2.4 Elements of an orthogeriatric comanaged program
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1 Introduction
In light of the historically poor perioperative outcomes in fragility fracture patients (FFPs) [1–3], unique interdisciplinary team approaches in the treatment of these patients have been implemented to reduce peri- and postoperative complications. Orthogeriatric models of care were developed in England in the late 1950s and are now widely accepted [4]. Geriatricians are specialized in addressing comorbidities, ensuring optimal medical management for older multimorbid individuals, and can help to improve the outcomes of older patients with fragility fractures [3]. These interdisciplinary approaches have been described in various terms including orthogeriatric management, comprehensive geriatric care, or comanagement [5, 6]. The implementation of a successful orthogeriatric comanagement model of care varies from one hospital to another, but some key elements have to be considered.
Key elements of the comanaged care model, adapted from Lisk and Yeong [7], are:
Prompt admission to orthopedic care
Rapid and comprehensive medical, surgical, and anesthesiologic assessment
Minimal delay to surgery
Accurate and well-performed surgery (single-shot surgery)
Prompt mobilization and rehabilitation
Early supported discharge and ongoing community rehabilitation
Secondary prevention, addressing bone protection and falls assessment
In order to ensure these elements, certain principles must be applied:
Interdisciplinary teamwork and co-ownership: Patients should be treated in a coordinated manner and without conflicts among orthopedic, geriatric, and anesthesiological teams.
Interdisciplinary communication including team meetings.
Goal setting: Based on protocols and guidelines, patient-specific short-term and medium-term treatment goals must be set and revised according to the dynamic status and functional potential of each patient. Diagnostic and therapeutic interventions must be aligned with those goals. Consented goal setting is an excellent technique to get all clinicians and family members on the same page and to ease interprofessional and interdisciplinary communication.
These elements require a lot of additional resources, thus the importance of the individual elements have to be further discussed.
2 Key elements of comanaged care
2.1 Rapid comprehensive medical, surgical, and anesthesiologic assessment
Up to a quarter of patients with hip fractures have a preexisting cardiovascular disease, and some patients already have subclinical infections prior to their fracture [8, 9]. The postoperative course is often marked by an increased incidence of chest infections due to the combination of pain, immobility and reduced ability to cough [7].
The following correctable comorbidities should be identified and addressed immediately in order not to delay surgery [10] (see chapter 1.4 Preoperative risk assessment and preparation):
Anemia
Anticoagulation
Volume depletion
Electrolyte imbalance
Uncontrolled diabetes
Uncontrolled heart failure
Correctable cardiac arrhythmia or ischemia
Acute chest infection
Exacerbation of chronic chest conditions
Data on the power of rapid comprehensive assessment still remain weak. It is recommended that an interdisciplinary prioritization of orthogeriatric trauma patients should start in the emergency department and the postoperative care unit should be informed as soon as possible to allocate capacities.
2.2 Minimal delay to surgery
There is growing emphasis on the benefits of minimizing surgical delay for orthogeriatric hip fracture patients [11]. It has been shown that a prolonged time to surgery is a risk factor for delirium, whereas delirium was found to be associated with a poor functional outcome and increased mortality [12, 13].
However, there are still authors querying the necessity of early surgery. Lizaur-Utrilla et al [14] stated recently that delaying surgery up to 4 days was not associated with higher morbidity or mortality rates. The authors recommended concentrating more on preoperative optimization with sufficient medical treatment rather than being bound by a universal timing of surgery [14].
The majority of studies consistently show that early surgery has a strong impact on reducing patient′s mortality ( Fig 2.4-1 ).
2.3 Single-shot surgery
Adapted surgical techniques respecting the low bone quality, bleeding issues, and reduced reserves in the soft tissues are required (see chapter 1.2 Principles of orthogeriatric surgical care). Revision surgeries must be avoided because they usually lead to significant deterioration.
2.4 Prompt mobilization
Immobilization of FFPs can be associated with various medical complications such as pressure ulcers, venous thromboembolism, wound and systemic infections, loss of muscle mass and muscle strength, or demineralization of bone that deteriorates during postoperative recovery. Postoperative mortality is known to be associated with the extent of postoperative mobilization. This was shown for patients suffering from femoral periprosthetic fractures ( Fig 2.4-2 ) [16].
The importance of targeting the vulnerability of these patients at an early stage to prevent functional decline in the long run was also illustrated in the Trondheim Hip Fracture Trial [17]. Geriatric trauma patients were investigated in a randomized controlled trial comparing comprehensive geriatric care (CGC) to conventional orthopedic care. In this study, participants who received CGC had significantly higher gait speed, less asymmetry, better gait control, and more efficient gait patterns. Furthermore, the CGC participants were more often able to walk and reported better mobility at 4 and 12 months.
In conclusion, prompt mobilization remains an essential element for the treatment of orthogeriatric patients (see chapter 1.8 Postoperative surgical management).
2.5 Early multidisciplinary rehabilitation
In orthogeriatric patients, it is of particular importance to start rehabilitation immediately after surgery to prevent a loss of self-care and independence. Especially in patients with high degrees of comorbidity, frailty and polypharmacy, a multidisciplinary rehabilitation process is an important factor leading to optimal outcomes and a successful surgical procedure [18]. To determine the most appropriate rehabilitation program, the individual′s baseline health status should be assessed. The assessment of prefracture mobility, cognition, depression, fall risk, nutritional status, incontinence, and visual function are of importance to plan the optimal rehabilitation program [19]. Interdisciplinary rehabilitation programs are known to have the best outcomes in terms of quality of life, reduced readmission rates, depression and fall prevention, highlighting the importance of early multidisciplinary rehabilitation [20].
2.6 Early supported discharge and ongoing community rehabilitation
Planning patients’ rehabilitation should start as early as possible, ideally on the day of admission to the hospital. Cooperation with rehabilitation facilities and specialists with expertise in the care of older adults, including departments for acute geriatrics, represent a proven approach to ensure early and safe discharge of patients [21]. Rehabilitation within the hospital has the advantage of continuity of care. When being discharged home, early supported discharge should also ensure as much home care as possible.
2.7 Secondary prevention, combining bone protection and falls assessment
In a double-blind, placebo-controlled trial, treatment with zoledronic acid compared with placebo reduced the risk of morphometric vertebral fractures by 70% during a 3-year period. These findings strengthen the need of secondary fracture prevention [22]. However, in women eligible for the treatment of osteoporosis in Germany, only 23% of them received appropriate treatment [23]. The implementation of a fracture liaison service (FLS) that provides a standardized identification and treatment of osteoporosis to orthogeriatric patients has proven to be an effective approach for secondary fracture prevention (see also chapter 2.8 Fracture liaison service and improving treatment rates for osteoporosis). In one trial, the FLS produced a 30% reduction for any fracture and a 40% reduction for major refractures compared to a standard approach hospital, whereas only 20 patients needed to be treated to prevent one new fracture over 3 years [24]. The impact of comprehensive geriatric care on the patients’ mobility and subsequent fall prevention is also important for secondary fracture prevention.
3 Cost of care
At first glance, the comprehensive orthogeriatric model appears to require a lot of additional resources. Cost-utility analyses integrating epidemiological and economic aspects for hip fracture patients treated within a comprehensive orthogeriatric model of care, as compared with the standard of care model, are of interest. In hip fracture patients it has been shown that a comprehensive orthogeriatric care modality is more cost-effective, as it provides additional quality-adjusted life years (QALYs) while using fewer resources compared with standard care [25].
Another prospective randomized controlled trial compared the effectiveness of comprehensive geriatric care in a dedicated geriatric ward with usual orthopedic care and supported the above findings ( Table 2.4-1 ). The staffing ratios of medical professionals used in this study is listed in Table 2.4-2 .
Related posts:
2.2 Overcoming barriers to implementation of a care model
2.3 Clinical practice guidelines
2.9 Use of registry data to improve care
2.8 Fracture liaison service and improving treatment rates for osteoporosis
2.5 Adapting facilities to fragility fracture patients
2.6 Orthogeriatric team—principles, roles, and responsibilities
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