2 final PPT ANP Folbert 1 year mortality...-No insightin performance during geriatricrehabin nursing...

ChirurgieZiekenhuisgroep

TwenteLocatie Almelo

Disclosure presenter



The effectiveness of integratedorthogeriatric treatment on 1-year outcome in frail elderly

with hip fracture

E. Folbert, MANP, PhD Hospital Group Twente, Almelo-Hengelo

Rotterdam, 2018 august 27



Geriatric TraumatologyPhD thesis

Finished 27 march 2017



Elderly patients and fracture

Its a challenge to treat them well!



The GFC treatment model

From an international perspective

Ø Awareness that these patients need special attention

Ø Different models of care

Ø No clear evidence which model is most effective*

* Kammerlander et al, Osteoporos Int 2010



Aim study

Evaluate the effectiviness of an orthogeriatric treatment model in elderly patients with a hip fracture on 1-year mortality and to identify associated

risk factors*

* Folbert et al, Osteoporos Int 2017



Design

Prospective cohort with historical controls



PatientsInclusionØ Acute admission hip fractureØ Age 70 yrs. or olderØ Treated by traumasurgeon

ExclusionØ Pathological or periprosthetic fracture Ø Indication total hip artroplasty

PeriodsØ 2008 - 2013: n=850 GFCØ 2002 - 2008: n=535 usual care



Data collectionVariables & outcome measures

GFC UC Sociodemografic variables Sociodemografic variables

Frailty score

Dementia diagnosed

ASA ASA

History of osteoporosis, previous osteopotic fracture

Type of fracture Type of fracture

Barthelindex and Parker Mobility score

Prefracture living

Charlson comorbidity Score

Length of stay on the ED

Time to surgery Time to surgery

Type of operation; conservative or operative treatment

Type of operation; conservative or operative treatment

Length of hospital stay Length of hospital stay

Incidence of postoperative surgical and medical complications Complicated course or not

Mortality rate (in hospital, 30 days, 1 year) Mortality rate (in hospital, 30 days, 1 year)



BaselineGFC n=850 UC n=535 P value

♀: ♂, % 74:26 71:29 0.361Age 83 82 0.015ASA* ≥ 3, % 78 53 <0.001Independent: Institutionalized; %

84:16 90:10 0.019

Ref. * https://www.asahq.org/



GFC patients n=850VMS Frailty score; % delirium falls < 6mnd. malnutrition (SNAQ) physical limitations (KATZ)

mean (IQR)

289819702.0 (2.0-3.0)

Dementia, % 21CCI-score* ≥3 29Barthel**-before: Barthel-after 16:10 (-6)PMS***-before: PMS-after 6:2 (-4)

Ref.* Charlson (1987), ** Mahoney (1965), *** Parker (1993)

GFC cohort



GFC n=850 UC n=535 P value

ED, min, mean (SD) 102 (50.0) No priority

Time till surgery from admission, %<24 hrs. >24 hrs.

7624

7822

0.259

Conservative treatment, % 2 0 <0.001Length of hospital stay, daysmediaan (IQR)

9 (6-13) 10 (7-17) <0.001

Logistics treatment process



GFC n=850 UC n=535 P value

Patients with a complicatedcourse; %

53.4 66.9 <0.001

In hospital mortality; % 4.4 6.2 0.133

Mortality ≤ 30 days; % 7.5 10.3 0.075

Mortality ≤ 365 days; % 23.2 35.1 <0.001

Complications and mortality



Kaplan-meier survival curve

GFC group

Usual care group



OR 95% BI P valueMale 1.68 1.13-2.45 0.011

Age in years 1.06 1.02-1.09 0.001

VMS Frailty score physical limitations 2.35 1.32-4.20 0.004

VMS Frailty malnutrition 2.01 1.34-3.02 <0.001

ASA 3 2.43 1.25-4.74 0.009

ASA 4-5 7.05 3.20-15.52 <0.001

CCI 5 of > 2.71 1.23-5.93 0.013

Barthel Index preop 0.96 0.92-1.01 0.091

Independent risk factors 1 year mortality



Strenght and limitations

+ First study in the Netherlands

+ Fittest patients excluded, overestimating seems unlikely

+ Good description of case mix

+ Use of specifically defined measuring instruments and outcome measures

- Use of historical control group instead of randomized study design

- Q of life not analyzed

- No insight in performance during geriatric rehab in nursing homes



Conclusion

Ø After integrated care, a significant decrease in the 1-year mortality rate in frail elderly patients compared to historical controls treated with standard care.

Ø Gender, increasing age, malnutrition, physical limitations and medical conditions were independent risk factors for 1–year mortality .

Ø Awareness of the RF can be usefull in an attempt to optimize care and outcomes.

Ø Due to the multidimensional needs orthogeriatric treatment should be the standard.



Our future goals

Ø The development and implementation of a clinical path way and a Q auditing system withour stakeholders in the geriatric rehabilitation nursing homes

Ø Monitoring recovery during rehab with health wearables

Ø To improve Q of care it would be a challenge to collaborate with international GFC’s forresearch purposes.



Thank you for your attention

Questions?

[email protected]

2 final PPT ANP Folbert 1 year mortality...-No insightin performance during geriatricrehabin nursing...

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