.3% 28.7%/71.3% 1 Age (years) 80.3 (12.6) 80.5 (12.2) 0.8 Length of stay (days) 13.1 (11.4) 12.3 (8.4) 0.2 ASA 2.3 (0.7) 2.4 (0.7)

30 In-hospital mortality (Average) 12,0 Percent OR 1 10,0 Before orthogeriatrics N=456, N dead =35 After orthogeriatrics N=818, N dead =32 0,8 0,6 Odds ratio for In-hospital death After vs before Orthogeriatrics 8,0 0,4 0,2 P=0.004 Univariate analysis 6,0 0 4,0 2,0 0,0 Sep-2008 Dec-2008 Mar-2009 Jun-2009 Sep-2009 Dec-2009 Mar-2010 Jun-2010 Sep-2010 Dec-2010 Mar

31 Three months mortality (Average) Percent Before orthogeriatrics N=352, N dead =104 After orthogeriatrics N=677, N dead =141 OR 1 Odds ratio for 0,8 0,6 Three months mort. After vs before Orthogeriatrics 25 0,4 0,2 P=0.02 Univariate analysis Sep-2008 Dec-2008 Mar-2009 Jun-2009 Sep-2009 Dec-2009 Mar-2010 Jun-2010 Sep-2010 Dec-2010 Mar

32 REGION Multivariate cox regression analysis of three months mortality risk 3 Hazard ratio for death P< P= P< P= Age, per 10 years Per ASA increment Male gender vs female gender Orthogeriatrics vs no orthogeriatrics 32 Department of Orthopaedic Surgery, Bispebjerg Hospital, Denmark

33 Orthogeriatric ward Length of Stay reduced days (Oct to Aug. 2010) 33

34 The Bispebjerg Model cultures are merging Significant decrease in mortality - in-hospital and 3 months 30 days mortality below national level Reduced Length of Stay Osteoporosis evaluation and treatment Systematic evaluation, care and treatment Delirium decreased General quality improved New tool for the surgeons Change of budget surgeons replaced by geriatricians 34

35 The Bispebjerg Model cultures are merging Identify the challenges Analyse the problem Involve the professionals Decide the rational changes Implement the changes Stick to the decisions 35

36 36

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