Monteore Journal of Musculoskeletal Medicine and Surgery
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Roe J, Merwin S, Cavaluzzi P, Horn W. Monteore comprehensive model of care for elderly patients with hip fractures. Monteore J Musculoskelet Med
Surg. 2016;1(1):40-4. http://dx.doi.org/10.12678/2470-3680.1.1.40
Monteore Comprehensive Model of Care for
Elderly Patients with Hip Fractures
John Roe, M.D., Sara Merwin, M.P.H., Paul Cavaluzzi, D.O., and Wanda Horn, M.D.
John Roe, M.D., Sara Merwin, M.P.H., Paul Cavaluzzi, D.O., and
Wanda Horn, M.D., Department of Orthopaedic Surgery, Monte-
ore Medical Center, Bronx, New York.
Correspondence: Sara Merwin, M.P.H., Department of Orthopaedic
Surgery, Monteore Medical Center, 11 East 210th Street, Bronx,
New York; smerwin@monteore.org.
Abstract
Background: Hip fractures are highly prevalent in the geri-
atric population, accounting for signicant morbidity, mortal-
ity, and health-care associated costs. Geriatrics hip fracture
comanagement is a systems-based approach to optimize care
of these patients, prevent further decompensation, and reduce
costs associated with the inpatient stay and consequent sequelae.
is study examines preliminary results aer implementation
of orthopaedic and geriatrics hip fracture comanagement at our
large, urban, single center academic medical center.
Methods: is is a program evaluation comparing a novel
multidisciplinary service with usual care in 120 consecutive,
operatively managed hip fracture patients, aged 65 years or
over, in 2011. Patients with pathologic fractures, multiple injury
trauma, or requiring a monitored unit were excluded. Groups
were compared for age, sex, revised cardiac risk index (RCRI),
presence of delirium, and admission disposition. Outcome
measures included time to surgery, perioperative complications,
in-hospital mortality, length of stay (LOS), and 30 day readmis-
sion. Institutional Review Board approval was obtained prior
to the implementation of this initiative.
Results: Mean age, sex, admission disposition, RCRI score,
time to surgery, perioperative complications, in-hospital mor-
tality, and 30 day readmission did not dier between the two
groups. In the comanagement cohort, there was a signicant
increase of delirium diagnosis (3.8% versus 22%, p = 0.007)
and a reduced length of stay (7.1 versus 4.9 days, p = 0.008).
Conclusions: e results from this preliminary programmatic
implementation suggest that orthopaedic-geriatrics comanage-
ment reduced LOS by 2 days. Complications, readmissions,
and in-hospital deaths were similar. ere were higher rates of
delirium noted in the comanagement group, which we attribute
to increased surveillance, detection, and documentation and
similar to rates seen in comparable programs. Our investigation
supports the experience in other centers in which a systems-based
program with well-dened principles and protocols improves
processes and outcomes for a common condition in a high-risk
population.
G
eriatric hip fractures constitute a life-dening, senti-
nel event, and frequently foretell functional decline
and downward spiral in those aicted. Hip fractures
accounted for 258,000 hospital admissions in 2010 and are
expected to rise 12.3% by 2030 as longevity and the propor-
tion of older Americans increase. Hip fractures account for
72% of osteoporotic fractures, costing $13.5 billion per year.
irty percent of patients sustaining a hip fracture require
care in skilled nursing facilities, and the associated mortality
is 20% within 1 year.
1
e goals of surgical intervention are
pain control, return to prior functional status, and reducing
morbidity while improving quality of life.
roughout the last decade, there has been signicant
eort to reduce morbidity and mortality among elderly hip
fracture patients, resulting in heightened use of evidence-
based approaches based on research ndings. Rapid time to
surgery, and early and aggressive physical therapy, osteoporo-
sis management, early and continued comprehensive medical
care have been demonstrated as eective strategies and have
determined the direction of optimization.
2-4
A systems-based
approach of coordinated medical and surgical care between
services has focused on postoperative optimization, decreas-
ing length of stay, reducing morbidity and mortality, and
enhancing functionality. Several models of care have been
proposed and implemented: 1. orthopaedics as the primary
service with medicine or geriatrics consulted as needed, 2.
41
Monteore Journal of Musculoskeletal Medicine and Surgery
orthopaedics as the primary service with immediate, proac-
tive medical consultation, 3. medicine or geriatrics as the
primary service with orthopaedics consulted for surgery,
and 4. shared medical and orthopaedic comanagement.
5
Hospitalist comanagement has been in existence since 2005,
with 85% of hospitalist programs participating; the longest track
record is for patients with orthopaedic diagnosis related groups
(DRGs).
6
To date, there have been few studies worldwide exam-
ining geriatrics comanagement. In Australia, it was shown that
morbidity and mortality rates decreased with geriatrics co-care
when compared with a consultation model.
7
e “Sheba” model
from Israel evaluated 3,114 hip fractures comparing an ortho-
paedic service with the geriatric hip fracture unit and found
the geriatric hip fracture unit to have lower 90 day mortality
rates despite an older population with a greater prevalence of
comorbidities.
8
In 2008, Friedman and coworkers developed the
Rochester (NY) Model which outlined specic principles upon
which to base a geriatric hip fracture comanagement program:
1. most patients benet from surgical stabilization, 2. short time
to surgery limits iatrogenic illness, 3. frequent communication
between services limits iatrogenesis, 4. standardized protocols
decrease unwarranted variability, and 5. discharge planning
begins at admission.
9
Clinical implementation of these prin-
ciples include daily assessment by geriatrics and orthopaedics,
rapid preoperative medical optimization, early identication of
individual goals for multidisciplinary rehabilitation, continued
and coordinated re-evaluation of clinical data, and clinical and
service responsibilities for all stages of care.
10
Particular features
requiring attention in geriatric patients include serial cognitive
assessments, screening for depression and substance abuse, risk
factors for postoperative delirium, nutritional and functional
status, polypharmacy, postoperative goals, expectations, and
caregiver support (Fig. 1). To address these concerns, our
program has implemented a protocol beginning on arrival to
the emergency department and continuing through outpatient
follow-up (Fig. 2).
is study examines the eect of the orthopaedic-geriat-
rics comanagement (OGC) program at Monteore Medical
Center in the Bronx, NY, compared with a usual care model
in geriatric hip fracture admissions during 2011. Based upon
the precepts of the Rochester model, we sought to investigate
if OGC would lead to a constellation of improved outcomes,
including reduced time to the operating room, lowers rates
of postoperative complications, shorter length of stay (LOS),
less mortality, and fewer readmissions.
Material and Methods
is is a program evaluation comparing a novel multidisci-
plinary service with usual care in 120 consecutive, operatively
managed geriatric hip fracture patients admitted to a large
urban academic medical center in the Bronx during 2011.
Institutional Review Board approval was obtained prior to
the implementation of this initiative.
Male and female patients 65 years or older (range: 65 to 99
years of age) were included in the analysis. All fractures of the
proximal femur were included (ICD 9 codes: 82000-82003,
82009-82013, 82019-82022, 82030-82032, 8208, and 8209).
Exclusions were pathologic fractures, multiple injury traumas,
critical patients requiring cardiac or intensive care monitoring,
and patients already admitted to medical units. e intervention
consisted of an OGC model designed to improve processes of
care to enhance outcomes for the test cohort. is involved both
services independently assessing the patient in the emergency de-
partment before admission with continued care through patient
discharge. All hip fracture patients admitted to the orthopaedic
service that did not have a PCP with admitting privileges to our
hospital were included in the OGC cohort. All other patients
were included in the usual care cohort which functioned as
Figure 1
Principles of an orthopaedic-geriatric hip fracture
comanagement model. Adapted from Friedman and coworkers.
9
Figure 2 Timing and specic interventions as outlined by our
orthopaedic-geriatrics comanagement protocol from evaluation in
the ED to continued outpatient follow-up.
Monteore Journal of Musculoskeletal Medicine and Surgery
42
the control group and utilized the traditional medicine consult
practice on an as-needed basis with the consult service signing
o once the patient was stabilized (Fig. 3).
Patient characteristics including age, sex, admission dis-
position, RCRI category, and presence of delirium (dened
as a change of mental status at any time from presentation to
discharge as compared to baseline) were compared between
the two groups (Table 1). e Revised Cardiac Risk Index
(RCRI) is a validated tool that is used to estimate patient risk
of perioperative cardiac complications, described in 1999
derived from 2,893 patients and validated in 1,422 patients,
aged greater than or equal to 50 undergoing major noncardiac
surgery. e RCRI combines six independent variables that
predict an increased risk for cardiac complications: supra-
inguinal, vascular, intraperitoneal, or intrathoracic surgery,
history of congestive heart failure, history of cerebrovascular
disease (stroke or transient ischemic attack), history of diabetes
requiring preoperative insulin use, and chronic kidney disease
(creatinine > 2 mg/dL). Based on this risk calculator, patients
may be stratied as low cardiovascular risk (0 predictors =
0.4% risk of cardiac death, nonfatal cardiac arrest, and nonfatal
myocardial infarction), intermediate (1 to 2 predictors = 1%
to 2.4% risk), and high risk (3 to 6 predictors = > 5.4% risk).
11
Outcome measures included time to surgery, length of
stay, perioperative complications, in-hospital mortality, and
30-day readmission rates.
Statistics
Data were analyzed using SPSS version 20.0 with alpha level
set at 0.05 and beta level at 80%. We calculated measures of
central tendency (means, medians, and standard deviations)
and compared continuous data with t-tests and ANOVA. All
data was assumed to be parametrically distributed. Categori-
cal variables were compared using the chi-square test and in
the case of small cell frequencies, Fisher’s exact test.
Results
One hundred twenty patients with hip fractures admitted to
our hospital between January 2011 and December 2011 met
inclusion criteria: 52 patients in the usual care group, and 68
Figure 3
Study ow diagram.
Table 1 Clinical and Demographic Characteristics in Operatively Managed Hip Fracture
Patients in the Usual Care and the Orthopaedic-Geriatrics Comanagement Groups
Usual Care
(N = 52)
Orthopaedic-Geriatrics
Comanagement
(N = 68) P-Value
Age (years) 83.4 ± 7.8 85.2 ± 7.7 0.22
Women 39 (75%) 50 (73%) 0.99
Community Dwelling 37 (71%) 49 (72%) 0.53
Revised Cardiac Risk Index (RCRI)
Low Risk 17 (32.7%) 22 (32%)
Intermediate Risk 31 (59.6%) 38 (56%) 0.67
High Risk 4 (7.7%) 8 (12%)
43
Monteore Journal of Musculoskeletal Medicine and Surgery
patients in the comanagement group. e age range of patients
was from 65 to 99 years old with an average age in each group
of 83.4 ± 7.8 and 85.2 ± 7.7, respectively (p = 0.22). e number
of females in each group was 39 (75%) and 50 (73%), p = 0.99.
For both groups, there was a similar number of patients resid-
ing at home prior to admission: 37 (71%) versus 49 (72%). e
RCRI scores did not dier between the two groups: low risk, 17
(32.7%) versus 22 (32%); intermediate risk, 31 (59.6%) versus 38
(56%); and high risk, 4 (7.7%) versus 8 (12%); p = 0.67. Time to
surgery in days (1.1 ± 1.0 versus 0.8 ± 0.8, p = 0.15), frequency
of perioperative complications [7 (13%) versus 9 (13%), p =
0.99], in-hospital mortality [2 (4%) versus 0 (0.0%), p = 0.15],
and 30-day readmissions [7 (13%) versus 11 (16%), p = 0.42]
were not signicantly dierent. ere was a signicant increase
of delirium diagnosis in the comanagement group [2 (3.8%)
versus 15 (22%), p = 0.007] but a reduced length of stay (7.1 ±
6.2 versus 4.9 ± 2.2 days, p = 0.008), (Table 2 and Fig. 4).
Discussion
e results from this preliminary programmatic implemen-
tation suggest that in patients with operatively-managed
hip fractures, OGC leads to a reduced length of stay by ap-
proximately 2 days at our institution. Baseline characteristics
were similar between the two groups; however, there were
higher rates of delirium noted in the OGC group: a para-
doxical nding. It would be expected that delirium would be
decreased with OGC involvement due to an amplied focus
on population-specic adjustments to pain control, environ-
mental stimuli, polypharmacy, and geriatric syndromes such
as constipation, urinary retention, poor nutrition, and immo-
bilization. However, we believe that this nding arises from
an increased awareness and diagnosis of delirium with the
continued evaluation by a geriatrician trained in its detection.
is phenomenon is supported by similar rates of delirium
found in the Rochester Model, 24.1% compared to the 22%
in our investigation. Of note, the Rochester comanagement
model found similar rates to our model with respect to in-
hospital deaths (2.6%), 30-day readmission (10.4%), length of
stay (4.3 days), with a 21.2% mortality rate at 1 year, and total
cost of care of $15,188 versus $33,693 before the implementa-
tion of their program.
10
A major focus of an OGC program is on prompt identica-
tion, work-up, and management of delirium as it can aect
LOS, cost, rehabilitation, and overall medical and surgical
outcomes. Postoperative delirium can occur in up to 50% of
patients and is higher in femoral neck and intertrochanteric
fractures and patients with underlying cognitive impairment.
Postoperative delirium peaks at day 2, and there are no known
associations with the route of anesthesia, heart rate, or ane-
mia.
12,13
In patients diagnosed with postoperative delirium,
a signicant decline was seen in ADLs, ambulation, and
increases in death or nursing home placement.
14
e same
group found that proactive geriatrics consultation, in contrast
to usual care, signicantly reduced cumulative delirium and
Table 2 Comparison Between Patients Undergoing Hip Fracture Surgery in the Usual Care
and the Orthopaedic-Geriatrics Comanagement Groups
Usual Care
(N = 52)
Orthopaedic-Geriatrics
Comanagement
(N = 68) P-Value
Time to Surgery (Days) 1.1 ± 1.0 0.8 ± 0.8 0.15
Complications 7 (13%) 9 (13%) 0.99
Delirium Diagnosis 2 (3.8%) 15 (22%) 0.007
LOS (Days) 7.1 ± 6.2 4.9 ± 2.2 0.008
30-Day Readmissions 7 (13%) 11 (16%) 0.42
In-Hospital Deaths 2 (4%) 0 (0%) 0.15
Figure 4
Comparison between orthopaedic-geriatric comanage-
ment of hip fracture patients at Monteore Medical Center and the
Rochester Model at Highlands Hospital.
10
Monteore Journal of Musculoskeletal Medicine and Surgery
44
to a larger degree, severe delirium through interventions for
pain, polypharmacy, constipation, urinary retention, nutri-
tional decits, mobilization issues, and with the addition of
environmental stimuli.
15
Length of stay is a signicant outcome with implications
for cost of admission, regaining function, minimizing iatro-
genic illness, delirium, and mortality. Aer implementation
of a multidisciplinary geriatric hip fracture center in Fort
Worth, TX, investigators found a signicant decrease in time
from medical clearance to surgery as the sole factor contrib-
uting to overall length of stay.
16
Preventing delays in medical
clearance has been a major focus of our protocol with early,
prophylactic evaluation by both the orthopaedist and geri-
atrician. e geriatrician is responsible for directing medical
optimization and minimizing unnecessary consults and tests
which would delay time to surgery. At the other end of the
inpatient stay, the geriatrician has increased familiarity with
transitional care to skilled nursing facilities, family decision
making, and managing goals and expectations throughout
admission.
e strengths of the present study include its contribu-
tion to the small literature base about OGC, its utilization
of institutional resources without external funding, and its
demonstration that the methodology of health services re-
search can improve patient outcomes. is study is limited
by its small sample size, retrospective design, lack of formal
group allocation, and lack of blinding which may introduce
evaluation bias. e high rates of delirium in the OGC group
may be attributed to surveillance bias as a geriatrician is more
likely to detect delirium than other specialists.
As a result of the successful outcomes of the initial phase
implementation, in 2015 our center adopted the OGC hip
fracture program. is is similar to the program outlined
in this article but with all non-pathologic hip fractures in
our hospital system cohorted to a single center hip fracture
comanagement service. e team consists of the usual or-
thopaedic inpatient team (intern with or without physician
assistant for inpatient care, two operative second years, one
third or fourth year, two h years, and operative physi-
cian assistants), a geriatrician dedicated full time to the
hip fracture patients, unit social workers, and specialized
orthopaedic physical and occupational therapists.
We will continue to assess and evaluate processes and
outcomes in the OGC hip fracture program and believe that it
will serve as a platform from which to develop comanagement
between other specialties within and outside of our institution.
As hip fracture in geriatric patients frequently reveals
underlying comorbid conditions and triggers functional
decline, a geriatrician is essential to the management of
non-orthopaedic manifestations before and aer injury. e
investigators believe that cohorting patients to a dedicated
OGC program will benet patients and has the potential to
utilize health care resources eectively.
Conict of Interest Statement
None of the authors have a nancial or proprietary interest
in the subject matter or materials discussed, including, but
not limited to, employment, consultancies, stock ownership,
honoraria, and paid expert testimony.
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