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1 Disclosure presenter
2 The effectiveness of integrated orthogeriatric treatment on 1-year outcome in frail elderly withhip fracture E. Folbert, MANP, PhD Hospital Group, Almelo-Hengelo Rotterdam, 2018 august 27
3 Geriatric Traumatology PhD thesis Finished 27 march 2017
4 Elderly patients and fracture Its a challenge to treat them well!
5 From an international perspective The GFC treatment model Ø Awareness that these patients need special attention Ø Different models of care Ø No clear evidence which model is most effective* * Kammerlander et al, Osteoporos Int 2010
6 Aim study Evaluate the effectiviness of an orthogeriatric treatment model in elderly patients with a hip fracture on 1-year mortality and to identify associated risk factors* * Folbert et al, Osteoporos Int 2017
7 Design Prospective cohort with historical controls
8 Patients Inclusion Ø Acute admission hip fracture Ø Age 70 yrs. or older Ø Treated by traumasurgeon Exclusion Ø Pathological or periprosthetic fracture Ø Indication total hip artroplasty Periods Ø : n=850 GFC Ø : n=535 usual care
9 Variables & outcome measures GFC Sociodemografic variables Frailty score Dementia diagnosed ASA History of osteoporosis, previous osteopotic fracture Type of fracture Barthelindex and Parker Mobility score Prefracture living Charlson comorbidity Score Length of stay on the ED Time to surgery Type of operation; conservative or operative treatment Length of hospital stay Data collection Incidence of postoperative surgical and medical complications UC Sociodemografic variables ASA Type of fracture Time to surgery Type of operation; conservative or operative treatment Length of hospital stay Complicated course or not Mortality rate (in hospital, 30 days, 1 year) Mortality rate (in hospital, 30 days, 1 year)
10 Baseline GFC n=850 UC n=535 P value :, % 74:26 71: Age ASA* 3, % <0.001 Independent: Institutionalized; % 84:16 90: Ref. *
11 GFC cohort GFC patients n=850 VMS Frailty score; % delirium falls < 6mnd. malnutrition (SNAQ) physical limitations (KATZ) mean (IQR) Dementia, % 21 CCI-score* ( ) Barthel**-before: Barthel-after 16:10 (-6) PMS***-before: PMS-after 6:2 (-4) Ref.* Charlson (1987), ** Mahoney (1965), *** Parker (1993)
12 Logistics treatment process GFC n=850 UC n=535 P value ED, min, mean (SD) 102 (50.0) No priority Time till surgery from admission, % <24 hrs. >24 hrs Conservative treatment, % 2 0 <0.001 Length of hospital stay, days mediaan (IQR) 9 (6-13) 10 (7-17) <0.001
13 Complications and mortality GFC n=850 UC n=535 P value Patients with a complicated course; % <0.001 In hospital mortality; % Mortality 30 days; % Mortality 365 days; % <0.001
14 Kaplan-meier survival curve GFC group Usual care group
15 Independent risk factors 1 year mortality OR 95% BI P value Male Age in years VMS Frailty score physical limitations VMS Frailty malnutrition <0.001 ASA ASA <0.001 CCI 5 of > Barthel Index preop
16 Strenght and limitations + First study in the Netherlands + Fittest patients excluded, overestimating seems unlikely + Gooddescription of case mix + Use of specifically defined measuring instruments and outcome measures - Use of historical control group instead of randomized study design - Q of life not analyzed - No insight in performance during geriatric rehab in nursing homes
17 Conclusion Ø After integrated care, a significant decrease in the 1-year mortality rate in frail elderly patients compared to historical controls treated with standard care. Ø Gender, increasing age, malnutrition, physical limitations and medical conditions were independent risk factors for 1 year mortality. Ø Awareness of the RF can be usefull in an attempt to optimize care and outcomes. Ø Due to the multidimensional needs orthogeriatric treatment should be the standard.
18 Our future goals Ø The development and implementation of a clinical path way and a Q auditing system with our stakeholders in the geriatric rehabilitation nursing homes Ø Monitoring recovery during rehab with health wearables Ø To improve Q of care it would be a challenge to collaborate with international GFC s for research purposes.
19 Thank you for your attention Questions?
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