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      Geriatric intervention in elderly patients with hip fracture in an orthopedic ward

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          Abstract:

          Background:

          Hip fracture is a common cause of long hospital stay in the elderly. Approximately one third of these patients die within the first year. As a consequence geriatric and orthopedic collaboration (orthogeriatrics) has been organized in different ways. The aim of this study is to evaluate the efficiency of a multidisciplinary geriatric in-hospital intervention on patient outcome.

          Methods:

          A total of 495 elderly hip fracture patients consecutively admitted to orthopedic surgery, were followed. Data were based on medical records. The intervention group (n=233) was compared to a historical cohort group (n=262) receiving traditional orthopedic treatment. Intervention program was based on initial physical and mental screening and evaluation, geriatric-focused care, and early discharge planning. The intervention was provided by a multidisciplinary geriatric team. After discharge, follow-up home-visits by a physiotherapist were performed, except for patients discharged to nursing homes, due to a 24-hour staff and easy access to the GP.

          Results:

          Median length of stay was reduced from 15 to 13 days. More patients began treatment with calcium/vitamin-D and bisphosphonate (p=sig). There was no difference in hemoglobin variation between the time of admission and three to six months post admission, and no difference in three-month readmissions (odds ratio (OR) = 1.09 [95%CI: 0.71;1.67]). Discharge destination was unchanged (OR=0.93 [95%CI: 0.52; 1.65]). In-hospital mortality was 8% in the intervention group vs. 6% (p=0.48), in the control group. Three-month mortality was 16% in the intervention group vs. 15% (p=0.39), in the control group. In the intervention group, residents from nursing homes had a higher three-month mortality (OR=2.37 [95% CI: 0.99; 5.67]), and the risk of new fractures within two years decreased from 9.5% to 7.7%, though not statistically significant.

          Conclusion:

          Our study indicates that co-management of hip fracture patients by orthopedic surgeons and geriatricians may be associated with a reduction in length of hospital stay without negatively affecting major patient outcomes. The concept should be further developed particularly among the frail elderly.

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          Most cited references14

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          Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial.

          To evaluate whether an early multidisciplinary geriatric intervention in elderly patients with hip fracture reduced length of stay, morbidity, and mortality and improved functional evolution. Randomized, controlled intervention trial. Orthopedic ward in a university hospital. Three hundred nineteen patients aged 65 and older hospitalized for hip fracture surgery. Participants were randomly assigned to a daily multidisciplinary geriatric intervention (n=155) or usual care (n=164) during hospitalization in the acute phase of hip fracture. Primary endpoints were in-hospital length of stay and incidence of death or major medical complications. Secondary endpoints were the rate of recovery of previous activities of daily living and ambulation ability at 3, 6, and 12 months. Median length of stay was 16 days in the geriatric intervention group and 18 days in the usual care group (P=.06). Patients assigned to the geriatric intervention showed a lower in-hospital mortality (0.6% vs 5.8%, P=.03) and major medical complications rate (45.2% vs 61.7%, P=.003). After adjustment for confounding variables, geriatric intervention was associated with a 45% lower probability of death or major complications (95% confidence interval=7-68%). More patients in the geriatric intervention group achieved a partial recovery at 3 months (57% vs 44%, P=.03), but there were no differences between the groups at 6 and 12 months. Early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital stay or long-term functional recovery.
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            Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population.

            Hip fractures in older adults are a common event, leading to substantial morbidity and mortality. Hip fractures have been previously described as a "geriatric, rather than orthopedic disease." Patients with this condition have a high prevalence of comorbidity and a high risk of complications from surgery, and for this reason, geriatricians may be well suited to improve outcomes of care. Co-management of hip fracture patients by orthopedic surgeons and geriatricians has led to better outcomes in other countries but has rarely been described in the United States. This article describes a co-managed Geriatric Fracture Center program that has resulted in lower-than-predicted length of stay and readmission rates, with short time to surgery, low complication rates, and low mortality. This program is based on the principles of early evaluation of patients, ongoing co-management, protocol-driven geriatric-focused care, and early discharge planning. This is a potentially replicable model of care that uses the expertise of geriatricians to optimize the management of a common and serious condition.
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              Osteoporosis is markedly underdiagnosed: a nationwide study from Denmark.

              To compare the number of patients diagnosed with osteoporosis and osteoporotic fractures in Denmark, with the number of subjects expected to have osteoporosis. From the National Hospital Discharge Register, records for all patients diagnosed with osteoporosis and/or with osteoporotic fractures between 1995 and 1999 were retrieved. Based on normal Danish values for BMD, the expected number of subjects aged 50 years or more with osteoporosis according to the WHO definition was calculated. The estimated prevalence of osteoporosis was 40.8% of women aged >or=50 years and 17.7% among men. The expected annual incidence was 58,658/million inhabitants in women >or=50 years of age and 23,648/million in men >or=50 years. However, the observed incidence was only 4,823 and 862/million per year, respectively (8.2% and 3.6% of the expected). In 1999, a total of 34,691 hip, spine, and forearm fractures were reported in subjects >or=50 years, and of these, 18,566 were potentially attributable to osteoporosis (14,240 fractures in women and 4,326 in men equaling 14,976 and 5,297/million per year). Only 0.3% of men >or=50 years were receiving a bisphosphonate, while 2.2% of women received a bisphosphonate or raloxifene. Among women >or=50 years, 27.7% received hormone replacement therapy. Osteoporotic fractures of the hip, spine, and forearm are rather frequent in Denmark, but the diagnosis of osteoporosis is rarely used. It seems that osteoporosis is markedly underdiagnosed and undertreated in Denmark as probably also elsewhere. This may have significant implications for the prevention of osteoporotic fractures.
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                Author and article information

                Journal
                J Inj Violence Res
                J Inj Violence Res
                kums
                Journal of Injury and Violence Research
                Kermanshah University of Medical Sciences
                2008-2053
                2008-4072
                July 2012
                : 4
                : 2
                : 45-51
                Affiliations
                a Departments of Geriatrics, Aarhus University Hospital, DK-8000 Aarhus, Denmark.
                b Departments of Orthopedic Surgery, Aarhus University Hospital, DK-8000 Aarhus, Denmark.
                Author notes
                [* ] Corresponding Author at: Merete Gregersen, Master of Health Science Departments of Geriatrics, PP Ørumsgade 11, building 7, DK-8000 Aarhus, Denmark. Phone: +4529624147 Fax: +4589491950 E-mail: meregreg@ 123456rm.dk (Gregersen M.).
                Article
                10.5249/jivr.v4i2.96
                3426900
                21502786
                55a35c13-7526-4c51-aafc-27bdc1f42c60
                Copyright © 2012, KUMS

                This is an open-access article distributed under the terms of the Creative Commons Attribution 3.0 License( http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 12 August 2010
                : 10 November 2010
                Categories
                Injury &Violence
                Hip Fracture
                Elderly
                Orthogeiatrics
                Mortality
                in-Hospital

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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