2.1 Which patients should be targeted?

Theoretically, all older adults presenting with hip or other disabling fragility fractures (eg, ankle) should be managed within an orthogeriatric service unit. Randomized controlled trials and before-after observational studies include primarily hip fracture patients older than 65 or 70 years [4, 5]. In some cases, it has been proposed to include subjects older than 70 years presenting with relevant comorbidities and any patients older than 80 years. Indeed, the characteristics of the patients eligible for an orthogeriatric service unit should be based also on the available resources, since the setting of a given criterion may significantly influence the volume of patients.

There are no established criteria from the available literature, and, due to the small number of RCTs, cost-effectiveness analyses are lacking. Moreover, the baseline characteristics of hip fracture patients are of limited benefit in identifying subjects at greatest risk of adverse outcomes, given the high degree of frailty in almost all FFPs. Therefore, we believe that orthogeriatric services should make an effort to include all older adults with hip or other disabling fractures by optimizing the resources available.

2.2 Responsibility and leadership—who is in charge?

The multidisciplinary approach is now the gold standard in the care of older adults presenting with hip or other osteoporotic fractures. The basic multidisciplinary team of these orthogeriatric models includes an orthopedic surgeon, a geriatrician or internist, an anesthesiologist during the perioperative phase, and other healthcare providers, such as a physiotherapist, clinical nurse, nutritionist, and a social worker, during the acute and postacute phases [4]. Direct communication, scheduled meetings, and written orders are the usual way to share information and communicate between team members, even if, in some cases, a skilled care manager takes on the role of coordinating the pathway of care and fostering communications between professionals [4, 10].

The main difference between the variety of orthogeriatric models concerns which professional discipline retains the primary responsibility for the management of the patients throughout the care pathway ( Fig 2.1-1 ) [4, 5]:

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  In both the traditional model ( Fig 2.1-1a ) and the routine geriatric consultation model ( Fig 2.1-1b ), the primary responsibility for oversight and coordination lies with the orthopedic surgical staff.

  
  
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  The comanaged care model is characterized by the comanagement of the fracture patient by the geriatrician and the orthopedic surgeon, with shared responsibility and leadership from admission to discharge ( Fig 2.1-1c ).

  
  
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  Finally, geriatrician leadership distinguishes the third model, usually referred to as the geriatric-led model ( Fig 2.1-1d–e ).

2.3 Time to surgery

Recent data and metaanalyses support the beneficial effect of early surgery in the management of older adults presenting with hip fractures [4, 5, 11]. Indeed, there is no clear definition of early surgery, since, in the various studies, it has been defined as “within 24 hours”, “within 48 hours” or even “as soon as medical conditions are stable” [4, 5, 11]. Although the meaning of “early surgery” is debatable, guidelines suggest that medically stable patients should undergo surgery as soon as possible, while unstable ones should be quickly optimized to avoid detrimental delays [5, 11].

The recognition of hip fracture as an urgent scenario requiring early surgery has significantly impacted the organization and implementation of the orthogeriatric models. In an ideal model, the patient may be transferred directly to the operating room from the emergency department and admitted to a hospital ward only after surgical repair. The feasibility of this approach has been tested in a study undertaken at the Pitié-Salpêtrière Hospital in Paris, where the FFPs, following a fast-track procedure, are quickly repaired and are postoperatively admitted to a dedicated geriatric unit within 1–2 days from their arrival in the emergency department ( Fig 2.1-1e ) [12]. Although at least in part still theoretical, it is highly probable that this approach will significantly affect the development of orthogeriatric models in the near future.

In conclusion, early surgery appears to produce potential advantages in the management of older adults with hip fractures, without significant risks for the patients, and it is the most ethical and humane approach to deal with FFPs. Therefore, all orthogeriatric models should clearly support this goal, addressing underlying problems and identifying solutions through intensive teamwork involving physicians and hospital management staff.

2.4 Length of hospital stay, early and late rehabilitation

In many countries, orthogeriatric models of care have also been influenced by the need to reduce acute hospital stay and promote early discharge, and by the availability of rehabilitation facilities in the community. Even when strategies to reduce the LOS are implemented, LOS is largely dependent on the features of the local healthcare system and often related to local organizational factors [4].

In general, there is an inverse relationship between LOS and rate of transfer to rehabilitation services in the community ( Fig 2.1-2 ):

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  Models characterized by short LOS require the support of postdischarge rehabilitation services, with the ability to take care of the patients undergoing early discharge, and community rehabilitation. In the US, where the LOS for hip fracture has decreased dramatically over the last 20 years to a national average of 6.3 days [13, 14], patients are usually discharged on the third postoperative day if they are clinically stable and able to transfer from bed to a chair with assistance. In these circumstances, more than 70% of hip fracture patients should be transferred to inpatient rehabilitation or community skilled nursing facilities (SNFs) to continue rehabilitation. A similar picture has been observed in other countries where the LOS is less than 1 week [12, 15, 16].

  
  
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  The opposite scenario is typically represented by the UK system, where patients complete functional recovery during the hospital stay [17–20]. Although decreasing in recent years, the mean LOS in the UK remains more than 20 days, as less than 30% of hip fracture patients are discharged to rehabilitation facilities [18, 19].

  
  
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  In between these two scenarios are most European (and some other) countries with LOS between 10 and 15 days [21–31]. In the European models, the rehabilitation is usually broken down into two phases, ie, early rehabilitation that occurs during hospital stay and late rehabilitation that takes place after discharge.

The rehabilitation program and discharge planning should be the result of a comprehensive evaluation involving the different members of the orthogeriatric team. To optimize use of resources, the orthogeriatric team should also decide which patients are most likely to benefit from using rehabilitation.

2.5 Case volumes

A positive relationship between case volume and improved outcomes has been shown for a wide range of surgical procedures across a variety of specialties [4]. In particular, higher surgeon and hospital procedure volumes have been associated with lower mortality rates, fewer complications, and shorter LOS [4]. A minimum of 100 cases per year has been suggested to develop sufficient expertise in managing FFPs and to adopt an efficient orthogeriatric model of care [4, 32]. There are no studies to clearly define a precise minimum caseload.

In the case of hip fractures, current literature [4, 32–34] offers conflicting results about the optimum number of cases required to implement a successful fragility fracture program. Some additional considerations include:

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  Even if a precise minimum number of cases needed to implement a service for the management of FFPs cannot be defined, low-volume hospitals are at risk for suboptimal outcomes.

  
  
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  Both the acute care ward volume and the rehabilitation unit volume may be relevant.

  
  
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  The concentration of orthogeriatric services in high-volume hospitals may have significant implications in the (re)distribution of resources, (re)organization of healthcare, and costs in developed countries.

3.1 General considerations

Innovative models of care for the management of FFPs have been developed and implemented over the past 30 years, with the first RCT comparing a traditional model with an orthopedic geriatric inpatient service published by Gilchrist et al in 1988 [35].

High-level evidence establishing superiority of any specific model is still limited. Ideally, several features of these innovative models of care would be compared and clarified by head-to-head RCTs. One example where this approach would be helpful concerns the creation of an emergency department “fast track” for FFPs. While the evaluation and optimization of patients within the emergency department by the emergency staff or multispecialty team can reduce time to surgery, and, theoretically, improve in-hospital outcomes, this has not been demonstrated. Without clear evidence of benefit, it can be difficult to justify the costs of staff reorganization and changes in workload and workflow.

3.2 Traditional model

In the traditional model, the key elements are:

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  The patient is managed on a general orthopedic ward.

  
  
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  The orthopedic service holds primary responsibility for inpatient plan of care while nonsurgical concerns and complications are dealt with by consultative medical services upon request ( Fig 2.1-1a ) [4, 5, 8].

  
  
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  The medical physician is only involved when requested by the orthopedic service.

  
  
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  Early rehabilitation typically takes place on the orthopedic ward.

  
  
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  The patient is discharged directly home, to an SNF, or to a rehabilitation facility, without strong emphasis on continuity of care and careful handoffs.

While several lines of evidence have demonstrated that this approach is appropriate for younger adults presenting with a simple traumatic fracture, it is not adequate for the management of the complex needs of FFPs [1–5]. As a result, several care models involving collaboration between orthopedic surgeon and geriatrician have been developed [4, 5]. The first models introduced were simple variations of the traditional model. They were characterized by routine input from a specific consultant team of different professionals, with the overall responsibility of the care remaining with the orthopedic surgical staff.

Over the years these models evolved and were replaced by multidisciplinary and coordinated approaches that have been demonstrated to be more effective to meet patients’ complex needs. These experiences have been designated with different names, such as orthogeriatric units (OGUs), comanaged geriatric fracture centers, or geriatric hip fracture clinical pathways, which in most cases distinguish unique models in terms of setting and organization. The common goals of most of these models were to define a multidisciplinary team dedicated to the surgical and medical care of FFPs, to promote rapid management of the comorbid medical conditions, early surgical repair, mobilization and rehabilitation, coordinated discharge planning, and continuity of care [4].

Although a variety of experiences have been described, nontraditional services can be summarized by the following models ( Fig 2.1-1b–e ).

3.3 Geriatric consultant in the orthopedic ward

The geriatric consultant in the orthopedic ward model is the simplest model [4, 5, 8].

The key elements are:

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  The patient is managed on the orthopedic ward.

  
  
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  The overall responsibility of the care is under the orthopedic surgical staff.

  
  
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  A geriatric consultant is involved either preoperatively or postoperatively.

  
  
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  A multidisciplinary team holds regular rounds to develop and monitor treatment plans of all FFPs on the ward. Although many relevant clinical services may participate, these are typically not coordinated or integrated, and do not clearly impact the overall plan of care.

  
  
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  Prevention and management of common problems and complications are based on the individual choices of the surgeon or geriatric consultant.

This model and closely related variations have been investigated with the largest amount of studies including RCTs. Interpretation of the results of these trials is limited by the huge heterogeneity in design and outcomes, the small sample sizes, and the absence of long-term follow-up [4–7].

Significantly improved outcomes compared to usual care could not be demonstrated when the consultant team′s contribution started postoperatively [4]. Slightly better results were reported with involvement of the geriatric consultant team at the time of admission and in models with daily medical visits [4]. This approach reduced the LOS and the number of medical complications.

The implementation of a geriatric consultant team on the orthopedic ward seems to add some benefits to the traditional model of care, but only when the consultant team is involved early in the process of care. These benefits are probably related to an earlier identification of common issues and complications compared to the traditional model [8]. However, the absence of an active, integrated, and coordinated interdisciplinary care can increase the risk of delays or errors, produce a detrimental fragmentation of care, and compromise an early and adequate discharge [4, 8].

3.4 Orthogeriatric comanaged care

This is probably the most sophisticated and complex model implemented for the management of older adults with fractures. The geriatric fracture center developed at the University of Rochester (New York) is the reference model of the orthogeriatric comanaged care [14, 32], and it has been adopted by many other hospitals, mainly in North America and Europe [3, 15, 17, 22, 24, 31, 36–42]. This model has evolved over the last 10–15 years with gradual improvements over time.

Its key elements are:

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  The patient is managed on the orthopedic ward or orthogeriatric unit.

  
  
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  Co-ownership—the orthogeriatric team shares responsibility and leadership from admission to discharge [4, 8].

  
  
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  An interdisciplinary team including several healthcare professionals skilled in the care of FFPs supports this codirection, working in close and integrated collaboration.

  
  
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  Standardized patient-centered, protocol-driven treatments and pathways are implemented.

  
  
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  Geriatrician and surgeon visit the patient daily, write their own orders, and communicate frequently, sharing their opinions and choices with the other members of the interdisciplinary team. This approach reduces the risk of delays, inappropriate variations in care, and iatrogenic errors, and it promotes clinical coordination. Even traditionally surgical issues like evaluation of surgical fitness, timing of procedure, and preoperative planning are usually shared and discussed between both the medical and surgical service to optimize the management of the patients.

The beneficial effects on short-term and long-term functional and clinical outcomes of this innovative model have been illustrated in a number of well-designed before-after observational studies and RCTs, in their reviews, and metaanalyses [4–7, 43]. Table 2.1-1 and Table 2.1-2 describe most relevant studies published in the last 15 years. Trials are heterogeneous in terms of design, duration of follow-up, and outcomes considered.

In most of the studies, the implementation of a comanaged care model for FFPs demonstrates a clinically significant reduction in both short-term and long-term adverse events. Compared to the traditional model, the comanaged care model has been shown to improve many short-term outcomes, including length of stay, time to surgery, in-hospital complications, and in-hospital mortality. Specifically, three of five studies demonstrated a significant decrease in the incidence of in-hospital complications [14, 37, 41], and four well-designed trials reported a significant reduction of in-hospital mortality [3, 15, 40, 41].

Few long-term trials have been published ( Table 2.1-2 ), with inconsistent and sometimes skewed results. In these studies, this model has been shown to increase long-term survival, and possibly improve functional recovery compared to the traditional model. For example, in three studies (ie, one RCT and two before-after trials), the 1-year survival rates were about 10% higher in the orthogeriatric comanaged care group than in the controls [3, 22, 41]. Vidan et al [41] also reported, after adjustment for confounding variables, a 45% lower probability of death or major complications, and a significantly greater functional recovery at 3 months.

In conclusion, the orthogeriatric comanaged care service represents a valuable and more effective alternative to the traditional approach to inpatient management of FFPs. Unfortunately, there are no published head-to-head RCTs comparing this model with the geriatric consultant in the orthopedic ward service. The fully implemented model requires considerable effort, consistent administrative support, strong physician leadership, and a commitment to continuous quality improvement. Given the relevant resources needed to implement an orthogeriatric comanaged care model, additional studies are warranted for a better understanding of its impact on long-term functional outcomes, to evaluate its cost-effectiveness, and whether this service is translatable and applicable to any hospital organization and framework [4].