Susan M. Friedman

Falls and Fear of Falling: Which Comes First? A Longitudinal Prediction Model Suggests Strategies for Primary and Secondary Prevention

OBJECTIVES: Previous cross‐sectional studies have shown a correlation between falls and fear of falling, but it is unclear which comes first. Our objectives were to determine the temporal relationship between falls and fear of falling, and to see whether these two outcomes share predictors.

Impact of a Comanaged Geriatric Fracture Center on Short-term Hip Fracture Outcomes

BACKGROUND Hip fractures are associated with substantial morbidity and mortality for older adults. Patients sustaining hip fractures usually have comorbid conditions that may benefit from comanagement by geriatricians and orthopedic surgeons. METHODS The Geriatric Fracture Center (GFC) is part of a community teaching hospital. Patients are comanaged daily by a geriatrician and orthopedic surgeon, emphasizing total quality management, timely treatment, and standardized care. We reviewed medical records to compare process and outcome measures in the GFC with a local institution that did not have a fracture management service. Patients 60 years or older admitted for a proximal femur fracture from May 1, 2005, to April 30, 2006, were included; pathological, recurrent, high-energy, periprosthetic, and nonoperative fractures were excluded. RESULTS Geriatric Fracture Center patients (n = 193) were significantly older, were less likely to reside in the community, and had more comorbid conditions and dementia than usual care patients (n = 121). Despite baseline differences, GFC patients, compared with usual care patients, had shorter times to surgery (24.1 vs 37.4 hours), fewer postoperative infections (2.3% vs 19.8%), fewer complications overall (30.6% vs 46.3%), and shorter length of stay (4.6 vs 8.3 days). Compared with GFC patients, physical restraint use was significantly higher in usual care patients (0% vs 14.1%). After we adjusted for baseline characteristics, patients treated in the GFC had shorter times to surgery, shorter length of stay, fewer cardiac complications, and fewer cases of thromboembolism, delirium, and infection. There was no difference in in-hospital mortality or 30-day readmission rate. CONCLUSION Comanagement by geriatricians and orthopedic surgeons, combined with standardized care, leads to improved processes and outcomes for patients with hip fractures.

Geriatric Co-Management of Proximal Femur Fractures: Total Quality Management and Protocol-Driven Care Result in Better Outcomes for a Frail Patient Population

Hip fractures in older adults are a common event, leading to substantial morbidity and mortality. Hip fractures have been previously described as a “geriatric, rather than orthopedic disease.” Patients with this condition have a high prevalence of comorbidity and a high risk of complications from surgery, and for this reason, geriatricians may be well suited to improve outcomes of care. Co‐management of hip fracture patients by orthopedic surgeons and geriatricians has led to better outcomes in other countries but has rarely been described in the United States. This article describes a co‐managed Geriatric Fracture Center program that has resulted in lower‐than‐predicted length of stay and readmission rates, with short time to surgery, low complication rates, and low mortality. This program is based on the principles of early evaluation of patients, ongoing co‐management, protocol‐driven geriatric‐focused care, and early discharge planning. This is a potentially replicable model of care that uses the expertise of geriatricians to optimize the management of a common and serious condition.

The Value of an Organized Fracture Program for the Elderly: Early Results

Objectives: To describe the early financial results of an organized hip fracture program for older adults. Design: Retrospective evaluation of financial data for a 1-year period on a hip fracture program for older adults. Setting: University medical center. Patients: All 193 adults older than age 60 with a native, nonpathologic hip fracture admitted to the hospital and surgically treated from May 2005 to April 2006 were included as subjects in this study. Intervention: The comanaged, protocol-driven fracture management program was used as the specific intervention for treating all patients with hip fractures. Main Outcome Measure: The primary outcome was profit or loss resulting from treatment of patients. Key quality measures studied included length of hospital stay, mortality rates, complication rates, and hospital readmission rates. Results: With use of an organized program, substantial savings in nearly all areas of expenditure is demonstrated. Adjusting for patient characteristics, costs are demonstrated to be 66.7% of the expected costs nationally. The length of stay, mortality, complication rates, and readmission rates were all noted to be below national averages. Conclusions: The improved quality measures suggest that better quality of patient care is associated with reduced costs.

The 1-Year Mortality of Patients Treated in a Hip Fracture Program for Elders

Comanagement of geriatric hip fracture patients with standardized protocols has been shown to improve short-term outcomes after surgery. A standardized, patient-centered, comanaged Hip Fracture Program for Elders is examined for 1-year mortality. Patients ≥60 years of age who were treated in the Hip Fracture Program for Elders were comanaged by orthopaedic surgeons and geriatricians. Data including age, place of origin, procedure, length of stay, 1-year mortality, Charlson score, and activities of daily living (ADLs) were retrospectively collected. A total of 758 patients ≥60 years of age with hip fractures between April 15, 2005, and March 1, 2009, were included. Their data were analyzed, and the Social Security Death Index and the hospital data system were searched for mortality data. Seventy-eight percent were female, with a mean age of 84.8 years. The mean Charlson score was 3. Fifty percent were admitted from an institutional setting. The overall 1-year mortality was 21.2%. Age (odds ratio [OR] = 1.03, 95% confidence interval [CI] = 1.00-1.05; P = .02), male gender (OR = 1.55, 95% CI = 1.01-2.36; P = .04), low Parker mobility score (OR = 2.94, 95% CI = 1.31-6.57; P = .01), and a Charlson score of 4 or greater (OR = 2.15, 95% CI = 1.30-3.55; P = .002) were predictive of 1-year mortality. ADL dependence was a borderline predictor, as was medium Parker mobility score. Prefracture residence and moderate comorbidity (Charlson score of 2-3) were not independently predictive of mortality at 1 year after adjusting for other characteristics. A comprehensive comanaged hip fracture program for elders not only improves the short-term outcomes but also demonstrates a low 1-year mortality rate, particularly in patients from nursing facilities.

Increased Fall Rates in Nursing Home Residents After Relocation to a New Facility

OBJECTIVE: To examine the change in fall rates after relocation of nursing home residents from one facility to another and to identify resident risk factors for changes in falls following relocation.

Epidemiology of Fragility Fractures

As the world population of older adults-in particular those over age 85-increases, the incidence of fragility fractures will also increase. It is predicted that the worldwide incidence of hip fractures will grow to 6.3 million yearly by 2050. Fractures result in significant financial and personal costs. Older adults who sustain fractures are at risk for functional decline and mortality, both as a function of fractures and their complications and of the frailty of the patients who sustain fractures. Identifying individuals at high risk provides an opportunity for both primary and secondary prevention.

A Guide to Improving the Care of Patients With Fragility Fractures

This monograph is written as a guide for physicians, nurses, therapists, and students interested in ideal care for their patients with fragility fractures. The scope of fragility fractures in the United States is large and will grow over the next 20 years as the population ages. There is much that can be done currently to idealize the outcomes of these patients. Additional research in many areas is needed to further improve the quality of care for these patients. We plan to update this monograph as new information concerning the care of seniors with fragility fractures develops.

The impact of comorbidity on perioperative outcomes of hip fractures in a geriatric fracture model.

Background: Older adults who sustain hip fractures usually have multiple coexisting medical problems that may impact their treatment and outcomes. The geriatric fracture center (GFC) provides a model of care that standardizes treatment and optimizes outcomes. The purpose of this study is to determine whether GFC patients with a higher burden of comorbidity or specific comorbidities are at risk for worsened perioperative outcomes, such as increased time to surgery (TTS), postoperative complications, and longer length of hospital stay (LOS). Method: A total of 1077 patients aged 60 years and older who underwent surgery for a proximal femur fracture between April 15, 2005, and September 30, 2010, were evaluated. Comorbidities measured in the Charlson Comorbidity index were abstracted through chart review. Outcomes were TTS, postoperative complications, and LOS. Results: Most patients were white, with an average age of 85. One half lived in either a nursing home or an assisted living facility. The mean Charlson score was 3.06 and the nursing home residents had a significantly higher score compared to community dwellers (3.4 vs 2.8; P < .0001). Dementia was the most common comorbidity. There was no difference in the LOS or TTS based on Charlson score. The overall complication rate was 44% with delirium being the most common postoperative complication. Peripheral vascular disease, history of solid tumor, and peptic ulcer disease predicted delirium incidence. Charlson score predicted complication risk, with an odds ratio of 1.12 for each point increase. Conclusion: Frailty and comorbidity put this hip fracture population at high risk for adverse perioperative outcomes. This study shows that in the GFC model of care the comorbidity burden did not impact the TTS and LOS but did predict postoperative complication rate.

Principles of comanagement and the geriatric fracture center.

This article describes the principles of comanagement in an optimized geriatric fracture center. This is a collaborative model of care that uses patient-centered, protocol-driven care to standardize the care for most patient fragility fractures. This model also uses shared decision making and frequent communication to improve clinically relevant outcomes. The orthopedic and medical teams are equally responsible from admission to discharge and are responsible for daily evaluation and clinical management of the patient.