Article
Geriatric Fracture Center vs Usual Care – what are the benefits? Results of a large prospective multicenter cohort study
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Authors
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Michael Blauth
- Medizinische Universität Innsbruck, Universitätsklinik f. Unfallchirurgie und Sporttraumatologie, Innsbruck, Austria
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Alexander Joeris
- AO Foundation, Dübendorf, Switzerland
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Elke Rometsch
- AO Foundation, Dübendorf, Switzerland
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Kathrin Espinoza
- AO Foundation, Dübendorf, Switzerland
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Markus Gosch
- Klinikum Nürnberg Nord, Klinik für Innere Medizin 2, Schwerpunkt Geriatrie, Nürnberg, Germany
| Published: | October 22, 2019 |
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Outline
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Objectives: The number of older trauma patients is increasing rapidly. These patients have complex needs far beyond fracture care itself, so usual care is often deemed sub-optimal. Geriatric fracture centers (GFC) have been established to improve both quality and cost-effectiveness. The aim of this study was to compare outcomes of GFC and Usual Care Centers (UCC) after treatment of proximal femoral fractures in older patients.
Methods: Based on clearly defined parameters, 6 GFC and 6 UCC from 6 countries were selected and enrolled 281 patients ≥ 70 years. The primary outcome was the major adverse events (MAE) rate at 1 year. Secondary outcomes included mortality, mobility and in-hospital parameters.
Odds ratios (OR) with confidence intervals (CI) were calculated for individual MAE rates. A multivariable regression model was developed controlling for age, gender, Charlson Comorbidity Index (CCI), number of falls within 3 months before surgery, type of surgery and residential status at baseline. Changes of mobility over time were evaluated with a mixed effects model, which in addition to the aforementioned parameters controlled for the respective score at baseline. Mortality was analyzed with Kaplan-Meier curves and the log-rank test.
Results: The gender distribution was similar in GFC and UCC. The CCI was slightly imbalanced (p=0.001), with more patients of a CCI ≥ 3 in GFC.
The rate of patients with MAEs at 1 year was low (18.1%) but higher (p<0.001) in GFC (28.2%, 95%CI 20.9-36.3) than in UCC (7.9%, 95%CI 4.0-13.7). The rate of in-hospital MAEs was also higher in GFC, which was based on the occurrence of delirium (Table 1 [Tab. 1]).
In the multivariable analysis, treatment group (GFC vs. UCC) was the only factor (OR 4.08, 95% CI 1.87-8.88, P<0.001) with a significant effect on the MAE rate.
The median length of hospital stay until discharge from the orthopedic/trauma department was shorter (p<0.001) in GFC (7 nights, 95%CI 6-10) vs. UCC (12 nights, 95%CI 9-16). Also, the median time from hospital admission to surgery was shorter (p<0.001) in GFC (28 hours, 95%CI 19-40) vs. UCC (43 hours, 95%CI 22-92). Changes over time of both Parker Mobility Score (PMS) and the timed up-and-go test (TUG) were more favorable in GFC at 1 year (PMS: GFC 3.1, UCC 2.2, p<0.001; TUG: GFC -39s, UCC -31s, p=0.017) and for the TUG also at 12 weeks (GFC -31s, UCC -17s, p=0.003).
The overall mortality rate was low, with a 1 year survival rate of 85.2% (95%CI 78.0-90.2) for GFC and 88.5% (95%CI 81.7-92.9) for UCC (p=0.46).
Conclusion: Contrary to our expectation, the rate of MAEs was higher in GFC despite several favorable clinical and hospital parameters. It is unclear whether a better awareness of age-specific adverse events in GFC introduced a reporting bias, whether unknown risk factors were unequally distributed in the populations, or whether treatment quality in UCC has nowadays reached a standard equal to GFC. Overall MAE and mortality rates were lower than expected.
