Progetto di ricerca Regione-Università Ortogeriatria: i risultati

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1 Bologna 26 novembre 2010 Progetto di ricerca Regione-Università Ortogeriatria: i risultati Giulio Pioli Azienda Ospedaliera di Reggio Emilia

2 Flow chart of the study Prospective observational study (audit) 4 general hospital with orthopedic geriatric liaison BO FE PR RE subjects # Enrolled all subject 75 consecutively admitted with fragility hip fracture over a twelve months period (unselected population of a similar catchment area except one #) anagraphical registries 1-year mortality Structured telephone questionnaire 1-year functional status and burden 3 rd month 51 lost to follow up 6 th month 46 lost to follow up 12 th month 42 lost to follow up 1-year follow up trough telephone interview to patient or caregiver after 3, 6 and 12 months

3 Flow chart of the study Intervention trial vs historical control 3 general hospital with an orthogeriatric model recently implemented BO PR RE All subject 75 admitted with fragility hip fracture during the previous year 1-year mortality Surgical data Length of stay anagraphical registries administrative data medical records

4 Analisi dei dati Caratteristiche basali dei pazienti e identificazione di profili tipici (4 centri) Analisi dei percorsi assistenziali nei diversi centri (4 centri) Confronto dei risultati tra i diversi modelli (3 centri) Confronto del modello ortogeriatrico con un controllo storico (3 centri)

5 Baseline Patient Characteristics BO FE PR RE p No Age (mean ± SD) 86,1 ± 5,6 85,9 ± 5,4 85,4 ± 5,6 85,5 ± 5,7,563 Sex (male %) 23,8% 19,1% 21,9% 27,6%,133 Living in nursing home (%) 15% 4% 7% 9%,002 Fracture type (intracapsular %) * 49% 49% 40% 43%,193 Charlson index 2,8 ± 1,8 2,1 ± 1,8 2,3 ± 1,1 2,6 ± 1,9 Score 5 14% 12% 4% 17%,000 Fully independent in 5 * 47% 50% 35% 43% ADL * Independent walk (%) 69% 63% 43% 75%,000 Stair climbing (%) 34,5% 28,4% 5,9% 32,1%,009 Dementia (%) 62% 62% 67% 63%,832 APS (mean score ± SD) 2,6 ± 2,2 2,6 ± 2,4 1,1 ± 0,9 3,4 ± 3,1,000 * * *

6 Baseline functional status and comorbidity Pooled analysis 974 subjects ADL (mean score 3.9 ± 2.0) Ambulation Stairs Charlson index (mean score 2.5 ± 1.8) Cognitive impairment (SPMSQ 7) Depression (GDS-5 2) Acute Physiology Score (mean score 2.5 ± 2.2)

7 Falls and bone health Type of falls BO FE PR RE ALL p Extrinsic factors 43% 33% 51% 31% 39% Intrinsic factors 24% 39% 36% 44% 36% Unpredictable 14% 7% 10% 7% 10% ND or other trauma 18% 20% 3% 17% 16% Falls in the previous year Previous osteoporosis evaluation no yes

8 Vitamin D status BO FE PR RE ALL p 25-OH2-(ng/ml) 13,0 ± 8,5 10,4 ± 9,2 19,1 ± 9,43 8,7 ± 7,9 12,2 ± 9,4,000 PTH (pg/ml) 94,6 ± 61,2 94,7 ± 68,24 80,4 ± 31,0 144 ± ± 80,000 Hyper-PTH (%) 52% 51% 60% 75% 60% Vitamin D status < 20 ng/ml ng/ml > 30 ng/ml Vitamin D supplementation *

9 Pathways of Care Pre OP Post OP PARE Rehab Rehab SNH home NH In hospital Out of hospital Acute Hospital stay Post acute Rehabilitation Post acute Rehabilitation Home / Nursing Home

10 Pre-operative stay Pre OP Post OP PARE Rehab Reha b SNH home NH Conservative In hospital Surgery delay Out of hospital Percent of subjects operated within 48 h All 4% 3.4 ±2.9 44% 5% 2.7 ±2.3 60% 6% * 5.2 ±3.2 10% 2% 1% 2.8 ± ±2.1 60% 47% * Significant Difference (ANOVA with post hoc comparison)

11 In-hospital stay Pre OP Post OP PARE Rehab Reha b SNH home NH In hospital Orthopedic ward Transferred to other ward Out of hospital Total hospital stay (acute phase) All 12,9 ±6,3 7% 14,6 ±14,3 * Significant difference 11,6 ±5,2 6% 13,3 ±8,78 11,5 ±5,5 4% 12,1 ±5,9 15,0 ±7,6 * 10% * 17,1 ±9,7 * 14,4 ±6,1 * 7% 15,5 ±7,2 *

12 Early rehabilitation Percent of patients with full weight bearing and able to ambulate before fracture 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% stand in the upright position for 2 minutes Postoperative day

13 Early rehabilitation Percent of patients with full weight bearing and able to ambulate before fracture 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Postoperative day Ambulation for 5m

14 Post-acute Rehabilitation Pre OP Post OP PARE Rehab Reha b SNH home NH In hospital Out of hospital In-hospital PA Rehab All (community) 38% 63% 49% 9% 19%

15 Post-acute Rehabilitation Pre OP Post OP PARE Rehab Reha b SNH home NH In hospital In-hospital PA Rehab Out of hospital Out-of--hospital PA Rehab All (community) 38% 22% 63% 13% 49% 24% 9% 31% 19% 22%

16 Post-acute Rehabilitation Pre OP Post OP PARE Rehab Rehab SNH home NH In hospital Out of hospital In-hospital PA Rehab Out-of--hospital PA Rehab HomeRehab All (community) 38% 22% 8% 68% 63% 13% 6% 82% * 49% 24% 11% 84% * 9% 31% 18% 58% 19% 22% 41% * Significant difference

17 Changes in functional status: ADLs Activities of Daily Living 5 items (bathing, dressing, toileting, transferring, eating) Fully independent ADLs = 5 Partially independent ADLs = 2-4 Totally dependent ADLs = 0-1 Before fracture 3 rd month 6 th month 12 th month

18 Changes in functional status at 6 th month Activities of Daily Living 5 items (bathing, dressing, toileting, transferring, eating) Subjects able in 2 or more ADL before fracture (80% of the whole sample) 80% 60% Percent of survivals 48% 56% 46% Lower functional level 1 ADL lost 2 ADL lost 40% 20% 36% Same functional level 0% BO FE RE All

19 Changes in functional status at 6 th month variable OR 95% CI p Age (years) Multivariate logistic regression Dependent variable: lower functional status (ADL 1 lost) Male sex (yes/no) Charlson index (score) ADL prefracture ability (no.) Cognitive impairment (yes/no) centers Reference , Cohort: subjects able in 2 or more ADL before fracture (80% of the whole sample)

20 Changes in functional status: ambulation Ability to walk with or without tools Independent walking with or without tools Able to walk with help Unable Before fracture 3 rd month 6 th month 12 th month

21 Changes in functional status at 6 th month Ambulation Subjects able to walk independently with or without tools before fracture (69% of the whole sample) 100% Percent of survivals 80% 60% 65% 74% 65% 67% Still independent in walking 40% Worsened walk 20% Requiring help to walk 0% BO FE RE All Unable to walk

22 Changes in functional status at 6 th month variable OR 95% CI p Age (years) Multivariate logistic regression Dependent variable: independent ambulation at 6 month Male sex (yes/no) Charlson index (score) ADL prefracture ability (no.) Cognitive impairment (yes/no) centers , Reference Cohort: subjects able to walk independently before fracture (69% of the whole sample)

23 Changes in functional status at 6 th month Rate of subjects still independent in walking (raw data) Postacute rehabilitaion yes no Group4 Multivariate logistic regression Dependent variable: independent ambulation at 6 month Group3 82% 68% 63% 60% Group2 yes Group1 no Early rehabilitation Ambulation within POD 3 variable OR 95% CI p Age (years) Male sex (yes/no) Charlson index (score) ADL prefracture ability (no.) Cognitive impairment (yes/no) Rehabilitation Group 1 (no/no) Group 2 (yes/no) Group 3 (no/yes) Group 4 (yes/yes) reference All subjects with independent walk before fracture were included (69% of sample)

24 Changes in functional status at 6 th month Postacute rehabilitaion Rate of subjects bed ridden (raw data) yes no Group4 Multivariate logistic regression Dependent variable: bed ridden at 6 month Group3 5% 15% 9% 25% Group2 yes Group1 no Early rehabilitation Ambulation within POD 3 variable OR 95% CI p Age (years) Male sex (yes/no) 1, Charlson index (score) ADL prefracture ability (no.) Cognitive impairment (yes/no) Rehabilitation Group 1 (no/no) Group 2 (yes/no) Group 3 (no/yes) Group 4 (yes/yes) reference All subjects walking before fracture even with help (96% of sample)

25 Changes in functional status at 6 th month Ambulation Subjects requiring help to walk before fracture (27% of the whole sample) 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent of survivals BO FE RE All independent in walking Requiring help to walk Unable to walk

26 Rate of transition at 18 months Deaths 4.2% Deaths 4.9% Deaths 13.1% 40.1% 24.9% Non frail Intermediate Frail 11.9% 23% 51.5% 58.3% 63.9% 754 community-living persons, aged 70 years or older, nondisabled in 4 essential activities of daily living. Frailty defined on the basis of Fried criteria assessment every 18 months for 54 months

27 Medical complication during hospital stay All subjects 70% 60% 50% 40% 45% 39% 47% 44% cardiac infective 30% all 20% 10% 0% BO FE RE All

28 Medical complication during hospital stay 30% 25% Infective 30% 25% Cardiac 20% 20% 15% 15% 10% 10% 5% 5% 0% Pre-S % Pre-S % 25% Other medical 20% 15% 10% 5% 0% Pre-S Distribution of complications during hospital stay Relative percent of total incidence

29 mortality Probability of survival 1,0 0,8 Probability of death variable HR 95% CI p Age (years) Male sex (yes/no) Charlson index (score) ADL prefracture (no.) , days 400 Cognitive impairment (yes/no) centers Ref Survival curves of patients in the four hospitals Multivariate Cox regression

30 mortality Probability of survival 1,0 0,8 Probability of death variable HR 95% CI p Age (years) Male sex (yes/no) Charlson index (score) ADL prefracture (no.) , days 400 Cognitive impairment (yes/no) centers Ref Surgery delay (days) Survival curves of patients in the four hospitals Multivariate Cox regression including surgery delay

31 Survival after hip fracture Orthogeriatric intervention vs historical control 1,0 1,0 1,0 survival probability 0,8 0,6 survival probability 0,8 p = 0,158 p = 0,683 0,6 survival probability 0,8 0,6 p = 0,885 p = 0,158 p = 0,683 p = 0, days days days 400 Orthogeriatric unit: comanaged care Orthopedic unit: comanaged care Orthopedic unit: Consultant geriatric

32 Survival after hip fracture Orthogeriatric intervention vs historical control Pooled data of the 2 centers with comanaged model (1155 subjects) 1,0 intervention RRR 17% survival probability 0,8 p = 0,072 RRR 9% p = 0,175 control 0, days 400

33 Operative delay Percent of subjects operated within 48 hour Orthogeriatric intervention vs historical control p = 0, p = 0,000 p = BO RE PR

34 Mortality rate 25 mortality at 90 days R = 0.76; p = percent of subjects operate within 48 h

35 Key points in a complex system Hip fracture Surgical delay Early Rehab Post-Ac Rehab Falls & bone Long term outcomes (mortality and functional status) Center 1 Center 2 Center

36 Key points in a complex system Hip fracture Surgical delay Early Rehab Post-Ac Rehab Falls & bone Long term outcomes (mortality and functional status) woman 85 years old with high comorbidity but able to walk (with or without help) Alive after 6 months Mean probability on the basis of observed data Probability in the best situation (raw data) Still able to walk 82% 85% 86% Up to 95%

37 Conclusioni Il percorso del paziente con frattura di femore sembra differente non solo per il tipo di assistenza in fase acuta (modello ortogeriatrico diverso) ma anche nella fase postacuta e nell accesso ai servizi Il confronto tra i modelli ortogeriatrici non è semplice in quanto sebbene la gestione della fase acuta sia cruciale per gli outcome a lungo termine, anche la gestione successiva può influire sul risultato finale In ogni modello analizzato vi sono punti di forza e punti di debolezza spesso diversi tra loro. Con i limiti derivati da studi osservazionali e da controlli non randomizzati, l insieme dei dati sembra comunque a favore di modelli di comanagment con responsabilità separate rispetto a quelli consulenziali La gestione del paziente con frattura di femore dovrebbe comunque essere considerata un sistema complesso in cui numerosi aspetti devono essere ottimizzati per ottenere elevati risultati.