Canadian Inpatient Orthogeriatric Models of Care: A Mixed Methods Survey of Facilitators and Barriers.

Background: Fragility fractures are a serious and common consequence of falls in older adults. Orthogeriatric models of care reduce mortality and morbidity, but, despite this evidence, orthogeriatric programs (OGPs) are not standardized across Canada. The aim of this study was to better understand the facilitators and barriers of OGPs across Canada. Methods: Data on OGPs across Canada were gathered via email survey to all Canadian Geriatric Society (CGS) members and distributed April 1st to May 1st 2021. Respondents answered 15 questions, using SKIP LOGIC, and data analysis was conducted with QualtricsXM software. Results: 62 CGS members completed the survey. Respondents came from nine provinces/territories, with most being physicians from academic centres. 77% respondents indicated an existing OGP at their site, commonly an optional or automatic geriatrician consult. 23% indicated no formal OGP, of which 56% had an alternative service automatically consulted for older adults with fragility fracture, commonly internal medicine or a hospitalist. Responders indicated the most important factor in establishing an OGP is clinical leadership (56%, 10/18), and the most common barriers are lack of hospital prioritization and lack of funding (41%, 62/153). Conclusions: The survey found that clinical leadership, hospital prioritization, and available funding are imperative to establishing OGPs. Limitations include the survey being distributed only to CGS members, a lower response rate, and respondents predominantly from academic centres in Ontario. Further qualitative data from other specialties (for example, orthopedics) and greater representation from community hospitals would be helpful to understand additional perceived barriers and facilitators.

Mobile assessment of visual function helps to prevent Re-Injury in elderly patients with recent hip fractures.

INTRODUCTION: Patients undergoing surgery due to hip fracture face an elevated risk of a subsequent fall during rehabilitation. An important contributing factor to this risk is deteriorated visual function, often responsive to intervention. This study aims to explore differences in visual acuity (VA) and stereovision (SV) between individuals with a history of fall-related hip injuries (study group) and age-matched controls, utilizing a mobile application (EuvisionTab, ET) to distinguish age-related visual decline from pathological vision. MATERIALS & METHODS: A total of 32 and 71 participants were enrolled in the study and control groups, respectively (mean age: 74.9 years, range: 60-96). Monocular logMAR VA was measured using a tablet by means of an adaptive threshold-search algorithm. SV was assessed using low-dot density static and dynamic random dot stereograms. An age-dependent reference limit for VA was established. For ET stereotests, the number of correctly identified optotypes out of 10 random presentations served as the measure for further comparisons. Visually impaired status in the study group was determined if patients failed either the VA threshold or the SV criteria. RESULTS: In the control group, an apparent but statistically nonsignificant decline in VA was observed, while stereovision remained stable and did not exhibit significant age-related variations based on ET stereotests. Conversely, the study group demonstrated significantly worse results in monocular VA (p = 0.0032) and for both stereotests (p = 0.018 for static, p = 0.036 for dynamic) according to paired samples t-test and chi-square test, respectively. Hip injuries were significantly associated with visual impairment (OR = 4.88, p = 0.0012). DISCUSSION: This study focuses on one possible risk factor of elderly falls, namely, vision impairment. Patients with visual decay present a higher incidence of hip injuries compared to age-matched controls. This data suggest that vision screening and, when feasible, restoration of visual function may contribute to the prevention of secondary falls, refractures, or contralateral fractures. A mobile-based screening protocol, executable as part of a postoperative bedside examination and independent of specialized eye care, can be proposed.

Perioperative and Postoperative Outcomes of Proximal Hip Fracture: A Comparison of Orthopedic and Geriatric Care Models.

Introduction Orthogeriatric patients with femur fractures, despite their multiple comorbidities and associated healthcare costs, have a promising new approach. This approach suggests that most patients should be hospitalized in the geriatric department, with daily orthopedic follow-up. The potential for lower mortality rates through orthogeriatric co-management and dual care is a reason for hope in our field. Methods This study is retrospective and involved 285 patients with proximal hip fractures. Two treatment models were compared: hospitalization in orthopedic and geriatric departments with different treatment protocols. The study analyzed demographic data and postoperative outcomes. It also included an analysis of 26 patients who received conservative treatment. Results Our study revealed significant differences between patients hospitalized in the orthopedic and geriatric departments. Geriatric department patients, who were significantly older and had higher comorbidities, experienced extended hospitalization and higher mortality rates during hospitalization, at 30 days, and at one-year follow-up (p<0.05). Notably, a significantly higher proportion of geriatric patients were discharged to home rehabilitation at the end of hospitalization compared to orthopedic patients (17.5% vs. 7.4%; p<0.01). Among non-operated patients, the mortality rate was 57.7% compared to 16.5% in patients who underwent surgery during the one-year follow-up. Discussion Our study suggests that elderly patients with hip fractures may benefit from management in the geriatric department. Despite experiencing significantly longer hospital stays, these patients have a higher likelihood of being discharged home compared to those managed in the orthopedic department. These findings have important implications for the care of orthogeriatric patients and may help guide future treatment strategies.

First year report of the IMSS Multicenter Hip Fracture Registry.

The population has aged; there is a greater risk of osteoporosis and hip fracture. We describe the standards of care for hip fractures in various hospitals of Mexico. A total of 1042 subjects participated. The acute mortality was 4.3%. SIGNIFICANCE: Hip fracture registries provide a means to compare care and establish improvement processes. BACKGROUND: The Mexican population has aged; thus, there is a greater risk of osteoporosis, and its main consequence is hip fracture due to fragility. Its incidence is high, and it is expected to increase due to aging in our country. International guidelines provide standardized recommendations for the care of people with hip fractures, while hip fracture registries provide a means to compare care with local, national, and international clinical standards and establish improvement processes. OBJECTIVE: Describe the standards of care for hip fractures in various hospital centers of the Mexican Social Security Institute. METHODS: This was an observational, multicenter, longitudinal, and descriptive study. It included 24 hospital centers in Mexico. Informed consent was obtained. Data were recorded during the hospital stay, epidemiological data, and management, and follow-up was carried out 30 and 120 days after discharge. The information was analyzed using SPSS version 22.0. RESULTS: A total of 1042 subjects aged 79.5 ± 7.6 years participated, mostly women (n = 739; 70.9%) from the community (n = 1,021; 98.0%) and with functional independence (Barthel 80.9 ± 22.2). The transfer time to the emergency room was 4.6 ± 14.6 days. Pertrochanteric hip fracture was the most common (n = 570, 54.7%). The most common type of procedure was dynamic hip screw (DHS) (n = 399; 40.1%). Documented thromboprophylaxis was granted in 91.5% (n = 953) and antibiotic prophylaxis in 53.0% (n = 552) of the patients. The goal of 36 h for the surgical procedure was achieved in 7.6% of the subjects (n = 76), with the most frequent cause being a delay in scheduling (n = 673, 67.6%). The mean time from emergency room to surgery was 7.8 ± 7.0 days. The acute mortality rate was 4.3%. Secondary pharmacologic prevention upon discharge occurred in 64.2% of patients. At 30 days, 370 subjects (37.1%) were lost to follow-up, with a mortality of 3%, while at 120 days, 166 subjects (27.8%) were lost, with a mortality of 2.8%. CONCLUSION: In the hospital centers where the study was carried out, there are still no standards of care for hip fractures, which makes it necessary to rethink the care for this population group through a strategy focused on meeting those standards.

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.

Optimizing Orthogeriatric Hip Fracture Care: Why Fracture Type Matters.

Hip fractures significantly impact morbidity and mortality among frail older adults, posing ongoing challenges in orthogeriatric care despite significant advancements. Established in the 1960s by Devas and Irvine, this field integrates orthopedics, trauma services, and geriatric medicine to address the complex needs of this population comprehensively. A critical and underexplored aspect is the precise identification and tailored treatment of various fracture types, each linked to unique clinical challenges and outcomes. This special article emphasizes the complex interplay between specific fracture types, their management options, and the roles of comorbidity and polypharmacy, highlighting the essential role of orthogeriatricians. Orthogeriatricians navigate the complexities posed by comorbidities, frailty, and polypharmacy, significantly influencing treatment outcomes. Their roles have expanded to include decision making about both operative and nonoperative strategies, emphasizing patient-centered care and moving beyond simplistic categorizations of "hip fractures." As future experts on the nuances of fracture types and their broader health implications, orthogeriatricians are also crucial in advancing treatment protocols that address preoperative and postoperative needs. Their comprehensive knowledge ensures effective in-hospital management and postdischarge planning, aligning treatment strategies with the holistic needs of frail older adults. The ongoing evolution of orthogeriatric practices promises to enhance decision-making and patient outcomes through a more informed and integrated care approach.

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.

Rehabilitation after surgery for hip fracture - the impact of prompt, frequent and mobilisation-focused physiotherapy on discharge outcomes: an observational cohort study.

PURPOSE: To determine the relationship between three postoperative physiotherapy activities (time to first postoperative walk, activity on the day after surgery, and physiotherapy frequency), and the outcomes of hospital length of stay (LOS) and discharge destination after hip fracture. METHODS: A cohort study was conducted on 437 hip fracture surgery patients aged ≥ 50 years across 36 participating hospitals from the Australian and New Zealand Hip Fracture Registry Acute Rehabilitation Sprint Audit during June 2022. Study outcomes included hospital LOS and discharge destination. Generalised linear and logistic regressions were used respectively, adjusted for potential confounders. RESULTS: Of 437 patients, 62% were female, 56% were aged ≥ 85 years, 23% were previously living in a residential aged care facility, 48% usually walked with a gait aid, and 38% were cognitively impaired prior to their injury. The median acute and total LOS were 8 (IQR 5-13) and 20 (IQR 8-38) days. Approximately 71% (n = 179/251) of patients originally living in private residence returned home and 29% (n = 72/251) were discharged to a residential aged care facility. Previously mobile patients had a higher total LOS if they walked day 2-3 (10.3 days; 95% CI 3.2, 17.4) or transferred with a mechanical lifter or did not get out of bed day 1 (7.6 days; 95% CI 0.6, 14.6) compared to those who walked day 1 postoperatively. Previously mobile patients from private residence had a reduced odds of return to private residence if they walked day 2-3 (OR 0.38; 95% CI 0.17, 0.87), day 4 + (OR 0.38; 95% CI 0.15, 0.96), or if they only sat, stood or stepped on the spot day 1 (OR 0.29; 95% CI 0.13, 0.62) when compared to those who walked day 1 postoperatively. Among patients from private residence, each additional physiotherapy session per day was associated with a -2.2 (95% CI -3.3, -1.0) day shorter acute LOS, and an increased log odds of return to private residence (OR 1.76; 95% CI 1.02, 3.02). CONCLUSION: Hip fracture patients who walked earlier, were more active day 1 postoperatively, and/or received a higher number of physiotherapy sessions were more likely to return home after a shorter LOS.

[Conservative fracture treatment in old people]. / Konservative Frakturversorgung bei alten Menschen.

The numbers of osteoporotic fractures will increase due to the demographic change, which particularly affects the proximal femur, pelvis, proximal humerus, wrist and vertebral column. Surgical treatment is superior to conservative treatment of proximal femoral fractures. Non-dislocated fractures of the wrist can also be treated with a plaster cast but studies suggest that the results in the first 12 months are better after surgical treatment. The situation is similar for fractures of the proximal humerus and non-dislocated fractures in particular can also be treated conservatively. A score and classification were recently developed for making decisions on the treatment of osteoporotic vertebral fractures. Fractures of the anterior and posterior pelvic ring can be treated conservatively with the patient under sufficient analgesia as long as there is no substantial dislocation. The highest priority in geriatric traumatology is fast remobilization.

Impressive Short-Term Improvement in Functional Outcome and Quality of Life after Primary Total Hip Arthroplasty (THA) in the Orthogeriatric Patient in a Prospective Monocentric Trial.

Background/Objectives: Osteoarthritis (OA) represents the most frequent chronic joint disease worldwide. Facing an aging population, resulting from the demographic change, the number of primary total hip arthroplasties (THA) will further increase. Although the geriatric patient strongly differs from the younger one, the current literature on elective orthopedic surgery in the geriatric patient is scarce. This work analyses, whether geriatric patients receiving primary THA significantly improve in terms of their (1) mobility and functional outcome and (2) health-related quality of life at four to six weeks as well as three months postoperatively. Methods: In a prospective study design, we analyzed 101 geriatric patients with osteoarthritis of the hip receiving primary THA. The study is part of the ongoing "Special Orthopaedic Geriatrics" (SOG) trial, which is funded by the German Federal Joint Committee (GBA). In addition to a preoperative comprehensive geriatric assessment (CGA), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the EQ5D-5L were imposed preoperatively (t0), at four to six weeks (t1), and at three months (t2) postoperatively. Results: The 101 enrolled patients had a mean age of 78.1 ± 4.9 years. The total WOMAC score and almost all subcategories significantly improved at four to six weeks as well as three months postoperatively in comparison to the preoperative results (p < 0.001). The same was observed for the EQ-5D-5L, showing significant improvement in overall health at both time points (p < 0.001) and all subcategories (p < 0.05). Conclusions: This study implies that a geriatric patient benefits as much from elective primary THA as a younger patient. However, the preoperative comprehensive geriatric assessment with screening for risk factors is of utmost importance. Regarding the aging population, a lot of effort is needed to obtain more knowledge about geriatric patients receiving elective orthopedic surgery.

Barriers and facilitators to early mobilisation and weight-bearing as tolerated after hip fracture surgery among older adults in Saudi Arabia: a qualitative study.

OBJECTIVE: To explore the practice of prescribing and implementing early mobilisation and weight-bearing as tolerated after hip fracture surgery in older adults and identify barriers and facilitators to their implementation. METHODS: Semi-structured interviews were conducted with 20 healthcare providers (10 orthopaedic surgeons and 10 physiotherapists) from Saudi Arabian government hospitals. Data were analysed using inductive thematic analysis. RESULTS: While early mobilisation and weight-bearing as tolerated were viewed as important by most participants, they highlighted barriers to the implementation of these practices. Most participants advocated for mobility within 48 h of surgery, aligning with international guidance; however, the implementation of weight-bearing as tolerated was varied. Some participants stressed the type of surgery undertaken as a key factor in weight-bearing prescription. For others, local protocols or clinician preference was seen as most important, the latter partially influenced by where they were trained. Interdisciplinary collaboration between orthopaedic surgeons and physiotherapists was seen as a crucial part of postoperative care and weight-bearing. Patient and family member buy-in was also noted as a key factor, as fear of further injury can impact a patient's adherence to weight-bearing prescriptions. Participants noted a lack of standardised postoperative protocols and the need for routine patient audits to better understand current practices and outcomes. CONCLUSION: This study contributes to national and global discussions on the prescription of early mobilisation and weight-bearing as tolerated. It highlights the necessity for a harmonised approach, incorporating standardised, evidence-based protocols with patient-specific care, robust healthcare governance and routine audits and monitoring for quality assurance and better patient outcomes.

[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.

Orthogeriatric Care Following Hip Fracture: Improving Post-Operative Outcomes in an Aged Population.

INTRODUCTION: Hip fractures globally are associated with high levels of morbidity, mortality, and significant financial burden. This audit aimed to assess the impact of orthogeriatric liaison care on post-operative outcomes following surgical management of neck or femur fractures. METHODS: Here, 258 patients who underwent hip fracture surgery over 1-year were included. Data were collected as an audit following the transition to an orthogeriatric liaison care model, involving regular orthogeriatric review (thrice weekly ward rounds, daily board rounds), superseding orthogeriatric review as requested. The audit is meant to assess the development of post-operative non-surgical site infection (NSSI) and mortality and duration of inpatient stay. Outcomes were compared to previous data from our hospital site in 2015/2016. RESULTS: Patients with severe cognitive impairment and systemic disease (Abbreviated Mental Test Score (AMTS) < 7 and American Society of Anesthesiologists (ASA) grade ≥ 3) showed significantly elevated NSSI risk, consistent across the study periods. Both periods demonstrated an increased risk of NSSI associated with admission from nursing homes. Despite the 2021/2022 cohort being notably older, NSSI risk decreased from 40.6% to 37.2% after implementing the orthogeriatric care model. NSSI risk was notably reduced for severe cognitive impairment (51.6% vs. 71%), and the p-value was 0.025. Average hospital stay decreased post-intervention (2.4 days shorter), with a notable reduction for NSSI patients (3.4 days shorter). Overall mortality rates were similar, although mortality due to infection was significantly reduced in 2021/2022 (44.4% vs. 93.3%), and the p-value was 0.003. CONCLUSION: The orthogeriatric liaison care model significantly decreased NSSI only in individuals with severe cognitive impairment and infection-associated mortality. This highlights the integral role of orthogeriatricians in the care of elderly hip fracture patients.

Respiratory Complications Are the Main Predictors of 1-Year Mortality in Patients with Hip Fractures: The Results from the Alzira Retrospective Cohort Study.

Introduction: Hip fractures pose a significant challenge for older individuals given their high incidence and one-year mortality rate. The objective of this study was to identify the primary predictors of one-year mortality in older adults hospitalized for hip fractures. Methods: We conducted a retrospective cohort study involving adults aged 70 years or older who were admitted to the hospital for fragility hip fractures between 1 January 2014 and 31 December 2021. A total of 3229 patients were recruited, with 846 (26.2%) experiencing one-year mortality. Results: Respiratory complications (HR 2.42, 95%CI 1.42-4.14; p = 0.001) were the most significant predictors of one-year mortality, followed by hospital readmission (HR 1.96, 95%CI 1.66-2.32; p < 0.001), the male sex (HR 1.88, 95%CI 1.46-2.32; p < 0.001), cardiac complications (HR 1.88, 95%CI 1.46-2.32; p < 0.001), and a diagnosis of dementia at admission (HR 1.37, 95%CI 1.13-1.66; p = 0.001). The Charlson Index and the American Society of Anesthesiologists physical status classification system also significantly increased the mortality risk. Conversely, higher hemoglobin levels at admission and elevated albumin at discharge significantly reduced the mortality risk. Conclusions: The one-year mortality rate is substantial in older adults with hip fractures who are admitted to an orthogeriatric unit. The appropriate management of anemia, nutritional disorders, and comorbidity at admission and during the follow-up could potentially mitigate long-term mortality after hip fractures.

Impact of Flagging/Risk Stratification System on Complications in Hospitalist Hip Fracture Co-management: Retrospective Cohort Study.

Purpose: Hip fractures are associated with high morbidity and mortality, the rates of which can be improved by comprehensive care. To improve hospitalist co-management of hip fractures, we designed and implemented hip fracture template (HFT), a flagging and risk stratification algorithm system. It includes consideration of perioperative management and preventative measures against hip fractures. We examined its effect on morbidity in patients with hip fractures and the factors associated with complications. Methods: We conducted a retrospective cohort study of patients who underwent surgery for hip fracture. The primary outcome was the perioperative complication rate, comparing patients managed with and without HFT. Multivariate analysis was adjusted for age, gender, and any significant variables shown in univariate analysis. Results: HFT was used in 121 patients and not used in 147 patients. In univariate analysis, patients were less likely to have complications if HFT was used (19.0% vs. 29.9%, P = 0.047), but there was no difference in length of stay (17 days vs. 17 days, P = 0.27) or in-hospital-mortality (0.8% vs. 0.7%, P = 1.00) between the groups. In adjusted analysis, patients managed by HFT had lower likelihood of complications (OR 0.55, 95% CI 0.31-0.98). Among patients managed by HFT, those with revised cardiac risk index (RCRI) ≥ 1 were more likely to have complications in both univariate (42.1% vs. 14.7%, P = 0.01) and adjusted analysis (OR 3.37, 95% CI 1.03-10.84). Conclusion: Patients with hip fractures managed with HFT were less likely to have complications, especially those with RCRI ≥ 1, suggesting benefits of using HFT.

The impact of primary total hip and knee replacement on frailty: an observational prospective analysis.

BACKGROUND: Osteoarthritis is a prevalent condition in frail older adults that requires hip or knee replacement in many patients. The aim of the study was to determine the impact of hip and knee arthroplasty on frailty. METHODS: In this prospective short-term study, we used data from 101 participants of the ongoing Special Orthopaedic Geriatrics (SOG) trial, funded by the German Federal Joint Committee (GBA). Frailty, measured by Fried's Physical Frailty Phenotype (PFP), was assessed preoperatively, 7 days postoperatively, 4-6 weeks and 3 months after hip and knee arthroplasty. ANOVA with repeated measures and post-hoc tests for the subgroups were used for the statistical analysis. RESULTS: Of the 101 participants, 50 were pre-frail (1-2 PFP criteria) and 51 were frail (≥ 3 PFP criteria) preoperatively. In the pre-frail group, the PFP score decreased from 1.56 ± 0.50 (median 2) preoperatively to 0.53 ± 0.73 (median 0) 3 months after surgery (p < 0.001). The PFP score in the frail cohort decreased from 3.39 ± 1.45 (median 3) preoperatively to 1.27 ± 1.14 (median 1) 3 months postoperatively (p < 0.001). While the PFP score of the pre-frail participants increased 7 days after surgery, the PFP score of the frail group decreased significantly. CONCLUSION: Pre-frail individuals often regain robustness and patients with frailty are no longer assessed as frail after surgery. Joint replacement is an effective intervention to improve frailty in hip and knee osteoarthritis. TRIAL REGISTRATION: This study is part of the Special Orthopaedic Geriatrics (SOG) trial, German Clinical Trials Register DRKS00024102. Registered on 19 January 2021.

Introducing a pharmacist-led transmural care program to reduce drug-related problems in orthogeriatric patients: a prospective interventional study.

BACKGROUND: Orthogeriatric patients have an increased risk for complications due to underlying comorbidities, chronic drug therapy and frequent treatment changes during hospitalization. The clinical pharmacist (CP) plays a key role in transmural communication concerning polypharmacy to improve continuity of care by the general practitioner (GP) after discharge. In this study, a pharmacist-led transmural care program, tailored to orthogeriatric patients, was evaluated to reduce drug related problems (DRPs) after discharge. METHODS: An interventional study was performed (pre-period: 1/10/2021-31/12/2021; post-period: 1/01/2022-31/03/2022). Patients (≥ 65 years) from the orthopedic department were included. The pre-group received usual care, the post-group received the pharmacist-led transmural care program. The DRP reduction rate one month after discharge was calculated. Associated factors for the DRP reduction rate were determined in a multiple linear regression analysis. The GP acceptance rate was determined for the proposed interventions, as well as their clinical impact using the Clinical, Economic and Organizational (CLEO) tool. Readmissions one month after discharge were evaluated. RESULTS: Overall, 127 patients were included (control n = 61, intervention n = 66). The DRP reduction rate was statistically significantly higher in the intervention group compared to the control group (p < 0.001). The pharmacist's intervention was associated with an increased DRP reduction rate (+ 1.750, 95% confidence interval 1.222-2.278). In total, 141 interventions were suggested by the CP, of which 71% were accepted one month after discharge. In both periods, four patients were readmitted one month after discharge. 58% of the interventions had a clinical impact (≥ 2 C level using the CLEO-tool) according to the geriatrician and for the CP it was 45%, indicating that they had the potential to avoid patient harm. CONCLUSIONS: The pharmacist-led transmural care program significantly reduced DRPs in geriatric patients from the orthopedic department one month after discharge. The transmural communication with GPs resulted in a high acceptance rate of the proposed interventions.

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.

The impact of elective total hip and knee arthroplasty on physical performance in orthogeriatric patients: a prospective intervention study.

BACKGROUND: Osteoarthritis is a prevalent condition in older adults that leads to reduced physical function in many patients and ultimately requires hip or knee replacement. The aim of the study was to determine the impact of hip and knee arthroplasty on the physical performance of orthogeriatric patients with osteoarthritis. METHODS: In this prospective study, we used data from 135 participants of the ongoing Special Orthopaedic Geriatrics (SOG) trial, funded by the German Federal Joint Committee (GBA). Physical function, measured by the Short Physical Performance Battery (SPPB), was assessed preoperatively, 3 and 7 days postoperatively, 4-6 weeks and 3 months after hip and knee arthroplasty. For the statistical analysis, the Friedman test and post-hoc tests were used. RESULTS: Of the 135 participants with a mean age of 78.5 ± 4.6 years, 81 underwent total hip arthroplasty and 54 total knee arthroplasty. In the total population, SPPB improved by a median of 2 points 3 months after joint replacement (p < 0.001). In the hip replacement group, SPPB increased by a median of 2 points 3 months after surgery (p < 0.001). At 3 months postoperatively, the SPPB increased by a median of 1 point in the knee replacement group (p = 0.003). CONCLUSION: Elective total hip and knee arthroplasty leads to a clinically meaningful improvement in physical performance in orthogeriatric patients with osteoarthritis after only a few weeks. TRIAL REGISTRATION: This study is part of the Special Orthopaedic Geriatrics (SOG) trial, German Clinical Trials Register DRKS00024102. Registered on 19 January 2021.

Pertrochanteric hip fracture is associated with mobility decline and poorer physical performance 4 to 6 months post-hip fracture.

BACKGROUND: To study the effect of hip fracture type on physical performance, functional ability and change in mobility four to six months after the injury. METHODS: A total of 1331 patients out of consecutive 2052 patients aged ≥ 65 years who underwent hip fracture surgery were included in the study. Patient information was collected on admission, during hospitalization, by phone interview and at the geriatric outpatient clinic 4 to 6 months after the fracture. Of the 1331 eligible patients, Grip strength, Timed Up and Go -test (TUG), Elderly Mobility Scale (EMS), mobility change compared to pre-fracture mobility level, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) were used to determine physical performance and functional ability. Logistic regression was used for the analyses which was adjusted for gender, age, American Society of Anesthesiologists score, diagnosis of cognitive disorder, pre-fracture living arrangements, mobility and need of mobility aid. RESULTS: Patients with pertrochanteric hip fracture had an EMS lower than 14 (Odds Ratio (OR) 1.38, 95% confidence intervals (CI) 1.00-1.90), TUG time ≥ 20 s (OR 1.69, 95% CI 1.22-2.33) and they had declined in mobility (OR 1.58, 95% CI 1.20-2.09) compared to femoral neck fracture patients 4 to 6 months post-hip fracture in multivariable-adjusted logistic regression analyses. Grip strength and functional ability (IADL, BADL) 4 to 6 months after hip fracture did not differ between fracture types. There were no statistically significant differences in physical performance in patients with a subtrochanteric fracture compared to patients with a femoral neck fracture. CONCLUSIONS: Pertrochanteric hip fracture independently associated with poorer physical performance 4 to 6 months post hip fracture compared to other hip fracture types. Pertrochanteric hip fracture patients should be given special attention in terms of regaining their previous level of mobility.