Complex problems in the geriatric patient: comanaged approach

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Complex problems in the geriatric patient
co-managed approach
Osteoporosis The magnitude of the problem for
the orthopaedic surgeon EFORT 2009 - Vienna

• David Marsh
• Professor of Clinical Orthopaedics, UCL
• Royal National Orthopaedic Hospital, Stanmore
• International Ambassador for the Bone and Joint
  Decade

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Fracture epidemiologyEdinburgh Trauma Unit

• Analysis of year 2000
• Adults (12 years and over)
• 534,715 people
• 5953 fractures
• Incidence of fracture types by age
• Rapid increase in old age taken as indicator of
  fragility fracture

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Fragility fractures

• 52 of all fractures
• 30 of fractures in males
• 66 of fractures in females
• 35 of outpatient fractures
• 70 of inpatient fractures

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Fragility fractures

• Proximal humerus
• Distal humerus
• Olecranon
• Proximal radius and ulna
• Distal radius
• Proximal femur

• Subtrochanteric femur
• Femoral diaphysis
• Distal femur
• Bimalleolar ankle
• Trimalleolar ankle
• Thoracolumbar vertebrae
• Pelvis

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Why focus on hip fracture?

• Hip Fracture Incidence
• Forecast in European Community

20 excess mortality at 1 yr 25 never get back
to own home 80 elderly women would rather die
than have a hip fracture
thousands
Tests the whole system Orthopaedics Geriatrics
Social services
European Commission, 1998
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Hip fracture

• gt1 per thousand population and rising in UK
• now - 70,000 pa
• 2015 - 91,500
• 2020 - 101,000
• More deaths pa than breast or prostate cancer
• More bed days pa than MI
• 12k acute episode, 13k next two years
• Fragility fractures cost 2bn pa, mostly hip

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Projected osteoporotic hip fractures worldwide
742
Total number ofhip fractures1990 1.66
million 2050 6.26 million
378
Adapted from Cooper C et al, Osteoporosis Int,
19922285-9
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Orthogeriatrics in hip fracture

• Dramatic increases in
• Numbers of geriatric patients with hip fractures
• Age of these patients (older old people)
• Medical complexity and mortality rates
• Demand for more cost-effectiveness
• Geriatric co-management reduces mortality, delay
  to surgery, length of stay and improves
  functional outcome
• Political alliance between orthopaedics and
  geriatrics is powerful

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Scottish Hip Fracture Audit
Injury (in press) Epub available

• Age-specific incidence fell by 10 1999-2004
• Demographic change 2004-2031 overwhelms this

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• Osteoporosis International (in press)
• Epub available

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Abrahamsen 2009. Excess mortality following hip
fracture a systematic epidemiological review.
Osteoporosis Int epub
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Deaths related to hip fracture, rather than
comorbidities

• 160,000 hip fractures in men and women aged 50
  years or more, from the patient register of
  Sweden
• Causally related deaths comprised 1732 of all
  deaths associated with hip fracture (depending
  on age) and accounted for more than 1.5 of all
  deaths in the population aged 50 or more.

Kanis JA, Oden A, Johnell O et al (2003). The
components of excess mortality after hip
fracture. Bone 32468473
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Mortality after hip fracture
Royal Victoria Hospital, Belfast 1999-2003 1003
deaths by one year in 5553 patients
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Whole-person issues

• why did the patient fall?
• can future falls be prevented?
• why did the bone break?
• can osteoporosis be treated?
• is there metastatic disease?
• what are the comorbidities?
• how can the patients condition be optimised
  prior to surgery?
• how can the patient best be rehabilitated after
  surgery?

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Whole-system issues

• should the patient be admitted to
• a fracture ward, with other fractures?
• a geriatric ward, with other old people?
• should fracture wards have physicians working in
  them?
• how long should the patient remain in the acute
  ward?
• where should they go from there?

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Complexity of elderly patients

• Mean age hip fracture 82 yrs
• Comorbidities (median ASA 3)
• Cardiac murmurs
• Renal - Dialysis
• COPD - home O2
• Diabetes
• Delirium / dementia
• Pseudo-obstruction
• Alcohol abuse

• Impaired metabolic response to injury
• Hyponatraemia
• Management problems
• Consent
• Theatre scheduling
• Discharge planning
• Polypharmacy
• Warfarin
• Plavix
• Neurotropics

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Acute medical management

• Difficult judgement balance between medical
  optimisation and prompt surgery
• Inexperienced surgical trainees not the best
  people to look after such people and prepare them
  for surgery
• Ideal solution is close supervision by senior
  physicians having expertise with elderly patients
• pre- and peri-operatively, not just for
  rehabilitation

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Senior medical backup

• Can come from different specialists, depending on
  health care system
• Anaesthesia
• Internal medicine
• Geriatrics
• Orthogeriatrics may play larger role in future

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The pay-off from orthogeriatric care in the acute
phase

• Superior medical care
• Better communication with patients and relatives
• A leader for the multidisciplinary team
• Optimal scheduling of fracture surgery
• Reduced length of stay
• Less interference with elective work

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Alternative models for orthogeriatric care

• Orthopaedic doctors and nurses supported by
  visiting medical specialist
• Nurse specialists on fracture wards, supervised
  by geriatricians
• Geriatricians employed on fracture wards
• Elderly fracture patients admitted to geriatric
  wards

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Orthogeriatrician role
optimise medical condition
anaesthetists
surgeons
junior surgical staff
medical students
orthogeriatrician
teaching, protocol development, research and audit
multidisciplinary team
discharge coordinator
communication, integration, logistics
rehab geriatricians
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Potential downside

• Medical problems detected that would have been
  ignored
• eg cardiac murmurs
• Worsens average delay to theatre
• Important to have a shared philosophy of balance
  between optimisation and minimal delay

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• J Am Geriatric Soc 2008

• Geriatric Fracture Center in Rochester, USA
• Comparison with other fracture services in
  locality
• In-hospital mortality 1.5 vs 3.2
• Readmission 9.7 vs 19.4
• Length of stay 4.6 vs 5.2 days

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Four big messages Multidisciplinary approach to
the management of fragility fracture
patients Reliable secondary prevention
osteoporosis falls Chronic disease model
Quality assurance the NHFD
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BOA-BGS Blue Booksix standards for hip fracture
care

• All patients with hip fracture should be admitted
  to an acute orthopaedic ward within 4 hours of
  presentation
• All patients with hip fracture who are medically
  fit should have surgery within 48 hours of
  admission, during normal working hours
• All patients with hip fracture should be assessed
  and cared for with a view to minimising their
  risk of developing a pressure ulcer
• All patients presenting with a fragility fracture
  should be managed on an orthopaedic ward with
  routine access to orthogeriatric medical support
  from the time of admission
• All patients presenting with fragility fracture
  should be assessed to determine their need for
  antiresorptive therapy to prevent future
  osteoporotic fractures
• All patients presenting with a fragility fracture
  following a fall should be offered
  multidisciplinary assessment and intervention to
  prevent future falls

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The National Hip Fracture Database- jointly led
by BOA and BGS

• Measures compliance with Blue Book standards
• Extension of the established hip fracture audits
  in Scotland, NI, Manchester, Cardiff, Nottingham,
  Oxford etc
• A web-based national database, aiming to include
  every UK fracture unit
• National linkage to ONS, pharmacy database etc
• Modelled on MINAP
• Feed back to units their performance compared to
  national
• A professional steering group to manage analysis
  of, and access to the data
• Extensile for research
• Parallel political initiatives by the BOA-BGS
  collaboration

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How the NHFD will help

• Measure the delivery of the standards
• Encourage orthogeriatric input
• Encourage secondary prevention
• Raise the profile of fragility fracture services
• Enable smart commissioning
• Provide epidemiological data
• Platform for clinical research

Change practice
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Goal

• Every fracture unit
• Orthogeriatric acute care and rehab
• Reliable secondary prevention
• Inpatient and outpatient
• Integrated primary/secondary care
• Falls as well as bone health
• NHFD participation and evolution in response to
  feedback
• Raise quality and reduce costs per case
• Government priority, with mandatory standards in
  place and being met

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Commissioning guidelines

• Invest in the joining up roles
• Orthogeriatrics
• Fracture liaison nurses
• Primary-secondary care
• Cost-effective
• More efficient trauma work
• Less interference with elective work
• Prevent future fractures

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Signs of progress

• Acceptance from DoH Director of Commissioning
  that
• osteoporosis and fragility fractures are
  currently under-represented in their thinking
  about long-term conditions
• there is robust evidence for cost-effectiveness
  of our proposals
• joining up roles (orthogeriatrics, fracture
  liaison, primary care) particularly good value
• Invitation to assist in developing commissioning
  guidelines

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UK Department of Health commissioning guidance
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Summary

• Skeletal fragility constitutes a high-volume,
  expensive chronic condition that health systems
  must address
• Hip fracture produces most mortality, morbidity
  and cost
• Joining-up roles are a cost-effective answer
• Guidance to commissioners along these lines is
  needed
• Alliance between orthopaedics and geriatricians
  is clinically and politically powerful
• Government preparedness to listen is increasing