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To the Editor: Hip fracture is a common problem that constitutes a major health concern in elderly people, because it is associated with significant comorbidity and mortality as a result of surgical complications and iatrogenic illnesses. Falls that result in a fracture are often a sign of frailty. A comprehensive geriatric assessment may help to identify hidden medical, geriatric, and psychosocial problems. There have been studies1,2 demonstrating that geriatric intervention with patients admitted for acute hip fracture would improve clinical outcomes. We would like to present the finding of a service program established in Prince of Wales Hospital in Hong Kong.

METHODS

  1. Top of page
  2. METHODS
  3. RESULTS
  4. DISCUSSIONS
  5. ACKNOWLEDGMENTS
  6. REFERENCES

The geriatric intervention program was introduced in 2005. The team consisted of an experienced geriatrician and a geriatric nurse specialist who provided thrice-weekly medical management in the orthopedic unit to all patients aged 65 and older who presented with acute hip fracture on admission. The orthopedic surgeons were mainly responsible for surgical procedures and related conditions. Although the interns and nurses in the orthopedic unit were not directly involved during consultations, they provided relevant information during the process. The team provided comprehensive geriatric assessment, identification of hidden medical and geriatric problems, optimization of clinical condition before surgery, and close monitoring postoperatively to prevent medical complications. All patients were reviewed regularly until discharge from the acute unit. Transitional care plans and appropriate medical follow-up were also formulated before patients were transferred to a rehabilitation unit. For patients who could be discharged directly back to their usual living place, community support or, if necessary, geriatric day care for further rehabilitation was arranged. Clinical outcomes for patients admitted from August 2005 to July 2006 (intervention group) were compared with those of patients admitted before implementation of the service (August 2004 to July 2005; control group).

Outcome measures include in-hospital and 1-year mortality, length of hospital stay, and time to surgery. An economic cost comparison of the two groups, measured in the acute and rehabilitation units, was also performed.

RESULTS

  1. Top of page
  2. METHODS
  3. RESULTS
  4. DISCUSSIONS
  5. ACKNOWLEDGMENTS
  6. REFERENCES

A total of 281 patients were recruited into the geriatric intervention group and 273 into the conventional care group. Baseline characteristics were comparable with regard to mean age (82.9 ± 7.7 in interventional group vs 82.4 ± 7.8 in control group, P=.46), sex (76.5% vs 73.6% female, P=.43), and nursing home dwelling (26.9% vs 23.3%, P=.38). Comorbidities were also similar in terms of presence of diabetes mellitus (21.6% vs 23.4%, P=.61) and hypertension (55.8% vs 55.8%, P>.99). A small percentage of patients underwent nonoperative management (5.9% vs 6.4%, P=.79). The percentage of patients admitted on weekends, which may affect length of stay, was also comparable between two groups (30.0% vs 25.1%, P=.34). Primary outcomes between the two cohorts are shown in Table 1. A binary logistic regression model was constructed to estimate the odds of all-cause mortality at 1 year. Geriatric intervention was associated with 46% lower probability of death (adjusted odds ratio (AOR)=0.54, 95% confidence interval (CI)=0.33–0.88, P=.01). Other factors included age (AOR=1.05, 95% CI=1.01–1.08, P=.006), male sex (AOR=2.84 95% CI=1.69–4.76, P<.001), and delay in surgery (AOR=1.98, 95% CI=1.17–3.35, P=.01). After estimation of the hospital cost in the acute and rehabilitation unit, the economic cost per patient was statistically significantly lower after the intervention in both groups. ($7,946 ± 3,803 vs $8,816 ± 4,431, 95% CI=$179–1,560, P=.01). It was possible to save $170,244 annually (2005/06 ($1=HK$7.8)).

Table 1. Comparison of Clinical Outcomes in Patients with Acute Hip Fracture Receiving Geriatric Intervention or Conventional Care
OutcomeGeriatric Intervention Group (n=281)Usual Care Group (n=273)P-Value
Length of stay, days, mean ± standard deviation (range)8.3 ± 4.4 (2–29)9.7 ± 5.7 (1–38).001
Discharge, n (%)278 (98.9)262 (96.0) 
 Home36 (12.8)22 (8.1) 
 Rehabilitation242 (86.1)240 (87.9) 
Mortality, n (%)
 In-hospital3 (1.1)11 (4.0).02
 90 day13 (4.6)25 (9.2).03
 1 year32 (11.4)55 (20.1).005
Time to surgery, days, median (interquartile range)1.0 (1.0–2.0)2.0 (1.0–3.0)<.001

DISCUSSIONS

  1. Top of page
  2. METHODS
  3. RESULTS
  4. DISCUSSIONS
  5. ACKNOWLEDGMENTS
  6. REFERENCES

This study demonstrated impressive outcomes from a geriatric intervention for elderly patients admitted for acute hip fractures. The intervention resulted in shorter length of hospital stay, shorter time to surgery, lower in-hospital and 1-year mortality, and significantly lower hospital cost. The intervention required minimum geriatric round sessions3 and was mainly geriatric-led, without much extra effort from the orthopedic surgeons. Not many studies have estimated hospital cost. This study, unlike a study published recently,4 was also able to demonstrate a significant cost reduction, because the analysis costs from acute and rehabilitation facilities, showing that rapid discharge did not shift the cost to the rehabilitation units. The study provides further evidence of the value of improved geriatric care in acute hip fractures. There are limitations in the data. It was a nonrandomized, single-center cohort, and retrospective data were used for comparison. Standardized protocols for the program were not established; instead the experience of the attending geriatrician was relied on, so the results may not be generalized. Further establishment of a protocol in a randomized trial would be able to test the model further.

ACKNOWLEDGMENTS

  1. Top of page
  2. METHODS
  3. RESULTS
  4. DISCUSSIONS
  5. ACKNOWLEDGMENTS
  6. REFERENCES

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter.

Author Contributions: Wency W.S. Ho: study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of the letter. David L.K. Dai, Kwok Sui Leung, and Jean Woo: study concept and design. Eliza Lau and Kin Wah Liu: acquisition of subjects. Kai Ming Chow: analysis and interpretation of data.

Sponsor's Role: This study was partially supported by the S.H. Ho Foundation.

REFERENCES

  1. Top of page
  2. METHODS
  3. RESULTS
  4. DISCUSSIONS
  5. ACKNOWLEDGMENTS
  6. REFERENCES
  • 1
    Friedman SM, Mendelson DA, Kates SL et al. Geriatric co-management of proximal femur fractures: Total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatr Soc 2008;56:13491356.
  • 2
    Fisher AA, Davis MW, Rubenach SE et al. Outcomes for older patients with hip fractures: The impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 2006;20:172178.
  • 3
    Vidan M, Serra JA, Moreno C et al. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: A randomized, controlled trial. J Am Geriatr Soc 2005;53:14761482.
  • 4
    Miura LN, DiPiero AR, Homer LD. Effects of a geriatrician-led hip fracture program: Improvements in clinical and economic outcomes. J Am Geriatr Soc 2009;57:159167.