The Orthogeriatrics Model of Care: Systematic Review of Predictors of Institutionalization and Mortality in Post-Hip Fracture Patients and Evidence for Interventions

doi:10.1016/j.jamda.2012.07.011

Journal of the American Medical Directors Association

Volume 13, Issue 9, November 2012, Pages 770-777

https://doi.org/10.1016/j.jamda.2012.07.011 Get rights and content

Abstract

Hip fracture is a common serious complication of osteoporosis, which is associated with high morbidity and mortality. In nursing home residents, incidence rates of hip fractures are at least twice to three times higher than in community-dwellers of the same age and sex. Older adults with hip fracture have a 5- to 8-fold increased risk for all-cause mortality and much higher risk of institutionalization. Therefore, interventions to prevent institutionalization, prevent a second fracture in institutionalized patients, and decrease mortality after a hip fracture are highly needed. The orthogeriatrics model of care is a shared-care approach to patients after suffering a hip fracture. This program, which has been studied in models run by geriatricians with the assistance of a multidisciplinary team, includes a comprehensive medical and nursing admission assessment focusing on the patient’s premorbid function, cognition, comorbidities, and risks is followed by a comprehensive care plan design. This systematic review describes and analyzes the interrelation between hip fracture and nursing home placement taking into consideration those evidence-based interventions to prevent later complications and future institutionalization.

Section snippets

Data Sources and Searches

In May 2012, a literature search was conducted through: Embase, PubMed (MEDLINE), and Cochrane Library Reviews. Controlled terms were used preferably. The two following searches were most frequently used:

-
(‘hip fracture’ OR ‘femur fracture’) AND ‘nursing home patient’.
-
(‘hip fracture’ OR ‘femur fracture’) AND ‘nursing home’ AND (‘risk factor’ OR ‘predictor’ OR ‘prevention’).

Additional searches of specific topics (eg, nutritional intervention after hip fracture in nursing home residents) were made

Results

Table E1 (available at http://dx.doi.org/10.1016/j.jamda.2012.07.011) describes all the articles included, type of article/study, sample, and outcomes divided into three categories: predictors of NHA, interventions to prevent NHA, and interventions to prevent later complications in nursing home patients.

Discussion

Hip fracture and institutionalization are closely interrelated. Incidence rates of hip fracture are higher in older adults living in nursing homes, with poorer in-hospital and follow-up outcomes. In addition, the requirement of new nursing home admission increases significantly after suffering a hip fracture. This review summarizes the evidence available regarding predictors of outcomes and interventions to improve the management and outcomes of this particular population.

Note that the articles

Conclusion

The orthogeriatrics model of care is an effective geriatrician-lead intervention that reduces morbidity and mortality in older persons after suffering a hip fracture. NHA is a common consequence of a hip fracture and, therefore, clinicians should be able to identify potential predictors of institutionalization in post-hip fracture patients. In addition, clinicians practicing in nursing homes should be aware of the high risk of subsequent fractures, decreased mobility and high mortality rates in

References (74)

R.V. Riggs et al.
Joint replacement and hip fracture readmission rates: Impact of discharge destination
PM and R
(2010)
D.E. Deakin et al.
Factors influencing discharge location following hip fracture
Injury
(2008)
L.A. Beaupre et al.
Does standardized rehabilitation and discharge planning improve functional recovery in elderly patients with hip fracture?
Arch Phys Med Rehabil
(2005)
J. Semel et al.
Predictors of outcome following hip fracture rehabilitation
PM and R
(2010)
N.A. Singh et al.
Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and NHA after hip fracture: A randomized controlled trial
J Am Med Dir Assoc
(2012)
A.M. Sawka et al.
Hip protectors decrease hip fracture risk in elderly nursing home residents: A Bayesian meta-analysis
J Clin Epidemiol
(2007)
D. Garfinkel et al.
High efficacy for hip protectors in the prevention of hip fractures among elderly people with dementia
J Am Med Dir Assoc
(2008)
J.A. Kanis et al.
A systematic review of hip fracture incidence and probability of fracture worldwide
Osteoporos Int
(2012)
K. Nakamura et al.
Fracture incidence in nursing homes in Japan
Osteoporos Int
(2010)
K. Rapp et al.
Hip fracture in institutionalized elderly people: Incidence rates and excess mortality
J Bone Miner Res
(2008)

J. Brennan et al.

Place of residence and risk of fracture in older people: A population-based study of over 65-years-olds in Cardiff

Osteoporos Int

(2003)

P. Haentjens et al.

Meta-analysis: Excess mortality after hip fracture among older women and men

Ann Intern Med

(2010)

J.P. Michel et al.

Prognosis of functional recovery 1 year after hip fracture: Typical patient profiles through cluster analysis

J Gerontol A Biol Sci Med Sci

(2000)

E.A. Eastwood et al.

Patients with hip fracture: Subgroups and their outcomes

J Am Geriatr Soc

(2002)

E.L. Hannan et al.

Mortality and locomotion 6 months after hospitalization for hip fracture: Risk factors and risk-adjusted hospital outcomes

JAMA

(2001)

M.D. Miller et al.

Lower limb fracture, cognitive impairment and risk of subsequent malnutrition: A prospective evaluation of dietary energy and protein intake on an orthopaedic ward

Eur J Clin Nutr

(2006)

C.L. Leibson et al.

Mortality, disability, and nursing home use for persons with and without hip fracture: A population-based study

J Am Geriatr Soc

(2002)

ACI Orthogeriatric model of care: Clinical practice guide 2010. Available at URL:...

I. Cameron

Australian and New Zealand Society for Geriatric Medicine Position Statement–Orthogeriatric care revised 2010

Australas J Ageing

(2011)

N. Siddiqi et al.

Interventions for preventing delirium in hospitalized patients

Cochrane Database Syst Rev

(2007)

I. Cameron et al.

Geriatric rehabilitation following fractures in older people: A systematic review

Health Technol Assess

(2000)

M. Vidan et al.

Efficacy of a comprehensive geriatric intervention on older patients hospitalized for hip fracture: A randomized controlled trial

J Am Geriatr Soc

(2005)

W.J. Gillespie

Extracts for clinical evidence. Hip fracture

BMJ

(2000)

E.K. Osnes et al.

Consequences of hip fracture on activities of daily life and residential needs

Osteoporos Int

(2004)

R. Van Balen et al.

Hip fracture in elderly patients: Outcomes for function, quality of life and type of residence

Clin Orthop Relat Res

(2001)

E. Bergeron et al.

Patients with isolated hip fracture must be considered for surgery irrespectively of their age, comorbidity status and provenance: A statement applicable even to nonagenerians

Arch Orthop Trauma Surg

(2009)

T. Hagino et al.

Prognostic prediction in patients with hip fracture: Risk factors predicting difficulties with discharge to own home

J Orthop Trauma

(2011)

A.J.H. Vochteloo et al.

Risk factors for failure to return to the pre-fracture place of residence after hip fracture: A prospective longitudinal study of 444 patients

Arch Orthop Trauma Surg

(2012)

K. Ganesan et al.

Racial differences in institutionalization after hip fractures: California hospital discharge data

Ethn Dis

(2005)

M. Fransen et al.

Excess mortality or institutionalization after hip fracture: Men are at greater risk than women

J Am Geriatr Soc

(2002)

M. Titler et al.

Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures

Nurs Res

(2006)

J.L. Givens et al.

Functional recovery after hip fracture: The combined effects of depressive symptoms, cognitive impairment, and delirium

J Am Geriatr Soc

(2008)

B. Samuelsson et al.

Gender differences and cognitive aspects in functional outcome after hip fracture–A 2 years’ follow-up of 2134 patients

Age Ageing

(2009)

K.S. Boockvard et al.

Patient relocation in the 6 months after hip fracture: Risk factors for fragmented care

J Am Geriatr Soc

(2004)

J. Visschedijk et al.

Fear of falling after hip fracture: A systematic review of measurement instruments, prevalence, interventions, and related factors

J Am Geriatr Soc

(2010)

K.J. Koval et al.

The effects of nutritional status on outcome after hip fracture

J Orthop Trauma

(1999)

A.J.H. Vochteloo et al.

Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: An analysis of 1262 surgically treated patients

BMC Musculoskelet Disord

(2011)

Cited by (50)

Perceptions of Medical and Surgical Health Care Providers Toward Orthogeriatric Care Delivery: An Exploratory Survey
2022, Journal of the American Medical Directors Association
Addition of 3D-CT evaluation to radiographic images and effect on diagnostic reliability of current 2018 AO/OTA classification of femoral trochanteric fractures
2021, Injury
The AO/OTA classification for diagnosing femoral trochanteric fractures (31A fractures) was revised in 2018. No studies have investigated whether the addition of CT to radiographic diagnosis improves the inter-rater reliability of classifying 31A fractures with the current AO/OTA criteria. The study aimed to test the hypothesis that the addition of three-dimensional CT (3D-CT) to radiographic diagnosis would improve diagnostic reliability.
A retrospective review was conducted to assess the diagnostic reliability of classification of 31A fractures with current AO/OTA criteria. Radiographs and 3D-CT images from 89 cases were assessed. Major fracture types (A1, A2, and A3) and subgroups were diagnosed by nine orthopedic surgeons who were classified into three groups (high-, intermediate-, and low-experience) according to their clinical experience. Anterior–posterior and lateral radiographs were provided to diagnose fracture type (first assessment). After a 6-week interval, radiographs and 3D-CT images of all cases were evaluated by each rater (second assessment). Fleiss's Kappa was used to determine inter-rater reliability.
In the first assessment, the Kappa value indicated fair inter-rater reliability in all groups (high-experience group: κ = 0.296, 95% confidence interval [CI] 0.239–0.352; intermediate-experience group: κ = 0.367, 95% CI 0.305–0.428; low-experience group: κ = 0.304, 95% CI 0.246–0.362). With the addition of 3D-CT (second assessment), reliability improved from fair to moderate in the high- and intermediate-experience groups (κ = 0.483, 95% CI 0.428–0.539 and κ = 0.409, 95% CI 0.352–0.466, respectively). By contrast, reliability remained fair in the low-experience group (κ = 0.322, 95% CI 0.322–0.431). The inter-rater reliability of diagnosing subgroup fracture types improved for A2.3 and A3.1 in all three groups and for A3.2 and A3.3 in the intermediate- and low-experience groups.
The current AO/OTA classification revised in 2018 provided fair reliability in diagnosing femoral trochanteric fractures in all three surgeon groups. The addition of 3D-CT to radiographic image evaluation improved reliability in high- and middle-expertise groups. The addition of 3D-CT to radiographic evaluation often improved the diagnostic reliability for unstable fractures, although there was some variation among fracture subgroups.
The role of having children for the incidence of and survival after hip fracture – A nationwide cohort study
2021, Bone
Citation Excerpt :
Few older Swedes live together with their adult children, but the majority stays in frequent contact [34,37] and children often provide support to their ageing parents [35]. Although a number of studies found a positive effect of social support on physical recovery and survival among hip fracture patients [38–44], none have examined whether having children may be associated with a survival advantage. Given the high mortality among hip fracture patients, it is important to identify factors influencing incidence and mortality in order to identify individuals at risk.
Childless older women have a higher risk of sustaining a hip fracture than mothers. Several biological mechanisms linking parity to bone health among women have been proposed but it remains unclear whether a similar association exists among men. Adult children may also support their ageing parents with hip fracture, thereby potentially increasing survival chances.
To investigate how having children is related to the incidence of and survival after hip fracture among Swedish men and women over the age of 70.
This nation-wide cohort study is based on data from several administrative population registers and a clinical hip fracture register. During 2013 to 2017, we estimated multivariable-adjusted incidence rate ratios to examine the association between number of children and incidence of first hip fracture and hazard ratios to examine survival after first hip fracture.
More than two million individuals were followed for hip fracture incidence and 45,991 patients for survival. Women had a higher risk of sustaining a hip fracture, but men had substantially higher mortality than women. Adjusting for education, comorbidity level, and further covariates, having children was associated with a lower risk of sustaining a hip fracture and a longer survival after hip fracture.
Older childless individuals may constitute risk groups for both the incidence of and mortality after hip fracture. Mechanisms linking parity to hip fracture risk are likely complex and not limited to biological mechanisms related to pregnancy, childbirth, or breastfeeding among women.
Rehabilitation Providers’ Prediction of the Likely Success of the SNF-to-Home Transition Differs by Discipline
2019, Journal of the American Medical Directors Association
Citation Excerpt :
With regard to our secondary objective to examine patient-level factors, we found that living alone, more medical conditions, and worse physical functioning and depression were associated with whether patients had a failed transition to home. Although these findings are congruent with prior research on risk factors for long-term care placement,5–16 direct comparison to other studies is limited in that our failed transition to home outcome is a composite measure that also includes outcomes such as mortality and prolonged hospitalization. The reasons why the predictions of some rehabilitation team members but not others were associated with post-SNF discharge outcomes are unclear.
Our article's primary objective is to examine whether rehabilitation providers can predict which patients discharged from skilled nursing facility (SNF) rehabilitation will be successful in their transition to home, controlling for sociodemographic factors and physical, mental, and social health characteristics.
Longitudinal cohort study.
One hundred-twelve English-speaking adults aged 65 years and older admitted to 2 SNF rehabilitation units.
Our outcome is time to “failed transition to home,” which identified SNF rehabilitation patients who did not successfully transition from the SNF to home during the study. Our primary independent variable consisted of the prediction of medical providers, occupational therapists, physical therapists, and social workers about the likely success of their patients' SNF-to-home transition. We also examined the association of sociodemographic factors and physical, mental, and social health with a failed transition to home.
The predictions of occupational and physical therapists were associated with whether patients successfully transitioned from the SNF to their homes in bivariate [hazard ratio (HR) = 4.96, P = .014; HR = 10.91, P = .002, respectively] and multivariate (HR = 5.07, P = .036; HR = 53.33, P = .004) analyses. The predictions of medical providers and social workers, however, were not associated with our outcome in either bivariate (HR = 1.44, P = .512; HR = 0.84, P = .794, respectively) or multivariate (HR = 0.57, P = .487; HR = 0.54, P = .665) analyses. Living alone, more medical conditions, lower physical functioning scores, and greater depression scores were also associated with time to failed transition to home.
These findings suggest that occupational and physical therapists may be better able to predict post-SNF discharge outcomes than are other rehabilitation providers. Why occupational and physical therapists' predictions are associated with the SNF-to-home outcome whereas the predictions of medical providers and social workers are not is uncertain. A better understanding of the factors informing the postdischarge predictions of occupational and physical therapists may help identify ways to improve the SNF-to-home discharge planning process.
Patient Characteristics as Indicator for Care Dependence after Hip Fracture: A Retrospective Cohort Study Using Health Insurance Claims Data From Germany
2019, Journal of the American Medical Directors Association
Hip fractures are common consequences of falls in older adults and, among other negative health outcomes, often lead to care dependence in the long term. Until 2016, the German long-term care insurance classified care recipients according to a standardized classification system consisting of 3 care levels. It was based on required assistance in performing activities of daily living and assessed by a qualified physician or nurse. Thus, care level reflects the degree of care dependence. The aim of this study was to determine relevant patient characteristics, which are related to the likelihood of increasing care dependence in terms of worsening care level after hip fracture.
Retrospective cohort study.
Statutory health insurance claims data including 122,922 insured individuals living in Germany and aged 65 years or older, who sustained a hip fracture from 2009 through 2011.
The association of patient characteristics with worsening care level in the quarterly period after hip fracture was investigated by means of multinomial logit regression analysis. Death constitutes a competing risk and was modeled as additional nominal outcome.
Among all patients, crude rates were 30.9% for worsening care level, 54.8% for unchanged care level, and 14.4% for death after hip fracture. The multivariate analysis revealed that patient factors male sex, increasing age, increasing comorbidity, increasing inpatient length of stay, and a lack of inpatient rehabilitation were significantly associated with a worsening care level.
This study uses the German standardized measurement of care dependence in terms of worsening care level after hip fracture and finds various related patient characteristics. Knowledge of these characteristics helps to identify possible risk groups for care dependence after hip fracture, for which special attention can be provided regarding treatment and prevention of hip fractures.
Association of depression with malnutrition, grip strength and impaired cognitive function among senior trauma patients
2019, Journal of Affective Disorders
Citation Excerpt :
Despite the extensive research on association between depression and adverse health events after hospitalization, few studies have evaluated the factors associated with depressive symptoms during acute trauma care. It is in acute trauma care where important risk factors for institutionalization should be identified and treated (Martinez-Reig et al., 2012). Since appropriate care management has shown to improve outcomes for depressed seniors in primary care settings (Unutzer and Park, 2012), understanding depression in this large population offers the potential for targeted interventions to improve patient outcomes.
Depression is common among senior adults, yet understudied among trauma patients. The purpose of this study was to assess the prevalence of depressive symptoms among seniors hospitalized in acute trauma care, to compare patients with depressive symptoms vs. those without, and to evaluate whether depression symptoms affects discharge destination.
This cross-sectional and prospective analysis was conducted among community-dwelling patients ≥70 years old, hospitalized at the Senior Trauma Center of the University Hospital Zurich, Switzerland. We used the Geriatric Depression Scale (GDS-15) to assess presence of depressive symptoms. Using a cutoff value of 5 points, we compared age- and gender-adjusted characteristics of patients with and without depressive symptoms. Multinomial logistic regression models were used to estimate the odds of returning home vs. not adjusting for age, gender, nutritional status, cognitive function and others.
Of the 273 seniors enrolled, 104 (38.1%) were men and the mean age was 79.4 (SD = 6.5) years. We identified 52 (19.0%) patients with depressive symptoms. These patients were more likely to be older (p = 0.04), at risk for malnutrition (p<0.0001), at least pre-frail (p = 0.005), and have decreased cognitive function (p = 0.001). They were also more than twice as likely to be discharged to acute geriatric care compared to home (OR = 2.28 (CI = 1.12–4.68)).
Depressive symptoms were assessed during acute care without data before hospitalization.
Senior trauma patients with depressive symptoms during acute care were more likely to be at higher risk of malnutrition, have cognitive decline and are more likely to receive additional geriatric care.

View all citing articles on Scopus

: The authors have no conflict of interest to declare.

View full text

ReviewThe Orthogeriatrics Model of Care: Systematic Review of Predictors of Institutionalization and Mortality in Post-Hip Fracture Patients and Evidence for Interventions

Abstract

Section snippets

Data Sources and Searches

Results

Discussion

Conclusion

PM and R

Injury

Arch Phys Med Rehabil

PM and R

J Am Med Dir Assoc

J Clin Epidemiol

J Am Med Dir Assoc

A systematic review of hip fracture incidence and probability of fracture worldwide

Osteoporos Int

Fracture incidence in nursing homes in Japan

Osteoporos Int

Hip fracture in institutionalized elderly people: Incidence rates and excess mortality

J Bone Miner Res

Place of residence and risk of fracture in older people: A population-based study of over 65-years-olds in Cardiff

Osteoporos Int

Meta-analysis: Excess mortality after hip fracture among older women and men

Ann Intern Med

Prognosis of functional recovery 1 year after hip fracture: Typical patient profiles through cluster analysis

J Gerontol A Biol Sci Med Sci

Patients with hip fracture: Subgroups and their outcomes

J Am Geriatr Soc

Mortality and locomotion 6 months after hospitalization for hip fracture: Risk factors and risk-adjusted hospital outcomes

JAMA

Lower limb fracture, cognitive impairment and risk of subsequent malnutrition: A prospective evaluation of dietary energy and protein intake on an orthopaedic ward

Eur J Clin Nutr

Mortality, disability, and nursing home use for persons with and without hip fracture: A population-based study

J Am Geriatr Soc

Australian and New Zealand Society for Geriatric Medicine Position Statement–Orthogeriatric care revised 2010

Australas J Ageing

Interventions for preventing delirium in hospitalized patients

Cochrane Database Syst Rev

Geriatric rehabilitation following fractures in older people: A systematic review

Health Technol Assess

Efficacy of a comprehensive geriatric intervention on older patients hospitalized for hip fracture: A randomized controlled trial

J Am Geriatr Soc

Extracts for clinical evidence. Hip fracture

BMJ

Consequences of hip fracture on activities of daily life and residential needs

Osteoporos Int

Hip fracture in elderly patients: Outcomes for function, quality of life and type of residence

Clin Orthop Relat Res

Patients with isolated hip fracture must be considered for surgery irrespectively of their age, comorbidity status and provenance: A statement applicable even to nonagenerians

Arch Orthop Trauma Surg

Prognostic prediction in patients with hip fracture: Risk factors predicting difficulties with discharge to own home

J Orthop Trauma

Risk factors for failure to return to the pre-fracture place of residence after hip fracture: A prospective longitudinal study of 444 patients

Arch Orthop Trauma Surg

Racial differences in institutionalization after hip fractures: California hospital discharge data

Ethn Dis

Excess mortality or institutionalization after hip fracture: Men are at greater risk than women

J Am Geriatr Soc

Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures

Nurs Res

Functional recovery after hip fracture: The combined effects of depressive symptoms, cognitive impairment, and delirium

J Am Geriatr Soc

Gender differences and cognitive aspects in functional outcome after hip fracture–A 2 years’ follow-up of 2134 patients

Age Ageing

Patient relocation in the 6 months after hip fracture: Risk factors for fragmented care

J Am Geriatr Soc

Fear of falling after hip fracture: A systematic review of measurement instruments, prevalence, interventions, and related factors

J Am Geriatr Soc

The effects of nutritional status on outcome after hip fracture

J Orthop Trauma

Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: An analysis of 1262 surgically treated patients

BMC Musculoskelet Disord

Review
The Orthogeriatrics Model of Care: Systematic Review of Predictors of Institutionalization and Mortality in Post-Hip Fracture Patients and Evidence for Interventions