Authors

1. Jesse Raszewski DO, MS – Kettering Health – Grandview Medical Center
2. David Houserman DO – Kettering Health – Grandview Medical Center
3. Brandi Palmer MS – Kettering Health – Kettering Medical Center
4. Bhakti Chavan MBBS, MPH – Ohio University – Dublin Campus
5. Steven Santanello DO, FAOAO – Kettering Health – Kettering Medical Center
6. Benjamin Taylor MD, FAAOS – OhioHealth – Grant Medical Center

ABSTRACT:

BACKGROUND: Multidisciplinary care teams have been initiated to improve patient outcomes, while mitigating cost. The purpose of this study was to evaluate two models (Model A = medical care team vs. Model B = critical care/trauma care team) associated with geriatric hip fractures. The primary objective was to determine which model improved length of stay. Secondary objectives were to compare baseline characteristics, comorbidities, pain control and outcomes.

METHODS: This was a multisite retrospective cohort study that included 1,304 isolated hip fracture patients, with 652 designated to Model A and 652 designated to Model B. The difference in study variables by admitting service type were assessed using independent sample t-test, fishers exact test, and chi-square test to compare cohorts.

RESULTS: After standardizing the comorbidities using CCI, the estimated 10-year survival was significantly higher in the Model A cohort, 52.9% vs. 46.4% (p < 0.001). When assessing pain scores, Model B demonstrated significantly lower rates in all comparisons. Overall opioid use measured in morphine equivalents during hospital stay was 35.7 in Model B vs. 72.7 in Model A (p < 0.001). The primary endpoint of length of stay was found to be significantly shorter in Model B 4.3 days vs. 4.7 days (p < 0.001).

CONCLUSION: In conclusion, when geriatric hip fractures are managed by a multidisciplinary team there are improved patient outcomes; moreover, our data demonstrates that the critical care/trauma team optimized post-operative pain control and lowered length of hospital stay after surgery.

Level of Evidence: LEVEL III – Therapeutic Retrospective Cohort Study

Keywords: Hip Fractures, Multidisciplinary Care Teams, Geriatric Hip Fractures, Care Pathways

INTRODUCTION:

As the mean age of the geriatric population continues to rise, the mortality in this group is nearing four times the rate of the general population.¹ In fact, when discussing geriatric hip fractures, the one-year mortality is as high as 30%.² As of now, the incidence of geriatric hip fractures in the United States is approximately 300,000 per year, and this number is expected to reach 500,000 by the year 2040.³ Moreover, the estimated annual cost for treatment is more than USD 12 billion dollars.4 In an effort to battle this epidemic, multidisciplinary care teams have been initiated to decrease time to surgery and costs, while improving patient outcomes.^2,3

Hip fractures in the elderly leading to operative intervention leads to a reduced quality of life and a large economic burden in society.² Many facets are used to gauge the level of efficiency at a hospital; such as, time to surgery, length of stay, and mortality rates.³ The multidisciplinary care team has been shown to decrease length of stay^5–12, time to the operating room^7,11, complication rates^5,6,13–15, while improving and identifying appropriate osteoporosis treatment^8,13.4 As the ever-increasing number of geriatric hip fractures rises, the team-based care approach has gained significant traction within many hospital systems.³

The purpose of this study was to evaluate two models of care delivery in associated geriatric hip fractures within an urban medical system. Model A is comprised of the medical team, including but not limited to a hospitalist team and the orthopaedic surgeon. Model B is comprised of the critical care/trauma team, including but not limited to a general surgery trauma team and the orthopaedic surgeon. The primary objective of the study was to determine which multidisciplinary model improved length of hospital stay. The secondary objectives were to compare baseline characteristics, comorbidities, opioid use and pain scores, and outcomes. We hypothesized that patients managed and optimized by Model B would have better patient outcomes as measured by our primary outcome compared to those managed by Model A. 

METHODS:

All hip fractures at the five hospitals within this urban medical setting were retrospectively reviewed from 2012 through 2019. One of these hospitals was an ACS Level 2 trauma center, and the remaining 4 hospitals were not designated trauma centers. Data was extracted from the trauma registry utilizing the international classification of diseases (ICD)-10-PCS, ICD-9-CM, current procedural terminology (CPT) and abbreviated injury scale (AIS) codes. The inclusion criteria: age 55 and older, isolated hip fracture, and surgical intervention. ICD codes for femoral neck, intertrochanteric, and subtrochanteric fractures were included. The exclusion criteria: non-operative management, additional fracture upon admission, head injury, periprosthetic hip fracture, and other surgeries during admission. This study was formally approved by the human subjects review board for each participating institution.

There were 1,304 patients who met the inclusion criteria, and this group was included in the study. Patients that presented to the trauma center were admitted primarily by the trauma team. This team consisted of the general surgery attending physician, trauma physician assistants, residents from both general surgery and orthopaedic surgery, social service team members, nutrition members, and physical therapy and occupational therapy members. The orthopaedic surgeon was consulted for fixation, while the patient was primarily managed by the trauma team. This model was deemed Model B, and there were 652 patients that met the inclusion criteria after data extraction. Patients that presented to the 4 satellite hospitals were admitted primarily by the medical team. This team consisted of a hospitalist group, along with social services and physical and occupational therapy teams. The orthopaedic surgeon was consulted for fixation, while the patient was primarily managed by the medical team. This model was deemed Model A, and there were 652 patients that met the inclusion criteria after data extraction. Management of the hip fractures was hospital dependent.

Patient characteristics and outcomes were obtained through medical record review and data extraction using ICD, CPT and AIS codes. Baseline characteristics are listed in Table 1.

The primary outcome that was assessed was length of stay. Once the patient is cleared from all respective care teams, the primary care team will place discharge orders, and the patient safely transitions from the hospital. The secondary outcomes that were assessed were: pre-operative time from emergency department arrival to time to surgery, 30-day mortality rate, 30-day readmission, disposition to a higher level of care, mean opioid use during hospitalization measured in morphine equivalents, pain score on admission, first pain score obtained on post-operative day (POD)^1-3, postoperative pneumonia and DVT/PE rates, anticoagulation status, and comorbidities. In order to standardize the comorbidities, the Charlson Comorbidity Index (CCI) was used to predict the estimated 10-year survival. Morphine equivalents were calculated to standardize opioid use during hospital stay.

After data extraction, descriptive statistics was performed to summarize the data. The corresponding mean, standard deviation, frequency, and percent distribution were reported. The difference in study variables by admitting service type was assessed using independent sample t-test, Fishers exact test, and the chi-square test to compare cohorts. If there was missing data during data extraction, the data point was excluded from comparison. The significance was evaluated at α<0.05. The analysis of the data was computed using SAS^® v9.4. 

RESULTS:

There were 2,168 patients that sustained a hip fracture and underwent surgical fixation in this urban setting from 2012 to 2019 based on CPT extraction of data. There were 1,152 records in the trauma cohort, and 500 were excluded. There were 1,016 records in the medical cohort, and 364 were excluded. After medical record review, there were 1,304 remaining isolated hip fractures, with 652 patients managed in Model A and 652 managed in the Model B cohort. Patients were excluded based on exclusion criteria and or insufficient data that could be extracted to compare results.

In Model A, there were 53.7% male and 48.4% female patient distribution, and in Model B, there were 46.4% male and 51.6% female distribution. The patient population in this urban setting were predominantly white in both cohorts, with 92.3% in Model A and 94.8% in Model B, which was statistically significant (p < 0.0001). The average age in Model A was 77.2 years and 80.8 years in Model B, which was also statistically significant (p < 0.0001). A complete list of baseline characteristics is listed in Table 1.

When assessing the comorbidities between the two cohorts, the rates of ICU admission, intubation, post-operative pneumonia, and DVT/PE were very low. Comparing Model B to Model A, the ICU admission was 2.1% vs. 1.8%, the intubation rate was 0.5% vs. 0.6%, the pneumonia rate was 0% vs. 0.3%, and the rate of DVT/PE was 0.5% vs. 0.6%, and these results were not statistically significant. To standardize the comparison of comorbidities, the CCI was calculated to determine the estimated 10-year survival rate. There was a statistically significant difference in the CCI, for Model B it was 4.2 with an estimated 10-year survival of 46.4% versus 3.9 with an estimated 10-year survival of 52.9% in Model A (p < 0.001). This data is summarized in Table 2.

When assessing the mean opioid use and pain scores, the rates were lower in Model B in all analyzed comparisons. The overall mean opioid use during hospitalization was dramatically lower in the Model B managed patient population. Using the morphine equivalents, the measured value was 35.7 compared with the 72.7 seen in the Model A managed patient population, which was statistically significant (p < 0.001). The pain score upon admission comparison was 6.6 for Model B versus 6.8 in Model A. The pain score on post-operative day 1 was significantly lower in Model B at 2.5 versus 3.0 (p < 0.01). The pain score comparisons on POD2 and 3 between Model B and Model A were 2.6 versus 2.8, and 2.2 versus 2.3, respectively. Neither of these comparisons reached significance. This data is summarized in Table 3.

When assessing the outcomes between the Model B and Model A, the primary endpoint was found to be statistically significant. The length of stay was significantly shorter at 4.3 days versus 4.7 in Model B (p < 0.001). Comparing mortality rates, Model B had a 3.8% mortality rate versus the Model A cohort at 2.8%, which was not statistically significant (p = 0.278). The time to operating room from the emergency department was lower in Model B at 26.1 hours versus the 26.8 hours in Model A. The readmission rate was ultimately higher in the Model B cohort at 14% versus 10.6% seen in Model A. And lastly, patients that were discharged to a higher level of care was also higher in Model B at 89.5% versus the 86.6% in the Model A cohort. This data is summarized in Table 4. 

DISCUSSION:

This study demonstrates the critical care/trauma multidisciplinary team was able to decrease the length of stay for the patient, which was our primary endpoint being assessed. This could be due to the fact that the trauma hospital is a larger facility, and there are more personnel dedicated to assist in patient care. One of the most important findings was post-operative pain control. The mean opioid use during the hospital stays and post-operative pain scores were lower in all analyzed comparisons between each cohort. This could be due to the fact that the trauma team instituted a pain-control post-operative regimen, which has been shown to decrease opioid use. The readmission rates were ultimately higher in the trauma team cohort, and this carries an increased financial burden to the hospital system.  

The interpretation of these findings is highly relevant to hospitals with established care teams associated with geriatric hip fractures. Our goal was to compare commonly used endpoints that are screened by hospital administration. We were able to standardize comorbidities in a high-powered analysis with a well-balanced patient population, which increases our external validity. The CCI has been shown to accurately correlate with prediction of mortality after hip fractures.^16,17 Our Model A and Model B multidisciplinary teams are commonly used within many hospital systems, so the endpoints that were analyzed are applicable to outside institutions as well.

This study adds to the growing body of literature that compares different multidisciplinary teams and outcomes of geriatric hip fracture patients. Patel et al conducted a systematic review of 17 articles that assessed outcomes in multidisciplinary approach to hip fractures, which demonstrated decreased time to surgery, shorter length of stay, improved post-operative clinical outcomes, decreased mortality and cost.³ Reguant et al evaluated the efficacy of a multidisciplinary approach, and demonstrated a decrease in post-operative complications, hospital stay and mortality.¹⁸ Not only do care teams play a role, but pathways to create a more efficient system also improve outcomes. Flikweert et al assessed a care pathway at multiple hospitals, and demonstrated decreased length of stay and lowered costs for these patients.² Della Rocca et al was able to demonstrate a cost savings of USD 700,000 dollars at their institution with the use of a standard protocol.⁶ Bano et al instituted a care pathway at a level 1 trauma center, and was able to demonstrate a reduction in mortality, improve functional outcomes, and increase the probability of transitioning the patient safely home by 6 months.¹⁹ There is clear evidence that supports the use of multidisciplinary teams and pathways in the care of geriatric hip fractures, but no evidence on which physicians should be included in a multidisciplinary team.

Although it was not demonstrated in all parameters in our study, there are proven benefits of geriatric hip fracture patients being managed by a medical team consisting of hospitalist and orthopaedic surgeons. This theme has been seen in previous literature. Batsis et al examined the effects of a hospitalist service managing geriatric hip fractures to see the effects on mortality, and demonstrated a reduced length of stay and time to surgery.¹¹ Phy et al was also able to demonstrate decreased time to surgery and length of stay with a hospitalist model care team.20 However, most studies that have shown improved outcomes in this model of care do include a dedicated geriatrician.^{3,7,8,21–23} The inclusion of a geriatrician on the care team may prove to be a benefit in either model of care presented in this paper.

This study has its limitations. The study is retrospective in nature and carries the inherent biases associated with this type of investigation. To minimize selection bias, all patients with an ICD-10 code for a hip fracture were included in the study regardless of outcome. To reduce information bias, all variables that were assessed were carefully selected and reviewed prior to data extraction. In the event that a patient did not have all data points, they were excluded from the study. Another limitation is the fact that both cohorts demonstrated a relatively narrow demographic section of patients, which makes conclusions difficult to apply to minority subsets. Lastly, the metric of emergency department time to the operating room is dependent on multiple factors, including but not limited to when the radiograph was ordered, when the orthopaedic surgery team was consulted, operating room availability, etc., but was included because it can be applied externally.

CONCLUSION

In conclusion, when geriatric hip fractures are managed by a multidisciplinary team there are improved patient outcomes; moreover, our data demonstrates that the critical care/trauma team optimized post-operative pain control and lowered length of hospital stay after surgery. This investigation presents the question of which medical personnel should ultimately be included on the geriatric hip fracture multidisciplinary team. Future studies should be devoted to not only personnel on the perioperative aspect, but on the post-operative course, specifically osteoporosis prevention and treatment. 

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