Comanejo de la fractura de cadera del anciano en un hospital de tercer nivel: un estudio de cohortes / Hip fracture co-management in the elderly in a tertiary referral hospital: a cohorts study

INTRODUCCIÓN: La fractura de cadera del anciano es de los diagnósticos más prevalentes en los servicios de Traumatología, con gran impacto en términos clínicos, económicos y sociales. Nuestro objetivo es analizar el impacto clínico de un modelo de comanejo entre Traumatología y Medicina Interna para pacientes ancianos ingresados por fractura de cadera en un hospital de tercer nivel. MATERIAL Y MÉTODOS: Cohortes retrospectivas de pacientes mayores de 65 años ingresados por fractura de cadera entre enero de 2005 y agosto de 2006 (cohorte HIST) sin modelo de comanejo, y entre enero de 2008 y agosto de 2010 (cohorte COFRAC) con dicho modelo. Se analizaron características demográficas, clínicas y quirúrgicas, incidencia de complicaciones, mortalidad y reingreso a los 30 días. RESULTADOS: Se incluyó a 701 pacientes (471 HIST, 230 COFRAC). No hubo diferencias en edad, género, demora quirúrgica, tiempo y tipo de cirugía e intervención, estancia, deambulación al alta, consulta en urgencias ni reingreso o mortalidad a 30 días. Hubo diferencias en identificación de pluripatológicos (16,8 vs. 24,4%; p = 0,02), osteoporosis (3,9 vs. 7,6%; p = 0,03) o déficit motor (3,5 vs. 8,8%; p = 0,03), fármacos del tratamiento (3,7+/-2,5 vs. 4,3+/-3,2; p < 0,01), aparición de delirium (15,6 vs. 20,9%, p = 0,048) e hipomotilidad intestinal (80,3 vs. 74,7%; p < 0,001), seguimiento de anemia (83,3 vs. 97,1%; p > 0,01) y de función renal (44,5 vs. 97,3%; p < 0,01) y mortalidad intrahospitalaria (4,6 vs. 1,3%; p = 0,02). CONCLUSIONES: El comanejo de pacientes ancianos ingresados por fractura de cadera permite mejorar la documentación de los problemas crónicos previos y el control de complicaciones hospitalarias y disminuye la mortalidad intrahospitalaria

INTRODUCTION: Hip fracture in the elderly is one of the most prevalent diagnoses in Orthopedic Surgery Departments. It has a great impact in medical, economic and social terms. Our objective is to analyze clinical impact of a co-management care model between orthopedic surgery and internal medicine departments for elderly patients admitted with hip fracture in a tertiary referral hospital. MATERIAL AND METHODS: Retrospective cohort study of patients older than 65 years old admitted with hip fracture between January 2005-August 2006 (HIST cohort) without a co-management care model, and between January 2008-August 2010 (COFRAC cohort) with a co-manEdadment care model. Analysis of demographic, clinical and surgery characteristics, complications incidence and mortality and re-admissions at 30 days was made. RESULTS: A total of 701 patients were included (471 HIST, 230 COFRAC). There were no differences in sex, gender, time to surgery, type of anesthesia and surgery, length of stay, ambulation at discharge and 30-days emergency room consultation, readmissions or mortality at 30 days. There were differences in identification of polypatological patients (16.8 vs. 24.4%, P=0.02), presence of osteoporosis (3.9 vs. 7.6%, P=0.03), motor deficit (3.5 vs. 8.8%, P=0.03), number of chronic drugs (3.7+/-2.5 vs. 4.3+/-3.2, P<0.01), diagnosis of delirium (15.6 vs. 20.9%, P=0.048), constipation (80.3 vs. 74.7%, p < 0.001), monitoring of anemia (83.3 vs. 97.1%, P>0.01) and renal failure at discharge (44.5 vs. 97.3%, P<0.01) and hospital mortality (4.6 vs. 1.3%, P=0.02). CONCLUSIONS: Co-management for elderly patients admitted with hip fracture provides a better information about previously chronic conditions, a higher control of hospital complications and decreases hospital mortality

Hip fracture co-management in the elderly in a tertiary referral hospital: A cohorts study. / Comanejo de la fractura de cadera del anciano en un hospital de tercer nivel: un estudio de cohortes.

INTRODUCTION: Hip fracture in the elderly is one of the most prevalent diagnoses in Orthopedic Surgery Departments. It has a great impact in medical, economic and social terms. Our objective is to analyze clinical impact of a co-management care model between orthopedic surgery and internal medicine departments for elderly patients admitted with hip fracture in a tertiary referral hospital. MATERIAL AND METHODS: Retrospective cohort study of patients older than 65 years old admitted with hip fracture between January 2005-August 2006 (HIST cohort) without a co-management care model, and between January 2008-August 2010 (COFRAC cohort) with a co-manEdadment care model. Analysis of demographic, clinical and surgery characteristics, complications incidence and mortality and re-admissions at 30 days was made. RESULTS: A total of 701 patients were included (471 HIST, 230 COFRAC). There were no differences in sex, gender, time to surgery, type of anesthesia and surgery, length of stay, ambulation at discharge and 30-days emergency room consultation, readmissions or mortality at 30 days. There were differences in identification of polypatological patients (16.8 vs. 24.4%, P=0.02), presence of osteoporosis (3.9 vs. 7.6%, P=0.03), motor deficit (3.5 vs. 8.8%, P=0.03), number of chronic drugs (3.7±2.5 vs. 4.3±3.2, P<0.01), diagnosis of delirium (15.6 vs. 20.9%, P=0.048), constipation (80.3 vs. 74.7%, p<0.001), monitoring of anemia (83.3 vs. 97.1%, P>0.01) and renal failure at discharge (44.5 vs. 97.3%, P<0.01) and hospital mortality (4.6 vs. 1.3%, P=0.02). CONCLUSIONS: Co-management for elderly patients admitted with hip fracture provides a better information about previously chronic conditions, a higher control of hospital complications and decreases hospital mortality.

Comparación de la pregunta sorpresa frente a un índice objetivo (Índice PALIAR) para la identificación de situación terminal en pacientes con enfermedades crónicas avanzadas / Comparison surprise question against a target index (PALIAR Index) for identifying terminal status in patients with advanced chronic disease

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Concordance of Barthel Index, ECOG-PS, and Palliative Performance Scale in the assessment of functional status in patients with advanced medical diseases.

OBJECTIVE: Analysing most relevant clinical features and concordance between different functional scales in patients with advanced medical diseases (PAMD). METHODS: Cross-sectional multicentre study that included PAMD (heart, lung, kidney, liver, and neurological diseases) in hospital settings from February 2009 to October 2010. We analysed clinical, biological and functional features in performing activities of daily living (ADL) by medians of Barthel Index (BI); additionally we assessed their performance status by medians of Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) and Palliative Performance Scale (PPS) scores. We evaluated the concordance of these instruments in assessing functional impairment by κ and intraclass correlation coefficient tests. RESULTS: 1847 patients were included (average age 79 years, 50.1% men). Most common symptoms were dyspnoea (62.31%), asthenia (23%) and delirium (20.14%). Functional assessment showed a high prevalence of severe or total impairment in performing basic ADL by medians of used instruments (BI median=35 (IQR=70), and 52.1% of patients with severe-total impairment; ECOG-PS median=2 (IQR 30), and 44% of patients with severe-total impairment; and PPS median=50 (IQR 30), and 32% of patients with severe-total impairment). Concordance among these instruments was acceptably good (κ indexes ranging from 0.653 to 0.745 (p<0.0001)). CONCLUSIONS: PAMD represent a population with severe functional impairment, which requires a multidisciplinary approach for proper management. Assessment of functional ability in this population by BI, ECOG-PS, and PPS showed good concordance.

Peeking through the cracks: an assessment of the prevalence, clinical characteristics and health-related quality of life (HRQoL) of people with polypathology in a hospital setting.

Little is known about the prevalence of the recently defined polypathology notion in hospital populations. Patients admitted to medical wards were assessed using established criteria of polypathology. Prevalence of polypathology, interobserver reliability, clinical features, nutritional status, and HRQoL were assessed using clinical data and interview, mini-nutritional assessment (MNA), and the 12-item short-form health survey (SF-12) scales. Of a total of 812 patients studied, 196 (24%) met polypathology criteria (65% men, of mean age 71.3+/-11.6 years, mean defining chronic diseases 2.4+/-0.046, and other comorbidities 2.6+/-0.094). Interobserver reliability for the detection of cases was good (kappa=0.628). Their mean Charlson index/prescribed drugs were 3.3/6, respectively. Severe dyspnea, delirium, or active neoplasia were present in 44, 15, and 11%. A bad nutritional status/risk of malnutrition was evident in 10.3/52.6%, and correlated with the number of previous hospitalizations (p=0.041), and the presence of active neoplasia (p=0.037). Mean physical/mental summaries of HRQoL were 33.9+/-10, and 42+/-13, and correlated with a better nutritional status (p=0.011, and p=0.001, respectively). Polypathology affects one quarter of inpatients in a hospital setting, and can be easily and reliably identified. The diversity and complexity of patient needs underscore the need for continuity of care between community and hospital, crossing sub-speciality lines and institutional boundaries.