The practice of using a geriatrician- or a hospitalist-based co-management team to care for elderly patients who are admitted to the hospital for treatment of fragility fractures or other orthopaedic procedures is now more than a decade old. These services have grown in popularity because patients are living longer with comorbidities and becoming more complex to manage medically, and because shift-based hospitalist practices have become more common. These coordinated partnerships help the hospitalist- or geriatrician-led medical team optimize the patient’s care medically, while allowing the orthopaedic surgeon to focus on the patient’s musculoskeletal condition. The consensus I have heard is that patients are better off with these co-management systems, but hard evidence has been sparse.
In the April 17, 2019 issue of The Journal, Blood et al. report on the use of the Institute for Healthcare Improvement (IHI) Global Trigger Tool to assess the adverse-event impact of a Geriatric Hip Fracture Program (GHFP). In a bivariate analysis of pre- and post-GHFP data, the authors document a decrease in the rate of adverse events and shorter lengths of stay among elderly hip-fracture patients after GHFP implementation. However, multivariable analysis confirmed only a trend toward decreasing adverse-event rates after the implementation of the program. This study also seems to confirm what many of us already know empirically—that hip-fracture patients with severe medical comorbidities (i.e., a high Charlson Comorbidity Index) are at increased risk of adverse events no matter what system of care they receive.
Still, what most orthopaedic surgeons have felt was a “no-brainer,” coordinated approach to optimizing patient care and decreasing adverse events now has more evidence of effectiveness. Because such programs decrease both adverse events and length of stay among elderly patients hospitalized for a hip fracture, orthopaedic surgeons everywhere should advocate for increased geriatrician training to support this movement. Furthermore, these findings should encourage further research into additional patient-centric medical care strategies that could improve outcomes for these patients.
Marc Swiontkowski, MD
The statistics about osteoporosis and associated fragility fractures are sobering:
- One-quarter of adults living in the US currently have osteoporosis or low bone density.
- Twenty-four percent of people aged 50 and older who sustain a hip fracture will die within a year after the fracture.
- Patients who have had one fragility fracture have an 86% increased risk for a second fracture.
Amid these troubling data stands hope from an effective, team-based clinical response—the fracture liaison service (FLS). In the April 15, 2015 edition of JBJS, Miller et al . explain how an FLS works and the results it achieves.
The authors define the fracture liaison service as “a coordinated care model of multiple providers who help guide the patient through osteoporosis management after a fragility fracture to help prevent future fractures.” The three key players on the FLS team are a coordinator (usually an advanced-practice provider), a physician champion (whom the authors say should be an orthopaedic surgeon), and a “nurse navigator.” Miller et al. describe the roles these FLS core team members play (including patient care and education and communication with other clinical services and administrators), suggest ways to organizationally justify an FLS, and lay out a stepwise implementation roadmap.
The authors conclude that an FLS “is adaptable to any type of health-care system, improves patient outcomes, and decreases complications and readmissions related to secondary fractures.” And there’s an important fringe benefit: “The FLS can help improve performance on quality measures…and help health-care organizations during this transition from volume payment to quality payment,” they say.