Evaluation of costs, osteoporosis treatment, and re-fractures in German collaborative orthogeriatric care after fragility fractures.

Orthogeriatric co-management (OGCM) may provide benefits for geriatric fragility fracture patients in terms of more frequent osteoporosis treatment and fewer re-fractures. Yet, we did not find higher costs in OGCM hospitals for re-fractures or antiosteoporotic medication for most fracture sites within 12 months, although antiosteoporotic medication was more often prescribed. PURPOSE: Evidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence for other fractures is rare. The aim of our study was to conduct an evaluation of economic and health outcomes after the German OGCM for geriatric fragility fracture patients. METHODS: This retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a fragility fracture in 2014-2018, and were treated in hospitals certified for OGCM (ATZ group), providing OGCM without certification (OGCM group) or usual care (control group). Healthcare costs from payer perspective, prescribed medications, and re-fractures were investigated within 6 and 12 months. We used weighted gamma and two-part models and applied entropy balancing to account for the lack of randomization. All analyses were stratified per fracture site. RESULTS: We observed 206,273 patients within 12-month follow-up, of whom 14,100 were treated in ATZ, 133,353 in OGCM, and 58,820 in other hospitals. Total average inpatient costs per patient were significantly higher in the OGCM and particularly ATZ group for all fracture sites, compared to control group. We did not find significant differences in costs for re-fractures or antiosteoporotic medication for most fracture sites, although antiosteoporotic medication was significantly more often observed in the OGCM and particularly ATZ group for hip, pelvic, and humerus fractures. CONCLUSION: The observed healthcare costs were higher in ATZ and OGCM hospitals within 12 months. Antiosteoporotic medication was prescribed more often in both groups for most fracture sites, although the corresponding medication costs did not increase.

Health-economic evaluation of orthogeriatric co-management for patients with pelvic or vertebral fragility fractures.

BACKGROUND: Orthogeriatric co-management (OGCM) addresses the special needs of geriatric fracture patients. Most of the research on OGCM focused on hip fractures while results concerning other severe fractures are rare. We conducted a health-economic evaluation of OGCM for pelvic and vertebral fractures. METHODS: In this retrospective cohort study, we used German health and long-term care insurance claims data and included cases of geriatric patients aged 80 years or older treated in an OGCM (OGCM group) or a non-OGCM hospital (non-OGCM group) due to pelvic or vertebral fractures in 2014-2018. We analyzed life years gained, fracture-free life years gained, healthcare costs, and cost-effectiveness within 1 year. We applied entropy balancing, weighted gamma and two-part models. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. RESULTS: We included 21,036 cases with pelvic (71.2% in the OGCM, 28.8% in the non-OGCM group) and 33,827 with vertebral fractures (72.8% OGCM, 27.2% non-OGCM group). 4.5-5.9% of the pelvic and 31.8-33.8% of the vertebral fracture cases were treated surgically. Total healthcare costs were significantly higher after treatment in OGCM compared to non-OGCM hospitals for both fracture cohorts. For both fracture cohorts, a 95% probability of cost-effectiveness was not exceeded for a willingness-to-pay of up to €150,000 per life year or €150,000 per fracture-free life year gained. CONCLUSION: We did not obtain distinct benefits of treatment in an OGCM hospital. Assigning cases to OGCM or non-OGCM group on hospital level might have underestimated the effect of OGCM as not all patients in the OGCM group have received OGCM.

Predicting perioperative myocardial injury/infarction after noncardiac surgery in patients under surgical and medical co-management: a prospective cohort study.

BACKGROUND: Perioperative myocardial injury/infarction (PMI) following noncardiac surgery is a frequent cardiac complication. This study aims to evaluate PMI risk and explore preoperative assessment tools of PMI in patients at increased cardiovascular (CV) risk who underwent noncardiac surgery under the surgical and medical co-management (SMC) model. METHODS: A prospective cohort study that included consecutive patients at increased CV risk who underwent intermediate- or high-risk noncardiac surgery at the Second Medical Center, Chinese PLA General Hospital, between January 2017 and December 2022. All patients were treated with perioperative management by the SMC team. The SMC model was initiated when surgical intervention was indicated and throughout the entire perioperative period. The incidence, risk factors, and impact of PMI on 30-day mortality were analyzed. The ability of the Revised Cardiac Risk Index (RCRI), frailty, and their combination to predict PMI was evaluated. RESULTS: 613 eligible patients (mean [standard deviation, SD] age 73.3[10.9] years, 94.6% male) were recruited consecutively. Under SMC, PMI occurred in 24/613 patients (3.9%). Patients with PMI had a higher rate of 30-day mortality than patients without PMI (29.2% vs. 0.7%, p = 0.00). The FRAIL Scale for frailty was independently associated with an increased risk for PMI (odds ratio = 5.91; 95% confidence interval [CI], 2.34-14.93; p = 0.00). The RCRI demonstrated adequate discriminatory capacity for predicting PMI (area under the curve [AUC], 0.78; 95% CI, 0.67-0.88). Combining frailty with the RCRI further increased the accuracy of predicting PMI (AUC, 0.87; 95% CI, 0.81-0.93). CONCLUSIONS: The incidence of PMI was relatively low in high CV risk patients undergoing intermediate- or high-risk noncardiac surgery under SMC. The RCRI adequately predicted PMI. Combining frailty with the RCRI further increased the accuracy of PMI predictions, achieving excellent discriminatory capacity. These findings may aid personalized evaluation and management of high-risk patients who undergo intermediate- or high-risk noncardiac surgery.

The collaborative framework for the management of tuberculosis and type 2 diabetes syndemic in low- and middle-income countries: a rapid review.

INTRODUCTION: Given the absence of international guidelines on the joint management and control of tuberculosis (TB) and type 2 diabetes mellitus (T2D), the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (The Union) launched in 2011 a policy framework to address the growing syndemic burden of TB-T2D. This review aimed at mapping the available evidence on the implementation of the Union-WHO Framework, explicitly, or bi-directional TB-T2D health programs as an initiative for co-management in patients in low- and middle-income countries (LMIC). METHODS: A rapid review was performed based on a systematic search in PubMed and Web of Science electronic databases for peer-reviewed articles on The Union-WHO Framework and bi-directional interventions of TB and T2D in LMIC. The search was restricted to English language articles and from 01/08/2011 to 20/05/2022. RESULTS: A total of 24 articles from 16 LMIC met the inclusion criteria. Four described the implementation of The Union-WHO Framework and 20 on the bi-directional interventions of TB and T2D. Bi-directional activities were found valuable, feasible and effective following the Union-WHO recommendations. Limited knowledge and awareness on TB-T2D comorbidity was identified as one of the barriers to ensure a functional and effective integration of services. CONCLUSIONS: This review revealed that it is valuable, feasible and effective to implement bi-directional TB and T2D activities (screening and management) according to the Union-WHO Framework recommendations, especially in countries that face TB-T2D syndemic. Additionally, it was apparent that gaps still exist in research aimed at providing evidence of costs to implement collaborative activities. There is need for TB and T2D services integration that should be done through the well-stablished TB programme. This integration of two vertical programmes, could ensure patient-centeredness, continuum of care and ultimately contribute for health systems strengthening.

The establishment of a collaborative surveillance program with indigenous hunters to characterize primate health in Southern Guyana.

The consumption of primates is integral to the traditional subsistence strategies of many Indigenous communities throughout Amazonia. Understanding the overall health of primates harvested for food in the region is critical to Indigenous food security and thus, these communities are highly invested in long-term primate population health. Here, we describe the establishment of a surveillance comanagement program among the Waiwai, an Indigenous community in the Konashen Amerindian Protected Area (KAPA). To assess primate health in the KAPA, hunters performed field necropsies on primates harvested for food and tissues collected from these individuals were analyzed using histopathology. From 2015 to 2019, hunters conducted 127 necropsies across seven species of primates. Of this sample, 82 primates (between 2015 and 2017) were submitted for histopathological screening. Our histopathology data revealed that KAPA primates had little evidence of underlying disease. Of the tissue abnormalities observed, the majority were either due to diet (e.g., hepatocellular pigment), degenerative changes resulting from aging (e.g., interstitial nephritis, myocyte lipofusion), or nonspecific responses to antigenic stimulation (renal and splenic lymphoid hyperplasia). In our sample, 7.32% of individuals had abnormalities that were consistent with a viral etiology, including myocarditis and hepatitis. Internal parasites were observed in 53.66% of individuals and is consistent with what would be expected from a free-ranging primate population. This study represents the importance of baseline data for long-term monitoring of primate populations hunted for food. More broadly, this research begins to close a critical gap in zoonotic disease risk related to primate harvesting in Amazonia, while also demonstrating the benefits of partnering with Indigenous hunters and leveraging hunting practices in disease surveillance and primate population health assessment.

A qualitative study of providers' perspectives on cross-institutional care coordination for pancreatic cancer: challenges and opportunities.

BACKGROUND: Despite calls for regionalizing pancreatic cancer (PC) care to high-volume centers (HVCs), many patients with PC elect to receive therapy closer to their home or at multiple institutions. In the context of cross-institutional PC care, the challenges associated with coordinating care are poorly understood. METHODS: In this qualitative study we conducted semi-structured interviews with oncology clinicians from a HVC (n = 9) and community-based hospitals (n = 11) to assess their perspectives related to coordinating the care of and treating PC patients across their respective institutions. Interviews were transcribed, coded, and analyzed using deductive and inductive approaches to identify themes related to cross-institutional coordination challenges and to note improvement opportunities. RESULTS: Clinicians identified challenges associated with closed-loop communication due, in part, to not having access to a shared electronic health record. Challenges with patient co-management were attributed to patients receiving inconsistent recommendations from different clinicians. To address these challenges, participants suggested several improvement opportunities such as building rapport with clinicians across institutions and updating tumor board processes. The opportunity to update tumor board processes was reportedly multi-dimensional and could involve: (1) designating a tumor board coordinator; (2) documenting and disseminating tumor board recommendations; and (3) using teleconferencing to facilitate community-based clinician engagement during tumor board meetings. CONCLUSIONS: In light of communication barriers and challenges associated with patient co-management, enabling the development of relationships among PC clinicians and improving the practices of multidisciplinary tumor boards could potentially foster cross-institutional coordination. Research examining how multidisciplinary tumor board coordinators and teleconferencing platforms could enhance cross-institutional communication and thereby improve patient outcomes is warranted.

Health-economic evaluation of orthogeriatric co-management for patients with forearm or humerus fractures: an analysis of insurance claims data from Germany.

Orthogeriatric co-management (OGCM) describes a collaboration of orthopedic surgeons and geriatricians for the treatment of fragility fractures in geriatric patients. While its cost-effectiveness for hip fractures has been widely investigated, research focusing on fractures of the upper extremities is lacking. Thus, we conducted a health economic evaluation of treatment in OGCM hospitals for forearm and humerus fractures.In a retrospective cohort study with nationwide health insurance claims data, we selected the first inpatient stay due to a forearm or humerus fracture in 2014-2018 either treated in hospitals that were able to offer OGCM (OGCM group) or not (non-OGCM group) and applied a 1-year follow-up. We included 31,557 cases with forearm (63.1% OGCM group) and 39,093 cases with humerus fractures (63.9% OGCM group) and balanced relevant covariates using entropy balancing. We investigated costs in different health sectors, length of stay, and cost-effectiveness regarding total cost per life year or fracture-free life year gained.In both fracture cohorts, initial hospital stay, inpatient stay, and total costs were higher in OGCM than in non-OGCM hospitals. For neither cohort nor effectiveness outcome, the probability that treatment in OGCM hospitals was cost-effective exceeded 95% for a willingness-to-pay of up to €150,000.We did not find distinct benefits of treatment in OGCM hospitals. Assigning cases to study groups on hospital-level and using life years and fracture-free life years, which might not adequately reflect the manifold ways these fractures affect the patients' health, as effectiveness outcomes, might have underestimated the effectiveness of treatment in OGCM hospitals.

How to compensate for frailty? The real life impact of geriatric co-management on morbi-mortality after colorectal cancer surgery in patients aged 70 years or older.

In Europe, CRC is the second most common cause of cancer death, and surgery remains the mainstay curative treatment. Age and frailty are associated with an increased risk of postoperative morbidity and 1-year mortality. Chronological age is not sufficient to assess the risk of postoperative complications. The CGA has been developed to better identify frail patients. Geriatric co-management have been developed to optimize the post-operative outcomes. We analyzed the real-life of geriatric co-management within an ERAS program on surgical outcomes at 90 days and oncologic outcomes at 1 year in patients aged 70 years or older after surgery for CRC. This was a retrospective study based on a prospective cohort. Fifty-one patients with a G8 score ≤ 14 were referred to geriatricians for preoperative CGA (Frail Group). They were compared with 151 patients with a G8 score ≥ 15 (Robust Group). In the Frail Group, patients were significantly older with more comorbidities than the patients in the Robust Group. Oncologic characteristics, treatments and global post-operative outcomes were comparable between the two groups. One year after surgery mortality and recurrence rates were similar between the two groups. Our study suggests that geriatric co-management is feasible and contributes to the reduction of postoperative morbimortality. Moreover, performing the CGA after G8 score screening and completion of geriatric interventions resulted in similar 90-day postoperative outcomes, in frail patients than in robust patients. Our results confirmed the benefit of geriatric co-management, involving G8 screening, CGA, and ERAS, for frail older patients undergoing surgery for CRC.

A Typology of National Park Co-management Agreements in the Era of Reconciliation in Canada.

Parks Canada, in response to commitments undertaken towards reconciliation, has signaled its readiness to reassess the participation of Indigenous peoples in the co-management of national parks, national park reserves, and national marine conservation areas (NMCAs). However, the effectiveness of co-management, as the established framework underpinning these and other longstanding partnerships between the state and Indigenous groups, has been disputed, based on an uneven track record in meeting the needs, interests, and aspirations of Indigenous communities. This paper explores the potential of co-management to facilitate reconciliation within national parks, reserves and NMCAs by developing a typology of various types of co-management agreements. Addressing a critical knowledge gap in co-management governance, we provide a comprehensive review of 23 negotiated co-management agreements involving the state and Indigenous groups in a national park context. The resulting typology categorizes these agreements according to contextual factors and governance arrangements, offering insights into the feasibility of shared governance approaches with Parks Canada. Moreover, it identifies the strengths and weaknesses of co-management agreements in fulfilling reconciliation commitments. Our findings indicate that, although Parks Canada has implemented innovative approaches to co-management and shown a willingness to support Indigenous-led conservation efforts, true shared governance with Indigenous groups, as defined by international standards, is limited by the Canadian government's evident reluctance to amend the foundational legislation to effectively share authority in national parks.

Boundary Spanning Methodological Approaches for Collaborative Moose Governance in Eeyou Istchee.

Natural resource governance challenges are often highly complex, particularly in Indigenous contexts. These challenges involve numerous landscape-level interactions, spanning jurisdictional, disciplinary, social, and ecological boundaries. In Eeyou Istchee, the James Bay Cree Territory of northern Quebec, Canada, traditional livelihoods depend on wild food species like moose. However, these species are increasingly being impacted by forestry and other resource development projects. The complex relationships between moose, resource development, and Cree livelihoods can limit shared understandings and the ability of diverse actors to respond to these pressures. Contributing to this complexity are the different knowledge systems held by governance actors who, while not always aligned, have broadly shared species conservation and sustainable development goals. This paper presents fuzzy cognitive mapping (FCM) as a methodological approach used to help elicit and interpret the knowledge of land-users concerning the impacts of forest management on moose habitat in Eeyou Istchee. We explore the difficulties of weaving this knowledge together with the results of moose GPS collar analysis and the knowledges of scientists and government agencies. The ways in which participatory, relational mapping approaches can be applied in practice, and what they offer to pluralistic natural resource governance research more widely, are then addressed.

A Weight-of-Evidence Approach for Understanding the Recovery of Okanagan Sockeye Salmon.

The productivity of Pacific Sockeye salmon (Oncorhynchus nerka) in the Columbia River has been declining over the past century. Yet, the Okanagan River Sockeye salmon population, which spawns in the Okanagan River, a Canadian tributary of the Columbia River, has seen a remarkable turnaround in abundance. Different hypotheses and lines of evidence covering multiple spatial scales have been proposed to explain this recovery; but they have never been comprehensively assessed. We adopted a weight-of-evidence approach to systematically assess the relative likelihood that each of these causal hypotheses contributed to the observed recovery. Our analysis disentangles the relative consequences of a set of environmental management actions that have been implemented to augment the Sockeye salmon freshwater productivity, while accounting for changes in freshwater and marine environmental conditions. Our list of potentially explanatory causal factors (anthropogenic and natural) included: (1) changes in escapement concurrent with improving local fish passage, (2) the implementation of fish-friendly flows in the Okanagan River, (3) initiating a hatchery restocking program, (4) potential improvements to Columbia dam operations to support higher relative survival of out-migrating juvenile fish, (5) possible shifts in survival-favorable conditions in the coastal marine environment for ocean-going life stages, and (6) broader changes to multi-stock harvest regimes in the Columbia River. Our assessment leveraged comparisons with the population dynamics of another Sockeye salmon stock in the Columbia River basin to differentiate between the impacts of management actions taken within the Okanagan watershed (our focus) from those occurring over the broader basin and marine scale. The results suggest that while shifts towards survival-favorable conditions in the coastal marine environment in 2007 played an important role in the upturn of the Okanagan population, alone it cannot explain the rate at which the Okanagan River Sockeye salmon recovered. Strong evidence supports the combined effect of increased escapement in conjunction with establishing and securing fish-friendly flows during spawning, incubation, and alevin emergence. Additionally, Sockeye salmon restocking improved the resilience of the stock against density-independent mortality events. These combined basin-level management actions played a pivotal role in magnifying the recovery trajectory afforded by improved marine survivorship. The spectacular response of the Okanagan River Sockeye salmon to the holistic perspectives and management interventions of Indigenous and other caretakers provides hope that other Pacific salmon stocks can be stabilized and recovered.

Evaluation of drug prescriptions on hospital admission in older trauma patients using the Fit fOR The Aged (FORTA) rules.

BACKGROUND: Orthogeriatric comanagement of older patients with hip fractures has been proven to provide significant benefits concerning functional status, readmissions, nursing home placement, in-hospital complications and mortality. Medication management in older individuals is a cornerstone in orthogeriatric comanagement. The aim of the study was to analyze the extent of overprescription and undertreatment in older trauma patients. METHODS: Personal and medical data of consecutively admitted older trauma patients were analyzed. Evaluation of medication was conducted according to the Fit fOR The Aged (FORTA) criteria. Data were retrieved from an ongoing observational study on the incidence of delirium in surgical patients. RESULTS: A total of 492 patients were enrolled. There were 374 cases of overprescription and 575 cases of undertreatment. Only 78 (16%) patients had neither overprescription nor undertreatment on admission. Overprescription and undertreatment were most prevalent in cardiovascular disease. Undertreatment was most prevalent concerning osteoporosis. The number of prescribed drugs correlated with the Charlson Comorbidity Index (r = 0.478, p < 0.001), age (r = 0.122; p < 0.01), anticholinergic burden (r = 0.528, p < 0.001), FORTA score (r = 0.352, p < 0.001), and overtreatment (r = 0.492, p < 0.001), but not with undertreatment. Undertreatment also correlated with age (r = 0.172, p < 0.001) and overtreatment (r = 0.364, p < 0.01). The FORTA score correlated significantly with age (r = 0.159, p < 0.001), anticholinergic burden (ACB) score (r = 0.496, p < 0.001), Katz index (r = -0.119, p < 0.01), IADL score (r = -0.243, p < 0.001), and clinical frailty scale (CFS, r = 0.23, p < 0.001). CONCLUSION: The high numbers of overprescription and undertreatment in older trauma patients underlines the need for orthogeriatric comanagement. Besides the evaluation of multimorbidity and geriatric problems, drug management is a core topic. Future studies should investigate the impact of medication management on outcome parameters such as quality of life, functional status, and mortality. A benefit can be expected.

[Fragility Fractures: Preoperative assessment and optimisation]. / Fragilitätsfraktur beim geriatrischen Patienten: Präoperative Abklärung und Optimierung.

Fragility fractures are associated with high morbidity and mortality. An interdisciplinary collaboration and an individualized, patient-centered approach are essential to ensure an optimized preoperative period and to improve perioperative safety. Preoperative responsibilities of trauma surgery include in the first step the identification of fragility fractures and the necessity for geriatric involvement. Orthogeriatric co-management (OCM) focuses on the identification of the medical, functional and social needs of the patient. In the preoperative period attention is focussed on acute diseases in need of treatment that have a negative impact on the course of further treatment and the prevention of delirium.

Impact of geriatric co-management on outcomes in hospitalised cardiology patients aged 85 and over.

OBJECTIVE: Cardiovascular disease and frailty are common among the population aged 85+. We hypothesised these patients might benefit from geriatric co-management, as has been shown in other frail patient populations. However, there is limited evidence supporting geriatric co-management in older, hospitalised cardiology patients. METHODS: A retrospective cohort study was performed in a large teaching hospital in the Netherlands. We compared patients aged 85 and over admitted to the cardiology ward before (control group) and after the implementation of standard geriatric co-management (intervention group). Data on readmission, mortality, length of stay, number of consultations, delirium, and falls were analysed. RESULTS: The data of 1163 patients were analysed (n = 542 control, n = 621 intervention). In the intervention group, 251 patients did not receive the intervention because of logistic reasons or the treating physician's decision. Baseline characteristics were comparable in the intervention and control groups. Patients in the intervention group had a shorter length of stay (-1 day, p = 0.01) and were more often discharged to a geriatric rehabilitation facility (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.10-3.54, p = 0.02) compared with the control patients. Other outcomes were not significantly different between the groups. CONCLUSIONS: After implementation of standard geriatric co-management for hospitalised cardiology patients aged 85 and over, the length of hospital stay shortened and the number of patients discharged to a geriatric rehabilitation facility increased. The adherence to geriatric team recommendations was high. Geriatric co-management would appear to optimise care for older hospitalised patients with cardiac disease.

Optimizing periprosthetic fracture management and in-hospital outcome: insights from the PIPPAS multicentric study of 1387 cases in Spain.

BACKGROUND: The incidence of all periprosthetic fractures (PPF), which require complex surgical treatment associated with high morbidity and mortality, is predicted to increase. The evolving surgical management has created a knowledge gap regarding its impact on immediate outcomes. This study aimed to describe current management strategies for PPF and their repercussions for in-hospital outcomes as well as to evaluate their implications for the community. METHODS: PIPPAS (Peri-Implant PeriProsthetic Survival Analysis) was a prospective multicentre observational study of 1387 PPF performed during 2021. Descriptive statistics summarized the epidemiology, fracture characteristics, management, and immediate outcomes. A mixed-effects logistic regression model was employed to evaluate potential predictors of in-hospital mortality, complications, discharge status, and weight-bearing restrictions. RESULTS: The study encompassed 32 (2.3%) shoulder, 4 (0.3%) elbow, 751 (54.1%) hip, 590 (42.5%) knee, and 10 (0.7%) ankle PPF. Patients were older (median 84 years, IQR 77-89), frail [median clinical frailty scale (CFS) 5, IQR 3-6], presented at least one comorbidity [median Charlson comorbidity index (CCI) 5, IQR 4-7], were community dwelling (81.8%), and had outdoor ambulation ability (65.6%). Femoral knee PPF were most frequently associated with uncemented femoral components, while femoral hip PPF occurred equally in cemented and uncemented stems. Patients were managed surgically (82%), with co-management (73.9%), through open approaches (85.9%) after almost 4 days (IQR, 51.9-153.6 h), with prosthesis revision performed in 33.8% of femoral hip PPF and 6.5% of femoral knee PPF. For half of the patients, the discharge instructions mandated weight-bearing restrictions. In-hospital mortality rates were 5.2% for all PPF and 6.2% for femoral hip PPF. Frailty, age > 84 years, mild cognitive impairment, CFS > 3, CCI > 3, and non-geriatric involvement were candidate predictors for in-hospital mortality, medical complications, and discharge to a nursing care facility. Management involving revision arthroplasty by experienced surgeons favoured full weight-bearing, while an open surgical approach favoured weight-bearing restrictions. CONCLUSIONS: Current arthroplasty fixation check and revision rates deviate from established guidelines, yet full weight-bearing is favoured. A surgical delay of over 100 h and a lack of geriatric co-management were related to in-hospital mortality and medical complications. This study recommends judicious hypoaggressive approaches. Addressing complications and individualizing the surgical strategy can lead to enhanced functional outcomes, alleviating the economic and social burdens upon hospital discharge. Level of Evidence Level IV case series. TRIAL REGISTRATION: registered at ClinicalTrials.gov (NCT04663893), protocol ID: PI 20-2041.

Implementing Heart Plus: Design and Early Results of a Novel Comanagement Clinic for Patients With Stimulant-associated Cardiomyopathy.

We describe the methodology, design, and early results of a novel multidisciplinary co management clinic model with Addiction Medicine and Cardiology providers using contingency management to engage patients with stimulant-associated cardiomyopathy (SA-CMP). Stimulant use, including methamphetamine and cocaine, is increasing in prevalence nationally and is associated with cardiovascular complications. People with SA-CMP have higher rates of mortality and acute care use (eg, emergency department visits, hospital admissions) and lower rates of outpatient care engagement than individuals with non-SA-CMP. This population also has disproportionately elevated rates of mental health and other medical comorbidities, challenges with social determinants of health, including housing and food insecurity, and representation from communities of color. This multidisciplinary comanagement care delivery model, called Heart Plus, was developed and funded as a quality improvement project. It led to a 5-fold increase in outpatient care engagement with a concomitant 53% decrease in acute care use. All participants reported a decrease in stimulant use. With increased clinical stability, patients were able to better engage with outpatient resources for social determinants of health, such as case management, social work, and housing and food service programs. Patients were also empowered to take control over their health while knowing that health care providers cared about their well-being.

Surgical and medical co-management optimizes surgical outcomes in older patients with chronic diseases undergoing robot-assisted laparoscopic radical prostatectomy.

INTRODUCTION: While robotic-assisted laparoscopic radical prostatectomy (RRP) is a standard mode for localized prostate cancer (PC), the risk of complications in older patients with chronic diseases and complex medical conditions can be a deterrent to surgery. Surgical and medical co-management (SMC) is a new strategy to improve patients' healthcare outcomes in surgical settings. METHODS: We reviewed the clinical data of older patients with chronic diseases who were cared for with SMC undergoing RRP in our hospital in the past 3 years and compared them with the clinical data from the general urology ward. Preoperative conditions and related indicators of recovery, and incidence of postoperative complications with the Clavien Grade System were compared between these two groups. RESULTS: The indicators of recovery were significantly better, and the incidence rates of complications were significantly reduced in the SMC group at grades I-IV (p < 0.05), as compared to the general urology ward group. CONCLUSIONS: The provision of care by SMC for older patients focused on early identification, comorbidity management, preoperative optimization, and collaborative management would significantly improve surgical outcomes. The SMC strategy is worthy of further clinical promotion in RRP treatment in older men with chronic diseases and complex medical conditions.

A Co-Management Model for Myeloid Malignancies That Evolved during the COVID-19 Pandemic.

INTRODUCTION: Myeloid malignancies are a heterogeneous group of clonal bone marrow disorders that are complex to manage in the community and therefore often referred to subspecialists at tertiary oncology referral centers. Many patients do not live in close proximity to tertiary referral centers and are unable to commute long distances due to age, comorbidities, and frailty. Interventions that minimize the travel time burden without compromising quality of care are an area of unmet need. We describe a cancer care delivery model for patients with myeloid malignancies that is built around telehealth and enables this vulnerable population access to care at an NCI-designated cancer center while receiving majority of their care close to home. METHODS AND MATERIALS: We report on a cohort of patients with myeloid malignancies who were co-managed by a general community oncologist and an academic leukemia subspecialist at Montefiore Einstein Cancer Center in New York. Patients were initially referred to our institute for a second opinion by community practices that are in partnership with Montefiore Health System, and initial visits were in-person or via telehealth. Treatment plans were made after discussion with patient's local community oncologist. Patients then continued to receive majority of their treatment and supportive care including transfusion support with their local oncologist, and follow-up visits were mainly via telehealth with the academic leukemia subspecialist. RESULTS: Our cohort of 12 patients had a median age of 81 years (range, 59-88 years). Patients remained on active treatment for a median time of 357 days (range, 154-557 days). Most of our patients had a performance status of ECOG 2 or higher. Three patients had myelodysplastic syndromes, 7 patients had acute myeloid leukemia, and 2 patients had myelofibrosis. The median number of hospitalizations over the total treatment time period was one. CONCLUSION: We demonstrate a shared academic and community care co-management model for the treatment of myeloid malignancies in elderly, frail patients using telehealth as a backbone with a very low hospitalization rate.

Orthogeriatric co-managements lower early mortality in long-lived elderly hip fracture: a post-hoc analysis of a prospective study.

OBJECTIVE: To evaluate the clinical effectiveness of orthogeriatric co-management care in long-lived elderly hip fracture patients (age ≥ 90). METHODS: Secondary analysis was conducted in long-lived hip fracture patients between 2018 to 2019 in 6 hospitals in Beijing, China. Patients were divided into the orthogeriatric co-management group (CM group) and traditional consultation mode group (TC group) depending on the management mode. With 30-day mortality as the primary outcome, multivariate regression analyses were performed after adjusting for potential covariates. 30-day mobility and quality of life were compared between groups. RESULTS: A total of 233 patients were included, 223 of whom completed follow-up (125 in CM group, 98 in TC group). The average age was 92.4 ± 2.5 years old (range 90-102). The 30-day mortality in CM group was significantly lower than that in TC group after adjustments for (2.4% vs. 10.2%; OR = 0.231; 95% CI 0.059 ~ 0.896; P = 0.034). The proportion of patients undergoing surgery and surgery performed within 48 h also favored the CM group (97.6% vs. 85.7%, P = 0.002; 74.4% vs. 24.5%, P < 0.001; respectively). In addition, much more patients in CM group could walk with or without aids in postoperative 30 days than in the TC group (87.7% vs. 60.2%, P < 0.05), although differences were not found after 1-year follow-up. And there was no significant difference in total cost between the two groups (P > 0.05). CONCLUSIONS: For long-lived elderly hip fracture patients, orthogeriatric co-management care lowered early mortality, improved early mobility and compared with the traditional consultation mode.

A comprehensive analysis of intraoperative factors associated with acute-on-chronic kidney injury in elderly trauma patients: blood loss as a key predictor.

BACKGROUND: Postoperative acute kidney injury (AKI) is a critical issue in geriatric patients with pre-existing chronic kidney disease (CKD) undergoing orthopedic trauma surgery. The goal of this study was to investigate modifiable intraoperative risk factors for AKI. METHODS: A retrospective study was conducted on 206 geriatric patients with CKD, who underwent orthopedic trauma surgery. Several variables, including intraoperative blood loss, postoperative hypoalbuminemia, intraoperative blood pressure and long-term use of potentially nephrotoxic drugs, were analyzed. RESULTS: Postoperative AKI (KIDGO) was observed in 25.2% of the patients. The 1-year mortality rate increased significantly from 26.7% to 30.8% in patients who developed AKI. Primary risk factors for AKI were blood loss (p < 0.001), postoperative hypoalbuminemia (p = 0.050), and potentially nephrotoxic drugs prior to admission (angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, diuretics, antibiotics, NSAIDs) (p = 0.003). Furthermore, the AKI stage negatively correlated with propofol dose per body weight (p = 0.001) and there was a significant association between AKI and the use of cement (p = 0.027). No significant association between intraoperative hypotension and AKI was observed in any statistical test. Femur fracture surgeries showed the greatest blood loss (524mL ± 357mL, p = 0.005), particularly intramedullary nailing at the proximal femur (598mL ± 395mL) and revision surgery (769mL ± 436mL). CONCLUSION: In geriatric trauma patients with pre-existing CKD, intraoperative blood loss, postoperative hypoalbuminemia, and pre-admission use of potentially nephrotoxic drugs are associated with postoperative AKI. The findings highlight the necessity to mitigate intraoperative blood loss and promote ortho-geriatric co-management to reduce the incidence and subsequent mortality in this high-risk population.