Elsevier

The Lancet

Volume 385, Issue 9978, 25 April–1 May 2015, Pages 1623-1633
The Lancet

Articles
Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial

https://doi.org/10.1016/S0140-6736(14)62409-0Get rights and content

Summary

Background

Most patients with hip fractures are characterised by older age (>70 years), frailty, and functional deterioration, and their long-term outcomes are poor with increased costs. We compared the effectiveness and cost-effectiveness of giving these patients comprehensive geriatric care in a dedicated geriatric ward versus the usual orthopaedic care.

Methods

We did a prospective, single-centre, randomised, parallel-group, controlled trial. Between April 18, 2008, and Dec 30, 2010, we randomly assigned home-dwelling patients with hip-fractures aged 70 years or older who were able to walk 10 m before their fracture, to either comprehensive geriatric care or orthopaedic care in the emergency department, to achieve the required sample of 400 patients. Randomisation was achieved via a web-based, computer-generated, block method with unknown block sizes. The primary outcome, analysed by intention to treat, was mobility measured with the Short Physical Performance Battery (SPPB) 4 months after surgery for the fracture. The type of treatment was not concealed from the patients or staff delivering the care, and assessors were only partly masked to the treatment during follow-up. This trial is registered with ClinicalTrials.gov, number NCT00667914.

Findings

We assessed 1077 patients for eligibility, and excluded 680, mainly for not meeting the inclusion criteria such as living in a nursing home or being aged less than 70 years. Of the remaining patients, we randomly assigned 198 to comprehensive geriatric care and 199 to orthopaedic care. At 4 months, 174 patients remained in the comprehensive geriatric care group and 170 in the orthopaedic care group; the main reason for dropout was death. Mean SPPB scores at 4 months were 5·12 (SE 0·20) for comprehensive geriatric care and 4·38 (SE 0·20) for orthopaedic care (between-group difference 0·74, 95% CI 0·18–1·30, p=0·010).

Interpretation

Immediate admission of patients aged 70 years or more with a hip fracture to comprehensive geriatric care in a dedicated ward improved mobility at 4 months, compared with the usual orthopaedic care. The results suggest that the treatment of older patients with hip fractures should be organised as orthogeriatric care.

Funding

Norwegian Research Council, Central Norway Regional Health Authority, St Olav Hospital Trust and Fund for Research and Innovation, Liaison Committee between Central Norway Regional Health Authority and the Norwegian University of Science and Technology, the Department of Neuroscience at the Norwegian University of Science and Technology, Foundation for Scientific and Industrial Research at the Norwegian Institute of Technology (SINTEF), and the Municipality of Trondheim.

Introduction

Hip fractures are frequent in older people (>70 years) and represent a worldwide challenge.1 Because of population ageing, fragility fractures are an increasing burden on health-care systems and societies.2 Most older people who fracture a hip are frail, have comorbidities, and show a functional deterioration that is typical of geriatric patients.3 After a fracture, both short-term and long-term outlooks for patients are generally poor, with increased 1 year mortality (18–33%),4 and negative effects on activities of daily living and mobility. A review of long-term disability in patients with hip-fractures that summarised a weighted average of relevant studies estimates that 42% of survivors do not return to their prefracture mobility, 35% are incapable of walking independently, 20% are unable to shop independently,5 and about 20% enter a long-term care facility during the first year after a fracture.6 Hip fractures have substantial socioeconomic effects and large, attributable costs, with acute and post-acute institutional care as the primary driver.6

Although surgical care is crucial for improving outcomes after a hip fracture, the proposal that a hip fracture in an older person represents a geriatric rather than an orthopaedic disorder calls for new clinical approaches.7 Comprehensive geriatric care is an alternative form of care; when practised in dedicated geriatric wards, it improves outcomes for frail older patients who are acutely admitted to hospital, and might be equally relevant for geriatric patients with hip fractures.8

Guidelines and recommendations have addressed the importance of combined geriatric and orthopaedic (orthogeriatric) care as an alternative to traditional treatment,9 although the optimum treatment model is unknown. As summarised in reviews,10, 11 several in-hospital models of orthogeriatric care have been developed, including geriatric consultation teams, comanaged care between geriatricians and orthopaedic surgeons, and a range of interdisciplinary orthogeriatric care pathways. These models have had beneficial effects on delirium, complication rates, and mortality.

Most models of orthogeriatric care reported in the scientific literature are initiated after surgery and undertaken in orthopaedic contexts, and are linked to specific in-hospital and post-discharge rehabilitation programmes10 A few, non-randomised studies have investigated acute orthogeriatric care pathways for which all assessments and treatments except surgery were done within a geriatric ward by an interdisciplinary team. One of these studies7 showed important benefits for complication rates, walking ability, and mortality. Investigators from the Oslo Orthogeriatric Trial12 reported a clinical pathway for patients with a hip fracture, for which the entire assessment and treatment programme, except surgery, took place in an acute geriatric setting; however, no effect was shown on cognition as the primary outcome.

The aim of our trial was to assess the effectiveness of comprehensive geriatric care versus usual orthopaedic care provided throughout an entire hospital stay, with only the fracture assessment and surgical treatment done by orthopaedic surgeons. We investigated both short-term and long-term outcomes in randomly assigned patients, with assessments done at 1, 4, and 12 months after surgery. Because immobility is an immediate result of a fracture and also later contributes to long-term functional deterioration,5 we chose mobility at 4 months as the primary outcome.

Section snippets

Study design and participants

We did a prospective, single-centre, randomised, controlled trial at St Olav University Hospital in Trondheim, Norway. St Olav is a central hospital for 300 000 inhabitants of Sør-Trøndelag County, with 25 municipalities and a total area of 18 848 km2, and a regional centre for 696 000 inhabitants in mid-Norway. The health-care system in Norway is organised and financed by the public sector, and based on equal access to services irrespective of social or economic status. In Norway, most

Results

Patients were recruited from April 18, 2008, to December 30, 2010 (the prespecified finishing timepoint). 1077 patients were screened for eligibility, of whom 397 were randomly assigned to receive either comprehensive geriatric care (n=198) or orthopaedic care (n=199) (figure 1). Most patients were randomly assigned in the emergency room before they were transferred to their assigned ward. 22 were randomly assigned in the orthopaedic ward within 24 h of admission; ten of these were randomly

Discussion

We investigated if any benefit was gained when patients with a hip fracture receive all assessments and treatments except surgery in an acute geriatric ward from an interdisciplinary team, rather than the usual orthopaedic care ward. For the primary outcome of mobility as measured by SPPB 4 months after surgery, the results were better with comprehensive geriatric care than with traditional orthopaedic care (see appendix for details). Most secondary outcomes were also better with comprehensive

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