As the life expectancy of the American population and the percentage of elderly Americans continue to increase, the incidence of hip fractures also continues to increase.1 After the age of 50 yr, the risk of fracture doubles with every decade.2 Multiple studies have documented that the aging population will drive an epidemic proportion of hip fractures that will need treatment by orthopedic surgeons over the next few decades;3,4 in the United States, there are approximately 350,000 hip fractures annually, and this number is projected to grow to 500,000 by 2040.5,6 This cohort of patients typically is extremely fragile, with multiple comorbidities at the time of presentation with a hip fracture, and many of these comorbidities are not well controlled and need further evaluation,7 with perioperative mortality rates over 20% within first year after surgery.8–13 Traditionally, the orthopaedic surgeon has cared for the fracture, with various nonsurgical consultants providing various medical and subspecialty support to optimize the patient for surgery. In many institutions, the consultants’ role in the care of the patient may withdraw or minimize after surgery.
One alternative treatment strategy to management by a single-care team with outside consultations is a model of comanagement using a multidisciplinary care team.14–18 In this system, all members of the team are empowered to act as the patient’s “primary” caregiver, i.e. treatment decisions can be implemented immediately by any member of the team rather than leaving recommendations that may or may not be followed. The goal of this system is to create a single-care team that can proactively prevent complications rather than reactively responding to problems once they’ve already arisen. Other retrospective studies (often using historical controls) have shown that similar systems can decrease time to the operating room,16–18 hospital length of stay (LOS),13,14,17,19–22 and complication rates.15,19,23–25
At the authors’ institution, there was a unique opportunity to evaluate the effectiveness of multidisciplinary care. Our medical center consists of a main tertiary care medical center (745 beds) and a satellite, smaller community hospital (300 beds). The main hospital employs a more traditional system in which patients with an acute hip fracture are admitted to the orthopaedic service for care. Hospitalists are called in as consultants to provide preoperative medical clearance for the patient before bringing the patient for operative fixation. Postoperatively, the orthopedic surgeon then manages all aspects of care, including pain management, venous thromboembolism prophylaxis, or any other medical issue that may arise. If a problem arises, the hospitalist must then be “re-consulted,” as there is no routine, postoperative follow-up by the hospitalist in that system.
Conversely, a multidisciplinary team approach was recently adopted at the smaller, satellite hospital in an attempt to improve care beginning in February 2011. In this program, the patient with acute hip fracture is admitted directly to a combined multidisciplinary service and seen within 4 hr by an attending hospitalist. Depending on patient comorbidities, further cardiologic evaluation is performed within 12 hr. Postoperatively, the patient is seen continuously by both the orthopaedic team and the hospitalist team (who have experienced geriatricians), who help provide further advice on medication strategies, bone metabolic follow-up, and strategies to help avoid common postoperative problems.
At both hospitals, patients who sustained hip fractures were cared for by the same group of attending orthopaedic surgeons. Their approaches to treatment did not deviate based on institution since both institutions have access to identical operating room equipment, implants, and anesthesia staff. Both institutions also have the same group of rotating residents, hospitalists, and ancillary medical staff. The electronic medical record system and order sets also are similar and shared between both hospitals; therefore, both institutions utilize the same standardized preoperative and postoperative geriatric hip fracture order sets with modifications or additions made on a patient-specific basis.
The purpose of this investigation was to evaluate the effect that these two different care models had on this group of medically fragile patients. We hypothesized that multidisciplinary care would significantly reduce the number and type of postoperative complications, decrease LOS, and possibly improve morbidity.
MATERIALS AND METHODS
This was a retrospective, cohort study evaluating outcomes from two institutions with different management strategies over an identical time interval between March 2012 through March 2014. Institutional review board approval was established for this investigation.
Our group collected data on 267 consecutive nonpathologic hip fractures treated at both institutions over a 3-year period. The patients with hip fractures were treated by a multidisciplinary (MD) team (129 patients) or an orthopaedic (non-MD) team (138 patients) based on the hospital to which they presented. Patients at both hospitals were admitted to a dedicated orthopaedic floor with nurses and social workers experienced with orthopaedic patients (although neither unit was exclusively designated for hip fractures).
The major difference in treatment was the organization of the care teams. At the academic center (non-MD), all orders were written by the orthopaedic team, and after initial consultation for medical clearance, the hospitalist team did not uniformly see the patients unless they were reconsulted. At that point, any suggested changes in the plan of care would be left as recommendations to be implemented by the orthopaedic team. Conversely, at the community hospital (MD team), patients were admitted to a combined “comanagement” service. Both teams rounded on the patients daily until discharge, and nurses could directly call either the orthopaedic team or the hospitalist team with any issues, depending on the nature of the problem. Orders were directly entered by both teams that would meet daily during a dedicated interdisciplinary rounding session, which included physicians, therapists, nurses, and social workers to discuss the plan of care.
Demographic variables (age, sex, race) obtained at the time of admission included preoperative comorbidities (accounted for with the Charlson Comorbidity Index26) listed on the preoperative medical clearance, anatomic location of the hip fracture as documented in the surgeon’s operative dictation, time until surgery as determined from the electronic medical record, type of surgical treatment as stated in the surgeon’s operative dictation, perioperative complications, and days until discharge as determined from the electronic medical record.
The in-hospital complications recorded for this study were: myocardial infarction, new-onset arrhythmia, atelectasis, deep venous thromboembolism, pulmonary embolism, delirium, ileus, new-onset urinary tract infection, wound infection, new-onset pneumonia, decubitus ulcer, and stroke. Myocardial infarction was defined by an abnormal increase of serial troponin levels, with or without ischemic changes noted on electrocardiogram. New-onset arrhythmias were defined based on history and physical examination and confirmed by electrocardiogram. Atelectasis was a clinical diagnosis that was further supported by chest radiograph. The diagnosis of deep venous thromboembolism was made based on results of ultrasound, while the diagnosis of pulmonary embolism was made based on results of computed tomography angiography (CTA). Delirium was defined to be a documented change in mental status from the preoperative state. Ileus was a clinical diagnosis made by the medical team and/or orthopaedic team and supported by findings on an abdominal radiograph. The diagnosis of postoperative urinary tract infection was made based on positive urinalysis or microbial growth from urine culture (as compared to preoperative urinalysis or urine culture). Wound infection was a clinical diagnosis made by the orthopaedic team and warranting initiation of antibiotics or surgical irrigation and debridement. Pneumonia was a clinical diagnosis confirmed by chest radiograph or chest CT, or sputum culture. Decubitus ulcer was a clinical diagnosis documented by a nurse or physician. Stroke was a diagnosis confirmed after evaluation by a neurologist and interpretation of MRI and angiography of brain, head, and neck. Transfer of patients to intensive care unit (ICU) or step-down units (or anywhere else within the institution) was documented by nurses and physicians in the electronic medical record. Ninety-day mortality was obtained through the hospital’s Social Security Database.
Age, Charlson Comorbidity Index, number of postoperative complications, time until surgery, and days until discharge were treated as continuous variables. When comparing continuous variables, normality was assessed with the Kolmogorov-Smirnov test and graphical analysis. Since these data did not meet assumptions of normality, a Wilcoxon Rank Sum test was used to compare values between the two cohorts. Sex, race, anatomic type of hip fracture, type of surgical treatment, the occurrence of a complication, the occurrence of a particular type of complication, transfer to ICU or step-down units, occurrence of in-hospital mortality, and occurrence of 90-day mortality were treated as categorical variables. Categorical variables were compared between the two cohorts with the use of a chi-square test. All P values less than 0.05 were considered significant. All statistical analyses were performed with R version 2.13.1 (The R Foundation for Statistical Computing).
A total of 267 patients were analyzed in this study; 129 patients were treated at the satellite institution by a MD team and 138 patients were treated at the main institution by a non-MD team. Table 1 summarizes characteristics of the two cohorts. With regards to demographic variables, patients in the MD group were older than the in the non-MD group and had a smaller percentage of men. With regards to outcomes, the MD group experienced a shorter time to operation and a shorter LOS. These two outcome differences were the only difference between the two cohorts that reached statistical significance (1.7 days ±1.8 vs. 2.4 days ±2.2; 8.2 days ±4.1 vs. 10.7 days ±13.6). There was no difference observed in the overall complication rates as well individual medical complications rates between the two cohorts. In-hospital and 90-day mortality rates also were comparable.
As the population ages and life expectancy continues to improve, we have seen a steady and continuous rise in the number of hip fractures in elderly patients.3,4 The cost of hip fracture care was estimated to be $7.2 billion in 1984 and $20 billion in 1997, with costs of hip fracture care estimated to reach 62 billion dollars by 2040.1,8 The complication rate for this cohort of patients is similarly high because many of them have multiple comorbid conditions, thus further complicating their care.8–12 The older, more traditional system of unilateral care by the orthopedic surgeon has evolved, and many institutions have adopted a multidisciplinary team of specialists to help care for this group of patients.
Our study provides evidence that a multidisciplinary approach can be more efficient in caring for these individuals. Among the significant findings of our study, we observed a shorter time to surgical admission and a decreased LOS for the patients cared for by the multidisciplinary team. We believe that the shorter time to operation is the direct result of early examination and more efficient preoperative medical stabilization by a hospitalist – especially given the similar preoperative Charlson Comorbidity Indices between the two groups. These improvements in preoperative workup have been modeled in cost-effectiveness studies,27 and it is encouraging that these data directly support those analyses. It is important to note that the patients treated by the multidisciplinary team were 5 yr older on average, and although Charlson Comorbidity Indices were similar between the two cohorts, the Charlson scale does not account for all clinically significant comorbidities requiring medical stabilization.26
In terms of complication rates, no differences were observed between the two cohorts. Compared to many other studies that have found lower rates of complications with comanaged care,7,16,21,28 the cohort in this study that was treated solely by an orthopaedic team had fewer complications than similar cohorts treated by unilateral orthopaedic teams in other studies. Thus, although our sample size was comparable to if not greater than that reported in similar studies, we may not have been adequately powered. We did observe a trend toward fewer strokes experienced by the cohort treated by a multidisciplinary team. Given that the rate of cerebrovascular attack after hip fracture is low, again, we were likely underpowered to detect a significant difference.29 Delirium rates were also lower but not statistically significant, a complication which has been shown in high-quality prospective randomized studies to improve with multidisciplinary comanagement.23,30
One noteworthy result was that LOS decreased in the multidisciplinary cohort. This result has also been demonstrated by multiple other studies,14,17,20–22 many of which also showed no statistical decrease in any single complication rate. We feel that LOS is a proxy for the myriad of minor improvements that a dedicated, experienced geriatrician can provide to make the perioperative period less turbulent for these medically fragile patients.
Although the LOS in both of our cohorts is longer than that reported in some other published studies,14,17,20–22,31,32 there are also studies that have reported far longer overall LOS.33,34 There are many possible reasons for our increased LOS. In addition to the 1.7-2.4 days needed for medical optimization, depending on the cohort, other contributions could be the medical management of more serious adverse events, such as postoperative stroke, as well as obstacles inherent to social work discharge planning.
One major strength of this study is that the orthopaedists and hospitalists are common to both institutions. This setup left the organizational logistics of medical care (rather than the physicians administering it) as the major variable to investigate. Other than these organizational differences, both cohorts of patients had a similar approach to the orthopaedic aspect of their care. Furthermore, this study compared two cohorts that were treated contemporaneously. Thus, surgeon experience and skill level also were adequately controlled. Many of the prospective studies published on comanaged care of hip fracture patients usually compare the comanaged cohort to a historical control cohort cared for by a unilateral orthopaedic team.
There are several weaknesses in the current investigation. The primary limitation is the retrospective nature of the study, which introduces some degree of reporting error. Another weakness is the possibility of subtle inconsistency of the medical care across institutions, given minor facility differences between the two hospitals. Finally, although we report no statistical differences in many variables (complications, mortality), it is likely that this study was underpowered to detect minor differences in these relatively rare events.
In conclusion, this data suggests that the implementation of a multidisciplinary model of care for the hip fracture patient may lead to faster time to operation and shorter hospital LOS. Furthermore, even though we did not observe a decreased complication rate in the multidisciplinary cohort, there was a trend towards fewer complications (number of strokes and incidence of delirium) in the multidisciplinary cohort that merits further study. By shifting our approach toward the care of geriatric hip fractures, we may find ways to improve the outcomes of this common injury in this medically frail population.
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