Comanagement of Geriatric Patients With Hip Fractures

Abstract

The objective of this 3-year retrospective, controlled, cohort study is to characterize an interdisciplinary method of managing geriatric patients with hip fracture. All patients aged 65 years or older admitted to a single academic level I trauma center during a 3-year period with an isolated hip fracture were included as participants for this study. Thirty-one geriatric patients with hip fracture were treated with historical methods of care (cohort 1). The comparison group of 115 similar patients was treated under a newly developed, institutional comanagement hip fracture protocol (cohort 2). There were no differences in age, sex distribution, or comorbidity distribution between the 2 cohorts. Patients requiring intensive care unit (ICU) admission decreased significantly from 48% in cohort 1 to 23% in cohort 2 (P ¼ .0091). Length of ICU stay for patients requiring ICU admission also decreased significantly, from a mean of 8.1 days in cohort 1 to 1.8 days in cohort 2 (P ¼ .024). Total hospital stay decreased significantly, from a mean of 9.9 days in cohort 1 to 7.1 days in cohort 2 (P ¼ .021). Although no decrease in in-hospital mortality rates was noted from cohort 1 to cohort 2, a trend toward decreased 1-year mortality rates was seen after implementation of the hip fracture protocol. Hospital charges decreased significantly, from US$52 323 per patient in cohort 1 to US$38 586 in cohort 2 (P ¼ .0183). Implementation of a comanagement protocol for care of geriatric patients with hip fracture, consisting of admission to a geriatric primary care service, standardized perioperative assessment regimens, expeditious surgical treatment, and continued primary geriatric care postoperatively, resulted in reductions in lengths of stay, ICU admissions, and hospital costs per patient. On an annualized basis, this represented a savings of over US$700 000 for our institution.

Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis

“…Of the more successful models, two of the common features are (1) a shift in focus where both physicians act as a patient's primary caregiver as opposed to the traditional model of admission to a single service with the other service acting as a consultant, and (2) a shared goal that common medical and surgical complications should be anticipated rather than treated after their occurrence. This approach has decreased complication rates [5,17,22,45,64], time from injury until the operating room [4,24,52], hospital length of stay [5,17,24,28,39,40,52,70], and has improved osteoporosis treatment [22,28].…”

Pediatric hospitalist comanagement of surgical patients: Structural, quality, and financial considerations

“…For example, in several studies of patients 65 years and older hospitalized with hip fractures, comanagement with a geriatric hospitalist was associated with improved clinical outcomes and shortened LOS. [8][9][10][11][12] An analogous group of pediatric patients to the geriatric population may be CSHCNs or children who are "medically complex." Several frameworks have been proposed to identify these patients.…”

CORR Insights®: Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis

“…New payment models initiated by the Patient Protection and Affordable Care Act (which encourages bundled payments and the formation of accountable care organizations) focuses on high-cost procedures [2,7]. The systems used to provide care for patients with diverse diagnoses, including hip fracture, also vary; this would appear to offer a meaningful opportunity to improve both outcomes and costs [5].…”

“…A small percentage of hospitals have adopted an organized medical comanagement model to improve both patient reported outcomes and process measures for patients with a hip fracture. Although the topic has been reasonably well-studied, most reports to this point involve retrospective analyses that may be subject to various types of bias [1][2][3][4]. While some studies have looked at the economics of these models, and although these reports generally suggest the models are cost-effective, these analyses only represent the study of program performance at individual hospitals [2,7,8].…”

“…There are varying degrees of comanagement in use in the United States. Additionally, some programs are more costeffective because they have implemented additional levels of sophistication including standard patient care protocols, standardized order sets, protocol driven operative treatment, and have used lean business processes to remove waste from their programs [1,2,6]. It would be essential to test the assumptions and conclusions reached in this paper to help hospital systems understand the benefits in terms of patient care and economic outcomes of the comanagement model for hip fractures.…”