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