An orthogeriatric service can reduce prolonged hospital length of stay in hospital for older adults admitted with hip fractures: a monocentric study

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Abstract

Background

The Blue Book (2005), recommended guidelines for patients care with fragility fractures. Together with introduction of a National Hip Fracture Database Audit and Best Practice Tariff model to financially incentivise hospitals by payment of a supplement for patients whose care satisfied six clinical standards), have improved hip fracture after-care. However, there is a lack of data-driven evidence to support its effectiveness. We aimed to verify the impact of an orthogeriatric service on hospital length of stay (LOS)—duration from admission to discharge.

Methods

We conducted a repeated cross-sectional study over a 10 year period of older individuals aged ≥ 60 years admitted with hip fractures to a hospital.

Results

Altogether 2798 patients, 741 men and 2057 women (respective mean ages; 80.5 ± 10.6 and 83.2 ± 8.9 years) were admitted from their own homes with a hip fracture and survived to discharge. Compared to 2009–2014, LOS during 2015–2019, when the orthogeriatric service was fully implemented, was shorter for all discharge destinations: 10.4 vs 17.5 days ( P < 0.001). Each discharge destination showed reductions: back to own homes, 9.7 vs 17.7 days ( P < 0.001); to rehabilitation units: 10.8 vs 13.1 days ( P < 0.001); to residential care: 15.4 vs 26.2 days ( P = 0.001); or nursing care, 24.4 vs 53.1 days ( P < 0.001). During 2009–2014, the risk of staying > 3 weeks in hospital was greater by six-fold and pressure ulcers by three-fold. The number of bed days for every thousand patients per year was also shortened during 2015–2019 by: 1665 days for discharge back to own homes; 469 days with transfer to rehabilitation units; 1258 days for discharge to residential care, and 5465 days to nursing care. Estimated annual savings (2017 costs) per thousand patients after complete establishment of the service was about £2.7 m.

Conclusions

Implementation of an orthogeriatric service generated significant reductions in hospital LOS for all patients, with associated cost-savings, especially for those discharged to nursing care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-023-02616-3.

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Most cited references 15

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Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis.

A. V. Grigoryan, Houman Javedan, James L Rudolph (2014)

Hip fractures are common, morbid, and costly health events that threaten independence and function of older patients. The purpose of this systematic review and meta-analysis was to determine if orthogeriatric collaboration models improve outcomes. Articles in English and Spanish languages were searched in the electronic databases including MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, and the Cochrane Registry from 1992 to 2012. Studies were included if they described an inpatient multidisciplinary approach to hip fracture management involving an orthopaedic surgeon and a geriatrician. Studies were grouped into 3 following categories: routine geriatric consultation, geriatric ward with orthopaedic consultation, and shared care. After independent review of 1480 citations by 2 authors, 18 studies (9094 patients) were identified as meeting the inclusion criteria. In-hospital mortality, length of stay, and long-term mortality outcomes were collected. A random effects model meta-analysis determined whether orthogeriatric collaboration was associated with improved outcomes. The overall meta-analysis found that orthogeriatric collaboration was associated with a significant reduction of in-hospital mortality [relative risk 0.60; 95% confidence interval (95% CI), 0.43-0.84) and long-term mortality (relative risk 0.83; 95% CI, 0.74-0.94). Length of stay (standardized mean difference -0.25; 95% CI, -0.44 to -0.05) was significantly reduced, particularly in the shared care model (standardized mean difference -0.61; 95% CI, -0.95 to -0.28), but heterogeneity limited this interpretation. Other variables such as time to surgery, delirium, and functional status were measured infrequently. This meta-analysis supports orthogeriatric collaboration to improve mortality after hip repair. Further study is needed to determine the best model of orthogeriatric collaboration and if these partnerships improve functional outcomes.

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Impact and experiences of delayed discharge: A mixed‐studies systematic review

Antonio Rojas-García, Simon Turner, Elena Pizzo … (2017)

Abstract Background The impact of delayed discharge on patients, health‐care staff and hospital costs has been incompletely characterized. Aim To systematically review experiences of delay from the perspectives of patients, health professionals and hospitals, and its impact on patients’ outcomes and costs. Methods Four of the main biomedical databases were searched for the period 2000‐2016 (February). Quantitative, qualitative and health economic studies conducted in OECD countries were included. Results Thirty‐seven papers reporting data on 35 studies were identified: 10 quantitative, 8 qualitative and 19 exploring costs. Seven of ten quantitative studies were at moderate/low methodological quality; 6 qualitative studies were deemed reliable; and the 19 studies on costs were of moderate quality. Delayed discharge was associated with mortality, infections, depression, reductions in patients’ mobility and their daily activities. The qualitative studies highlighted the pressure to reduce discharge delays on staff stress and interprofessional relationships, with implications for patient care and well‐being. Extra bed‐days could account for up to 30.7% of total costs and cause cancellations of elective operations, treatment delay and repercussions for subsequent services, especially for elderly patients. Conclusions The poor quality of the majority of the research means that implications for practice should be cautiously made. However, the results suggest that the adverse effects of delayed discharge are both direct (through increased opportunities for patients to acquire avoidable ill health) and indirect, secondary to the pressures placed on staff. These findings provide impetus to take a more holistic perspective to addressing delayed discharge.

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Ortho-geriatric service--a literature review comparing different models.

T Luger, T Roth, M. Blauth … (2010)

In the fast-growing geriatric population, we are confronted with both osteoporosis, which makes fixation of fractures more and more challenging, and several comorbidities, which are most likely to cause postoperative complications. Several models of shared care for these patients are described, and the goal of our systematic literature research was to point out the differences of the individual models. A systematic electronic database search was performed, identifying articles that evaluate in a multidisciplinary approach the elderly hip fracture patients, including at least a geriatrician and an orthopedic surgeon focused on in-hospital treatment. The different investigations were categorized into four groups defined by the type of intervention. The main outcome parameters were pooled across the studies and weighted by sample size. Out of 656 potentially relevant citations, 21 could be extracted and categorized into four groups. Regarding the main outcome parameters, the group with integrated care could show the lowest in-hospital mortality rate (1.14%), the lowest length of stay (7.39 days), and the lowest mean time to surgery (1.43 days). No clear statement could be found for the medical complication rates and the activities of daily living due to their inhomogeneity when comparing the models. The review of these investigations cannot tell us the best model, but there is a trend toward more recent models using an integrated approach. Integrated care summarizes all the positive features reported in the various investigations like integration of a Geriatrician in the trauma unit, having a multidisciplinary team, prioritizing the geriatric fracture patients, and developing guidelines for the patients' treatment. Each hospital implementing a special model for geriatric hip fracture patients should collect detailed data about the patients, process of care, and outcomes to be able to participate in audit processes and avoid peerlessness.

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Author and article information

Contributors

Thang Sieu Han:

ORCID: http://orcid.org/0000-0003-2570-0938

thang.han@rhul.ac.uk

Journal

Journal ID (nlm-ta): Aging Clin Exp Res

Journal ID (iso-abbrev): Aging Clin Exp Res

Title: Aging Clinical and Experimental Research

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1594-0667

ISSN (Electronic): 1720-8319

Publication date (Electronic): 14 November 2023

Publication date PMC-release: 14 November 2023

Publication date (Print): 2023

Volume: 35

Issue: 12

Pages: 3137-3146

Affiliations

[1 ]Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, ( https://ror.org/051p4rr20) Guildford Road, Chertsey, KT16 0PZ Surrey UK

[2 ]Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, ( https://ror.org/051p4rr20) Guildford Road, Chertsey, KT16 0PZ Surrey UK

[3 ]Department of Acute Medicine, Ashford and St Peter’s NHS Foundation Trust, ( https://ror.org/051p4rr20) Guildford Road, Chertsey, KT16 0PZ Surrey UK

[4 ]School of Physiology, Pharmacology and Neuroscience, University of Bristol, ( https://ror.org/0524sp257) Bristol, BS8 1TD UK

[5 ]Department of Endocrinology, Ashford and St Peter’s NHS Foundation Trust, ( https://ror.org/051p4rr20) Guildford Road, Chertsey, KT16 0PZ Surrey UK

[6 ]GRID grid.4970.a, ISNI 0000 0001 2188 881X, Institute of Cardiovascular Research, , Royal Holloway, University of London, ; Egham, TW20 0EX Surrey UK

Author information

Thang Sieu Han http://orcid.org/0000-0003-2570-0938

Article

Publisher ID: 2616

DOI: 10.1007/s40520-023-02616-3

PMC ID: 10721690

PubMed ID: 37962765

SO-VID: 57d2f40d-2038-4afe-a220-428de9a5a89e

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 6 July 2023

Date accepted : 1 November 2023

Custom metadata

Keywords: hip fractures,time to discharge,discharge destinations,health economics

Data availability:

Keywords: hip fractures, time to discharge, discharge destinations, health economics

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An orthogeriatric service can reduce prolonged hospital length of stay in hospital for older adults admitted with hip fractures: a monocentric study

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The Physician

Most cited references 15

Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis.

Impact and experiences of delayed discharge: A mixed‐studies systematic review

Ortho-geriatric service--a literature review comparing different models.

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