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
Diclosures None relevant for this presentation No relation to industry 2
The talk Demographics Comorbidity Change in pathways hip fx. patients Our results Different models of care Orthogeriatrics Our experiences and results 3
Demographics in Denmark National statistic bureau, Denmark 4
Challenges in general 30000 25000 Fall-related Hospital admissions 20000 15000 10000 5000 0 2003 2006 2009 2012 2015 2018 2021 2024 2027 2030 2033 2036 2039 85-80-84 75-79 65-74 5
Age standardized hip fx rate (women) SY Cheng et al; Osteoporosis int 2011 6
The burden of hip fractures Xia WB et al, J Bone Miner Res 2011 Beijing, China Figures from 1990-1992 and 2002 2006 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
Comorbidity and mortality in hip fx patients Kannegaard et al, Age and Ageing 2009 8
Mortality predicted by dementia, delirium and Barthel score 1.00 Gentofte n= 645, Age 84.7, Sex ratio f/m 0.73/0.27 0.75 No dementia Dementia P < 0.0001 1.00 0.75 No delirium Delirium P = 0.0004 1.00 Barthel 50 0.75 Barthel < 50 P = 0.0004 0.50 0 20 40 60 80 100 9
Change of adresses and admittances to nursing homes 100 90 80 70 60 number 50 40 30 20 10 0-5 -4-3 -2-1 0 1 2 3 4 5 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 2006 10
Pathway of Hip Fx Patients E.R Acute bed ward X-ray Operation theater E:R 1 of 4 bed wards 11
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
Optimized Program Hip Fx Unit RUN BY ORTHOPAEDIC SURGEONS E.R. X-ray Hip Fracture Unit Operation theater 13
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 Urinary tract infection Optimized Hip Fracture Program Controls 357 Opt Prg 178 Pedersen SJ et al, J Am Geriatr Soc 2008 17.4 % % P = 0.001 18 16 14 12 10 8 6 4 2 0 UVI 5.1 % controls Intervention
16 12 10 Pneumonia Optimized Hip Fracture Program Controls 357 Opt Prg 178 Pedersen SJ et al, J Am Geriatr Soc 2008 % 10.6 % P = 0.03 8 6 4 5.1 % controls Intervention 2 0
17 Mean Hospital Stay Following Hip Fracture Hospital stay - days Pedersen SJ et al, J Am Geriatr Soc 2008 16 14 I / C 178 / 357 12 10 8 6 4 2 0 Control Opt prg Intervention 9.7 d Controls 15.8 d T-test p < 0.05
Mortality & place of residence Optimized hip fx programme Pedersen SJ et al, J Am Geriatr Soc 2008 Community dwelling 1.00 0.75 0.50 0.25 p=0.02 Nursing home 1.00 0.75 0.50 0.25 Controls Optimised pathway p=0.9 0.00 0.00 0 100 200 300 400 500 0 100 200 300 400 500 N(C)=260 & N(I)=116 N(C)=97 & N(I)=62 Days 18
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
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
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
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
Combined orthogeriatric care A H-C Leung et al, Trauma 2011 23
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
Our department 89 beds 5 different wards 20 specialists 36 younger doctors 185 nurses and nurse asistents 5600 operations/year 22000 outpatient visits 45000 emergency visits 650 hip fracture patients 25
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
The hip fracture patient is not an orthopaedic patient with a medical comorbidity, but 27
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
Data base population N=1274 Before After Orthogeriatrics Orthogeriatrics P-value N 456 818 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) 0.005 29
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-2011 30
Three months mortality (Average) 35 30 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 20 0 15 10 5 0 Sep-2008 Dec-2008 Mar-2009 Jun-2009 Sep-2009 Dec-2009 Mar-2010 Jun-2010 Sep-2010 Dec-2010 Mar-2011 31
REGION Multivariate cox regression analysis of three months mortality risk 3 Hazard ratio for death P<0.0001 2.5 P=0.001 2 P<0.0001 1.5 1 P=0.004 0.5 0 Age, per 10 years Per ASA increment Male gender vs female gender Orthogeriatrics vs no orthogeriatrics 32 Department of Orthopaedic Surgery, Bispebjerg Hospital, Denmark
Orthogeriatric ward Length of Stay reduced 10.7 9 days (Oct. 2009 to Aug. 2010) 33
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
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