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Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment

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Abstract

Summary

To improve the quality of care and reduce the healthcare costs of elderly patients with a hip fracture, surgeons and geriatricians collaborated intensively due to the special needs of these patients. After treatment at the Centre for Geriatric Traumatology (CvGT), we found a significant decrease in the 1-year mortality rate in frail elderly patients compared to the historical control patients who were treated with standard care.

Introduction

The study aimed to evaluate the effect of an orthogeriatric treatment model on elderly patients with a hip fracture on the 1-year mortality rate and identify associated risk factors.

Methods

This study included patients, aged 70 years and older, who were admitted with a hip fracture and treated in accordance with the integrated orthogeriatric treatment model of the CvGT at the Hospital Group Twente (ZGT) between April 2008 and October 2013. Data registration was carried out by several disciplines using the clinical pathways of the CvGT database. A multivariate logistic regression analysis was used to identify independent risk factors for 1-year mortality. The outcome measures for the 850 patients were compared with those of 535 historical control patients who were managed under standard care between October 2002 and March 2008.

Results

The analysis demonstrated that the 1-year mortality rate was 23.2 % (n = 197) in the CvGT group compared to 35.1 % (n = 188) in the historical control group (p < 0.001). Independent risk factors for 1-year mortality were male gender (odds ratio (OR) 1.68), increasing age (OR 1.06), higher American Society of Anesthesiologists (ASA) score (ASA 3 OR 2.43, ASA 4–5 OR 7.05), higher Charlson Comorbidity Index (CCI) (CCI 1–2 OR 1.46, CCI 3–4 OR 1.59, CCI 5 OR 2.71), malnutrition (OR 2.01), physical limitations in activities of daily living (OR 2.35), and decreasing Barthel Index (BI) (OR 0.96).

Conclusion

After integrated orthogeriatric treatment, a significant decrease was seen in the 1-year mortality rate in the frail elderly patients with a hip fracture compared to the historical control patients who were treated with standard care. The most important risk factors for 1-year mortality were male gender, increasing age, malnutrition, physical limitations, increasing BI, and medical conditions. Awareness of risk factors that affect the 1-year mortality can be useful in optimizing care and outcomes. Orthogeriatric treatment should be standard for elderly patients with hip fractures due to the multidimensional needs of these patients.

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Authors and Affiliations

  1. Department of Trauma Surgery, Ziekenhuisgroep Twente, Almelo/Hengelo, The Netherlands

    E. C. Folbert, J. H. Hegeman & D. van der Velde

  2. ZGT Academy, Ziekenhuisgroep Twente, Almelo/Hengelo, The Netherlands

    M. Vermeer

  3. Department of Geriatric Medicine, Ziekenhuisgroep Twente, Almelo/Hengelo, The Netherlands

    E. M. Regtuijt

  4. Department of Surgery, University of Groningen (RUG), Groningen, The Netherlands

    H. J. ten Duis

  5. Department of Geriatric Medicine, Groningen and Leyden Academy on Vitality and Ageing, University Medical Centre Groningen, Leiden, The Netherlands

    J. P. Slaets

Authors
  1. E. C. Folbert
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  2. J. H. Hegeman
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  3. M. Vermeer
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  4. E. M. Regtuijt
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  5. D. van der Velde
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  6. H. J. ten Duis
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  7. J. P. Slaets
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Corresponding author

Correspondence to E. C. Folbert.

Ethics declarations

Conflicts of interest

Ellis Folbert states that there has been funding from the Nurse Practitioners Association Research Foundation (OWVS Foundation) for language editing of this manuscript. Ellis Folbert, Han Hegeman, Marloes Vermeer, Marlies Regtuijt, Detlef van der Velde, Henk Jan ten Duis, and Joris Slaets declare that they have no conflict of interest.

Ethical approval

The Medical Ethical Committee of Medisch Spectrum Twente (MST) at Enschede, the Netherlands, declares that this study does not meet the criteria necessary for an assessment by a medical ethical committee according to Dutch law (K15-54).

Appendix

Appendix

Definitions of measuring instruments used

The VMS frailty score was used to screen for frailty on the following items: delirium, falling, physical limitations and malnutrition. Score 0; not frail, maximum score 4; frail on all items.

Preoperative state of health was assessed using the American Society of Anesthesiologists physical status classification system (ASA): ASA 1–2 no or less comorbidity; ASA 3 severe systemic disease requiring medication, limitation of activities; ASA 4 extreme systemic disorder involving a chronic threat to life; ASA 5 extremely ill patient, death expected within 24 h with or without intervention.

We used the Charlson Comorbidity Index (CCI) to estimate the probability of death within 1 year after hip fracture as a reference. This score was first reported in 1987 [16]. The CCI categorizes and assigns weights and severities to 19 different patient comorbidities with a predicted 1-year mortality for CCI 0 of 12 %; CCI 1–2 of 26 %; CCI 3–4 of 52 %; CCI 5 or more of 85 %. At baseline, comorbidities were scored with the CCI and classified in 0, 1–2, 3–4, 5 or >.

The Barthel Index (BI) was used to measure the level of functioning in activities of daily living (ADL): score 0–4 completely dependent on help, 5–9 requires major help, 10–14 requires help but can do a lot independently, 15–19 reasonably to adequately independent, 20 completely independent in ADL.

The Parker Mobility Score (PMS) was used to measure mobility both within and outside the home as well as the ability to undertake activities outdoors. It is a composite score which results in a total score ranging from 0 (unable to mobilize) to 9 (independent).

In this study complications were registered as:

  1. 1.

    Surgical complications; defined as:

    • Superficial site infection: diffuse redness, serous fluid leakage, and no fever. (RIVM, 2014)

    • Deep wound infection; worse than superficial, need for revision.

    • Dislocation of the prosthesis and failure of osteosynthesis: diagnosis confirmed on XR, need for revision.

  2. 2.

    Medical complications; defined as:

    • Delirium: based on the Delirium Observation Screening Scale: score above 3, geriatrician diagnosis confirmed in medical record.

    • Anemia: requiring transfusion based on the transfusion guidelines (CBO, 2007)

    • New arrhythmia; in comparison with electrocardiogram at admission, with need for treatment.

    • Cerebrovascular accident; hemiparesis or hemiplegia, a CT cerebrum is performed.

    • Heart failure; clinical presentation, diagnosis confirmed on CXR, started diuretics.

    • Pressure sores; classified as Grade 1 till 4 Braden scale

    • Pulmonary embolism; confirmed with CT-angio.

    • Deep venous thrombosis; confirmed with echo duplex.

    • Myocardial infarction; elektrocardiogram abnormalities suspicious for ischemia and elevated cardiac troponin level.

    • Renal failure; significant decrease GFR in comparison with admission GFR.,

    • Pneumonia; clinical presentation, diagnosis confirmed on CXR, started antibiotics.

    • Urinary retention; retention of 300 mL or more confirmed with bladder scan.

    • Urinary tract infection; urine sediment with positive WBC and nitrite, started antibiotics.

    • Other complications; f.e. phlebitis, n.femoralis paralysis, ileus, electrolyte abnormalities.

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Folbert, E.C., Hegeman, J.H., Vermeer, M. et al. Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment. Osteoporos Int 28, 269–277 (2017). https://doi.org/10.1007/s00198-016-3711-7

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  • DOI: https://doi.org/10.1007/s00198-016-3711-7

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