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Komorbiditet og ortopædkirugi - erfaringer og viden Benn Rønnow Duus, Ledende overlæge, Ortopædkirurgisk afdeling

Bispebjerg Hospital

Kræft og komorbiditet – alle skal have del i de gode resultater Kræftens Bekæmpelse 6. marts 2013

Diclosures

• None relevant for this presentation • No relation to industry

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The talk • Demographics • Comorbidity • Change in pathways hip fx. patients • Our results • Different models of care • Orthogeriatrics • Our experiences and results

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Demographics in Denmark

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National statistic bureau, Denmark

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Challenges in general

Fall-related Hospital admissions

0

5000

10000

15000

20000

25000

30000

2003

2006

2009

2012

2015

2018

2021

2024

2027

2030

2033

2036

2039

85-

80-84

75-79

65-74

Age standardized hip fx rate (women)

SY Cheng et al; Osteoporosis int 2011

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The burden of hip fractures Beijing, China Figures from 1990 -1992 and 2002 – 2006

• Age specific rates of hip fracture

• > 50 years – 2.7 fold increase in women and 1.6 in men

• >70 years

– 3.8 fold increase in women and 2.0 fold in men

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Xia WB et al, J Bone Miner Res 2011

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Comorbidity and mortality in hip fx patients

Kannegaard et al, Age and Ageing 2009

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0.75

1.00

No dementia

Dementia

0.75

1.00

No delirium

Delirium

0.50

0.75

1.00

0 20 40 60 80 100

Barthel ≥ 50

Barthel < 50

Mortality predicted by dementia, delirium and Barthel score

Gentofte n= 645, Age 84.7 , Sex ratio f/m 0.73/0.27

P < 0.0001

P = 0.0004

P = 0.0004

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Change of adresses and admittances to nursing homes

0

10

20

30

40

50

60

70

80

90

100

-5 -4 -3 -2 -1 0 1 2 3 4 5

year

num

ber

average average + 2 SD nursing home admittances total change of adresses

Cohort of 1397 patients sustaining a hip fracture Petersen MB et al, Injury 2006

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X-ray

E:R

Acute bed ward

Operation

theater

E.R

1 of 4 bed wards

Pathway of Hip Fx Patients

Optimized hip fracture program Bispebjerg Hospital, Univ CPH

• Aim: Reduce complications

• Reduce waiting routines • Develop a Hip fracture room in the Emergency Department • Early anaesthesiological evalutation, before the orthopedic surgeon • Pain killers immediately (paracetamol) • Reduce thirst periods – nutrition and soft drinks orally immediately

after admission • Pre og postop.: Femoral nerve catheter og non-opioid pain treatment • Operation: Spinal anaesthesia, femoral, ischiadicus and sacral block • Training center in the bed ward • Defined patient care, multimodal team function • Personal physio, nurse and physician • Systematic schematic hip fracture medical record • Intracutaneous suture

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Pedersen SJ, J Am Geriatr Soc 2008

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E.R.

X-ray

Hip Fracture Unit

Operation theater

Optimized Program – Hip Fx Unit RUN BY ORTHOPAEDIC SURGEONS

Femoral nerve catheter VAS score postop in a hip fracture patient

• Effective pain relief • Immediate effect on

pain at rest • Mobilisation is possible

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Pedersen SJ, J Am Geriatr Soc 2008

Urinary tract infection Optimized Hip Fracture Program

Controls 357 Opt Prg 178

Pedersen SJ et al, J Am Geriatr Soc 2008

02468

1012141618

UVI

controlsIntervention

15

% P = 0.001 17.4 %

5.1 %

Pneumonia Optimized Hip Fracture Program

Controls 357 Opt Prg 178

Pedersen SJ et al, J Am Geriatr Soc 2008

0

2

4

6

8

10

12

controlsIntervention

16

% P = 0.03 10.6 %

5.1 %

Mean Hospital Stay Following Hip Fracture Pedersen SJ et al, J Am Geriatr Soc 2008

02468

10121416

ControlOpt prg

• I / C 178 / 357

• Intervention 9.7 d • Controls 15.8 d

• T-test p < 0.05

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Hospital stay - days

Mortality & place of residence Optimized hip fx programme

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Community dwelling

0 100 200 300 400 500 0 100 200 300 400 500

Nursing home 1.00

0.75

0.50

0.25

0.00

1.00

0.75

0.50

0.25

0.00

Days

p=0.02

p=0.9

Optimised pathway

Controls

N(C)=260 & N(I)=116 N(C)=97 & N(I)=62

Pedersen SJ et al, J Am Geriatr Soc 2008

The Challenge for a hip fx unit - run by Orthopaedic Surgeons

• The care of hip fx patients are demanding • Old patients with high comorbidity • High percentage of polypharmacy • Heavy social problems • Not the primary goal for orthopaedic

surgeons – after the first optimism! The unit had to be closed – even

though it was a huge succes! 19

Models of care • Traditional orthopaedic care

• Hip Fracture unit run by orthopaedic surgeons

• Geriatric Orthopaedic Rehabilitation Unit

• Orthogeriatric liaison and Hip Fracture Nurse

• Combined Orthogeriatric care

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Care and rehabilitation of patients with hip fracture is the central challenge for trauma services; and those that can provide good care for these patients will cope well with the range of other fragility fractures

Looking after hip fracture patients well - is a lot cheaper than looking after them badly.

BOA – BGS Blue Book Statements 2007

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Multidisciplinary rehabilitation for older people with hip fractures (2009) Handoll HHG, Cameron ID, Mak JCS, Finnegan TP

Authors’ conclusions While there was a tendency to a better overall result in patients receiving multidiscipli-nary inpatient rehabilitation, these results were not statistically significant. Future trials of multidisciplinary rehabilitation should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than evaluate its components.

Combined orthogeriatric care

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A H-C Leung et al, Trauma 2011

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Comprehensive care

Pioli G, et al Eur J Phys Rehabil Med 2011

The implementation of a comprehensive and multidisciplinary co-care model in an orthopedic unit is a difficult task because it is necessary to change cultural attitudes related to traditional model of care

Our department • 89 beds • 5 different wards • 20 specialists • 36 younger doctors • 185 nurses and nurse asistents • 5600 operations/year • 22000 outpatient visits • 45000 emergency visits • 650 hip fracture patients

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Challenges for our department

2008 patient evaluation

• 67 % > 65 years

• 75 % had significant medical comorbidity

• High percentage of polypharmacy

• Internal working group consisting of professionals

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The hip fracture patient is

not an orthopaedic patient with a medical comorbidity, but

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Orthogeriatric ward 2009

• Geriatrician daily leader of ward – close cooperation with committed surgeons

• Patients with severe medical conditions regardless of fracture type – 50% of all hip fracture patients

• Full geriatric assessment upon arrival – Medical history, medication, comorbidity, osteoporosis

• Systematic and standardized monitoring and interventions – Focus on delirium, infections, urinary retention, pain-assessment

• Early discharge planning

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Before After Orthogeriatrics Orthogeriatrics P-value

N 456 818

Sex (male % / female%) 28.7%/71.3% 28.7%/71.3% 1

Age (years) 80.3 (12.6) 80.5 (12.2) 0.8

Length of stay (days) 13.1 (11.4) 12.3 (8.4) 0.2

ASA 2.3 (0.7) 2.4 (0.7) 0.005

Data base population N=1274

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0,0

2,0

4,0

6,0

8,0

10,0

12,0

Sep-2008

Dec-2008 Mar-2009

Jun-2009 Sep-2009 Dec-2009 Mar-2010

Percent

In-hospital mortality (Average)

Before orthogeriatrics N=456, Ndead=35

After orthogeriatrics N=818, Ndead=32

Jun-2010 Sep-2010 Dec-2010 Mar-2011

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0,2

0,4

0,6

0,8

1

Odds ratio for In-hospital death After vs before Orthogeriatrics – P=0.004 Univariate analysis

OR

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0

5

10

15

20

25

30

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Three months mortality (Average)

Sep-2008

Dec-2008

Mar-2009

Jun-2009

Sep-2009

Dec-2009

Mar-2010

Jun-2010

Sep-2010

Dec-2010

Mar-2011

Before orthogeriatrics N=352, Ndead=104

After orthogeriatrics N=677, Ndead=141

0

0,2

0,4

0,6

0,8

1 Odds ratio for Three months mort. After vs before Orthogeriatrics – P=0.02 Univariate analysis

Percent OR

32 Department of Orthopaedic Surgery, Bispebjerg Hospital, Denmark

RE

GIO

N

0

0.5

1

1.5

2

2.5

3

Multivariate cox regression analysis ofthree months mortality risk

Hazard ratio for death

Orthogeriatricsvs no orthogeriatrics

Male gender vsfemale gender

Per ASAincrement

Age, per10 years

P<0.0001

P<0.0001

P=0.001

P=0.004

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Orthogeriatric ward

Length of Stay reduced 10.7 → 9 days (Oct. 2009 to Aug. 2010)

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The Bispebjerg Model – cultures are merging

• Significant decrease in mortality - in-hospital and 3 months • 30 days mortality below national level • Reduced Length of Stay • Osteoporosis evaluation and treatment • Systematic evaluation, care and treatment

• Delirium decreased

• General quality improved • “New tool for the surgeons” • Change of budget – surgeons replaced by geriatricians

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The Bispebjerg Model – cultures are merging

• Identify the challenges • Analyse the problem • Involve the professionals • Decide the rational changes • Implement the changes • Stick to the decisions

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