Elsevier

Injury

Volume 44, Issue 11, November 2013, Pages 1403-1412
Injury

Review
Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures

https://doi.org/10.1016/j.injury.2013.06.018Get rights and content

Summary

Background and purpose

Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Different models of orthogeriatric co-management are currently in use worldwide. These models differ for instance by the health-care professional who has the responsibility for care in the acute and early rehabilitation phases. There is no international consensus regarding the best model of care and which outcome parameters should be used to evaluate these models. The goal of this project was to identify which outcome parameters and assessment tools should be used to measure and compare outcome changes that can be made by the implementation of orthogeriatric co-management models and to develop recommendations about how and when these outcome parameters should be measured. It was not the purpose of this study to describe items that might have an impact on the outcome but cannot be influenced such as age, co-morbidities and cognitive impairment at admission.

Methods

Based on a review of the literature on existing orthogeriatric co-management evaluation studies, 14 outcome parameters were evaluated and discussed in a 2-day meeting with panellists. These panellists were selected based on research and/or clinical expertise in hip fracture management and a common interest in measuring outcome in hip fracture care.

Results

We defined 12 objective and subjective outcome parameters and how they should be measured: mortality, length of stay, time to surgery, complications, re-admission rate, mobility, quality of life, pain, activities of daily living, medication use, place of residence and costs. We could not recommend an appropriate tool to measure patients’ satisfaction and falls.

We defined the time points at which these outcome parameters should be collected to be at admission and discharge, 30 days, 90 days and 1 year after admission.

Conclusion

Twelve objective and patient-reported outcome parameters were selected to form a standard set for the measurement of influenceable outcome of patients treated in different models of orthogeriatric co-managed care.

Introduction

Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Older adults with osteoporotic fractures frequently have one or more co-morbidities, making the treatment of these patients complex. These fractures can lead to an increased risk of mortality, disability, complications and high health-care costs [1], [2], [3]. Due to the unsatisfactory treatment outcomes often seen in patients with osteoporotic fractures, multidisciplinary treatment approaches have been implemented to improve outcome [4].

A common multidisciplinary approach is a highly focussed team: orthopaedic surgeons, anaesthesiologists and geriatricians work together to reduce the number and severity of complications often seen in the usual treatment of patients with osteoporotic fractures. Other ‘team members’ such as physiotherapists, study nurses and nutritional care and physician assistants can contribute to the multidisciplinary treatment approach. Different models of orthogeriatric co-management are well described by Giusti et al. [5] and can be distinguished by the health-care professional who has the responsibility of care in the acute and early rehabilitation phases. These orthogeriatric models have been implemented in many institutions, have different key elements and use different outcome parameters [4], [6].

Some of the models have proven to be effective [7], but there is no consensus about the best possible treatment model. In order to compare the different models, it is important to agree on which outcome parameters should be measured and how they should be measured [6], [8].

Although no consensus about the goals of an orthogeriatric co-management exists yet in the literature, some primary targets have already been suggested [9], [10], [11]. The main goals of an orthogeriatric co-management are:

  • return to pre-fracture status as soon as possible,

  • improvement of patient and family satisfaction,

  • reduce complication, re-admission and mortality rates,

  • provide best value of care to the health system and

  • initiate secondary fracture prevention.

Our goal was to propose a definition of a standard set of outcome parameters which could be used in evaluation and comparison research studies of different models of orthogeriatric co-management used in hip fracture treatment. We also wanted to define time points for the evaluation of these parameters. These outcome parameters should be relatively easy to assess and should be able to evaluate the degree of achievement of the main goals of an orthogeriatric co-management.

Section snippets

List of outcome parameters

In order to establish a list of outcome parameters that should be considered in the evaluation of orthogeriatric co-management, the existing literature was reviewed. The systematic review of Kammerlander et al. [4] was used to identify studies comparing standard care and orthogeriatric co-management. The most-used outcome parameters based on frequency from the different studies presented in the review paper were selected. The following outcomes were further analysed:

  • mortality,

  • length of stay,

Mortality

Mortality is a common outcome parameter reported in the medical literature. It is known that mortality rates after osteoporotic fractures of the shoulder, hip and spine are increased in comparison to the age-matched population, but the reasons for this remains unclear [15], [16], [17], [18]. Mortality is clearly an important outcome parameter to be measured.

In-hospital mortality is frequently used as an outcome parameter, but it is difficult to use in an international comparison study because

Discussion

To evaluate the best possible treatment model in hip fracture management and allow for international comparison, a standard set of outcome parameters should be determined and defined. The authors were able to come to an agreement regarding which outcome parameters should be used in the evaluation and comparison of different orthogeriatric co-management models for the treatment of hip fractures. Further, the time points to record these outcome parameters are suggested as well as which score or

Conclusion

We have come to an agreement about the outcome parameters that we think should be used to evaluate and compare different orthogeriatric clinical care models in the treatment of hip fractures. The parameters to be collected include length of hospital stay, mortality, time to surgery, complications both medical and surgical, 30-day re-admission rate, mobility, quality of life, pain levels, adverse drug reactions, activities of daily living, place of residence and costs of care. The time points at

Role of the funding source

This project was sponsored by AO Trauma.

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgements

We would like to M. Neuman for his ideas and comments to help improve this manuscript. We would also like to thank P. Büscher and AOTrauma for their support of this effort to improve hip fracture care.

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