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AltersTraumaZentrum DGU®: Evaluation klinischer und ökonomischer Parameter

Eine Pilotstudie an einer deutschen Universitätsklinik

Geriatric Trauma Center DGU®: Evaluation of clinical and economic parameters

A pilot study in a german university hospital

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Zusammenfassung

Hintergrund

Die Datenlage zu Outcome und Kosten des orthopädisch-geriatrischen Komanagements oder solitärer Behandlungspfade zeigt sich uneinheitlich, da weltweit unterschiedliche Gesundheitssysteme und Managementmodelle existieren und das Studiendesign vielfältig ist.

Fragestellung

In der Übergangsphase zum AltersTraumaZentrum DGU® (ATZ, Deutsche Gesellschaft für Unfallchirurgie) sollte untersucht werden, wie sich die Umsetzung der Struktur- und Prozessanforderungen des Zertifizierungsverfahrens mit und ohne geriatrische Mitbehandlung auf die Versorgungsqualität, die Komplikationsrate, aber auch auf die Kostenstruktur im stationären Sektor auswirkt.

Methodik

Es wurde bei Patienten mit operationspflichtiger niedrigenergetischer Monoverletzung eine prospektive Kohortenstudie initiiert, welche 3 verschiedene Behandlungsansätze (jeweils 6 Monate) verglich: A: unfallchirurgische Standardversorgung; B: solitäre Umsetzung der Struktur- und Prozessanforderungen des Kriterienkatalogs ohne Geriater; C: interdisziplinäre Kooperation inklusive der geriatrischen Kompetenz (Visitenmodell).

Ergebnisse

Unfallchirurgisch-geriatrisches Komanagement (C) verbesserte die postoperative Mobilisation am 1. Tag (p = 0,004), steigerte die Osteoporoseprävention (p = 0,001) und veränderte das Entlassungsmanagement hin zu einer akut-geriatrischen Anschlussversorgung (p = 0,024). Die Krankenhausletalität (C) sank im Vergleich zur Standardversorgung (A) von 9 % auf 2 % (p = 0,147) und die kardiopulmonalen Komplikationen gingen von 39 % auf 28 % (p = 0,235) zurück. Dies zeigte sich insbesondere am Myokardinfarkt (6 % zu 0 %), an akuten Rhythmusstörungen (8 % zu 0 %), an pulmonalen Dekompensationen (28 % zu 16 %), der Exsikkose (6 % zu 0 %), an Elektrolytstörungen (34 % zu 19 %) und am Lungenödem (11 % zu 2 %). Der notwendige Intensivaufenthalt verringerte sich von 29 (A) auf 18 (C) Stunden (p = 0,205), was die anteiligen Kosten für die Intensivstation halbierte. Das alleinige Etablieren eines standardisierten Qualitätsmanagements (B) senkte die Myokardinfarktrate bei proximaler Femurfraktur (A: 11 %, B: 0 %, C: 0 %; p = 0,035).

Diskussion

Schon Basisvarianten des unfallchirurgisch-geriatrischen Komanagements oder das Etablieren einer strukturierten Prozessqualität zeigen klare Tendenzen einer verbesserten Patientenversorgung, was sich insbesondere am Rückgang bei kardiopulmonalen Komplikationen und der Krankenhausletalität zeigt. Patienten mit proximaler Femurfraktur und periprothetischer Fraktur stellen klinische sowie auch ökonomische Risikofälle dar.

Abstract

Background

Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable.

Objective

The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU).

Methods

A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model).

Results

In the 151 examined patients (m/w 47/104; 83.5 (70–100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035).

Conclusion

There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.

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Author information

Authors and Affiliations

  1. Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland

    M. Knobe MME, MHBA, B. Böttcher & M. Wollgarten

  2. Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Aachen, Deutschland

    M. Coburn

  3. Klinik für Unfall- und Handchirurgie, Zentrum für Alterstraumatologie im St. Clemens-Hospital Oberhausen, Oberhausen, Deutschland

    T. Friess

  4. Lehrstuhl für Altersmedizin, RWTH Aachen mit Klinik für Innere Medizin und Geriatrie am Franziskushospital Aachen, Aachen, Deutschland

    L. C. Bollheimer

  5. Geriatrische Klinik und Tagesklinik, Lehrstuhl für Geriatrie, Universität Witten/Herdecke, Witten, Deutschland

    H. J. Heppner

  6. Klinik für Neurologie, Sektion Interdisziplinäre Geriatrie, Uniklinik RWTH Aachen, Aachen, Deutschland

    C. J. Werner & J.-P. Bach

  7. Kaufmännisches Controlling, Uniklinik RWTH Aachen, Aachen, Deutschland

    S. Poßelt

  8. Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Marburg, Deutschland

    C. Bliemel & B. Bücking

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  1. M. Knobe MME, MHBA
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Correspondence to M. Knobe MME, MHBA.

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Interessenkonflikt

M. Knobe, B. Böttcher, M. Coburn, T. Friess, L. C. Bollheimer, H. J. Heppner, C. J. Werner, J.-P. Bach, M. Wollgarten, S. Poßelt, C. Bliemel und B. Bücking geben an, dass kein Interessenkonflikt besteht.

Alle im vorliegenden Manuskript beschriebenen Untersuchungen am Menschen wurden mit Zustimmung der zuständigen Ethikkommission, im Einklang mit nationalem Recht sowie gemäß der Deklaration von Helsinki von 1975 (in der aktuellen, überarbeiteten Fassung) durchgeführt. Von allen beteiligten Patienten liegt eine Einverständniserklärung vor.

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Knobe, M., Böttcher, B., Coburn, M. et al. AltersTraumaZentrum DGU®: Evaluation klinischer und ökonomischer Parameter. Unfallchirurg 122, 134–146 (2019). https://doi.org/10.1007/s00113-018-0502-y

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