Opportunities to redesign fracture care to support better outcomes, limit costs
As providers and health systems increasingly emphasize outcomes improvement and cost stewardship, care redesign efforts in elective total joint arthroplasty (TJA) have garnered attention for their impact on value. However, due to its emergent nature and degree of variation, redesign of the geriatric hip fracture care segment represents a unique challenge.
Success in delivering high-value hip fracture care will require different competencies and care delivery processes than elective TJA. It is important to note these inherent differences when developing and implementing standardized processes for hip fracture care. Although much of the cost savings under elective TJA bundles has been driven by reducing the level of postacute care, this may not be feasible or appropriate following hip fracture treatment. In this article, we offer several other strategies and considerations for improving the value of hip fracture care.
Medical optimization in-hospital
In elective TJA, the preoperative consultation allows providers to evaluate surgical candidates for risk factors, and patients proceed to surgery only after their modifiable risk factors (both clinical and social) have been optimized. The unexpected nature of hip fracture, however, renders the hospital the obligatory setting for medical optimization. Since time to surgery is an important predictor of outcomes in hip fracture management, providers must attempt to comprehensively, yet efficiently, evaluate patients prior to surgery. The use of coordinated services and standardized preoperative protocols can expedite the evaluation of hip fracture patients and identify potentially modifiable risk factors such as anemia, dehydration, or impending cardiac complications.
Early risk assessment also initiates the planning process to select and coordinate the most appropriate discharge destination. Using standardized preoperative evaluation for geriatric hip fracture patients allows for more efficient clinical workflows that maintain the delicate balance of optimization without delaying intervention and worsening prognosis.
Interdisciplinary care delivery team approach
Patients with multiple medical comorbidities are at risk for postoperative morbidity and mortality from a variety of issues, both related and unrelated to the surgery. Avoidance of these issues depends not only on excellent surgical technique, but also on patient-centered management. We believe that an interdisciplinary care delivery team (ICDT) composed of a geriatrician, orthopaedic surgeon, nutritionist, pain management specialist, physical therapist, behavioral health specialist, and social worker optimally facilitates this level of care. The surgeon’s expertise is supplemented by the collective wisdom of the ICDT, which allows for appropriate management of sequelae such as delirium, falls, malnutrition, and deconditioning that lead to functional decline and poor outcomes.
Given their clinical focus and training, geriatricians are well positioned to lead the ICDT and serve as the consistent point of contact for the patient and family throughout the hospital stay. Collaboration between geriatricians and orthopaedic surgeons has been associated with improved mobility and functionality, reduced length of stay and cost, and fewer postoperative complications for geriatric patients with hip fractures. This is facilitated by regular communication; daily ICDT rounding has shown its utility in optimizing patient care, and hospitals can leverage mobile platforms to further encourage efficient digital communication between care team members.
A lack of continuity between the inpatient and outpatient settings is associated with poor outcomes and a greater frequency of medical errors. Nearly half of adult hip fracture patients fail to reclaim their baseline functional status. Multiple handoffs and poor postdischarge coordination of care may contribute to this functional decline.
Standardized follow-up pathways, ideally overseen by a member of the ICDT, will improve care coordination and reduce errors. This enables providers to closely monitor recovery, adjust the treatment plan as appropriate, and provide feedback to the ICDT from which continuous learning can occur. The geriatrician can lead this effort and leverage the expertise of the rest of the ICDT as appropriate.
For example, for patients considered to be at increased risk of postoperative complications, partnering with postacute care providers that make home visits will reduce the chances of missed follow-up care, improve medical optimization in the postacute setting, and appropriately assess social and home-based risk factors impacting recovery. ICDT members such as social workers and nutritionists are well equipped to help patients navigate and identify resources to address issues that are difficult to address during the hospitalization. Efforts at coordinating postoperative management leverage the collective expertise of the care team to improve outcomes, enhance patient experience, and prevent unnecessary hospital readmissions that negatively impact patient outcomes and increase costs of care.
The mobility limitations that arise from hip fracture, as well as the burden of care, can take a significant toll on the mental health of geriatric hip fracture patients and their families. Social isolation, which is common in geriatric patients, has also been linked to poor mental health status as well as increased morbidity, mortality, and risk of postoperative complication. Thus, while various models of multidisciplinary care have focused on medical management, significant emphasis should also be placed on addressing social and psychological determinants of health both during and after the hospital stay. Care teams can assess and track these through patient-reported outcomes such as cognition, mental status, quality of life, function and mobility, and caregiver well-being.
Support from social work, nutrition, financial counseling, and behavioral health services can help improve recovery of the geriatric hip population. However, the provision of a variety of services in a fragmented manner is inconvenient and may cause confusion for the patient. Under the ICDT model presented, the geriatrician is positioned to coordinate all ancillary services for a seamless patient experience throughout the full care episode, enabling patients to experience the intended benefits of holistic, interdisciplinary care.
Despite the opportunities identified, a key challenge that providers and health systems will have to consider is cost stewardship in the face of variable medical complexity. Severity of illness (SOI) in geriatric hip fracture patients has a greater impact on hospital charges than elective TJA patients. For example, a recent study in New York state found that charges for total knee arthroplasties were 211 percent higher in patients with severe SOI levels than for patients with minor SOI levels. In comparison, hospital charges for femur fractures were 314 percent higher in patients with severe SOI levels than for patients with minor SOI levels. The number of geriatric hip fracture patients is also significantly less than the number of elective TJA patients, suggesting variability in medical complexity will have a greater impact on resource allocation than in elective, arthroplasty care.
In the absence of robust risk adjustment, the opportunities outlined in this article become especially important for the appropriate management of complex hip fracture patients. Financial implications aside, it is imperative that we advocate for our patients to prevent “cherry-picking” or “lemon dropping” and to ensure that all patients receive the high-quality care they deserve.
As providers and health systems seek to personalize care delivery and maximize value for geriatric hip fracture patients, we present strategies to optimize outcomes and reduce costs across the episode of care.
Facilities and providers can meaningfully impact care delivery to these patients through standardized perioperative management, greater care coordination, and the formation of ICDTs.
Tiffany C. Liu, BA, is a 4th-year medical student at the Perelman School of Medicine at the University of Pennsylvania. Tanmaya Sambare, BA, is a 2nd-year medical student at the Stanford University School of Medicine. Aakash Keswani, BA, is a 3rd-year medical student at the Icahn School of Medicine at Mount Sinai.
Kevin J. Bozic, MD, MBA, is the inaugural chair of the department of surgery and perioperative care and professor of orthopaedic surgery at the Dell Medical School at The University of Texas at Austin. He is chair of the AAOS Council on Research and Quality.
Karl M. Koenig, MD, MS, is the medical director of the Musculoskeletal Institute, residency program director, and an assistant professor of orthopaedic surgery at the Dell Medical School at The University of Texas at Austin. He serves on the AAOS Health Care Systems Committee.
- Dummit LA, Kahvecioglu D, Marrufo G, et al: Association between hospital participation in a Medicare bundled payment initiative and payments and quality outcomes for lower extremity joint replacement episodes. JAMA 2016;316(12):1267-1278.
- Navathe AS, Troxel AB, Liao JM, et al: Cost of joint replacement using bundled payment models. JAMA Intern Med 2017;177(2):214-222.
- Moja L, Piatti A, Pecoraro V, et al: Timing matters in hip fracture surgery: Patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One 2012;7(10):e46175.
- Hu F, Jiang C, Shen J, Tang P, Wang Y: Preoperative predictors for mortality following hip fracture surgery: A systematic review and meta-analysis. Injury 2012;43(6):676-685.
- Soong C, Cram P, Chezar K, et al: Impact of an integrated hip fracture inpatient program on length of stay and costs. J Orthop Trauma 2016;30(12):647-652.
- Vidán M, Serra JA, Moreno C, Riquelme G, Ortiz J: Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: A randomized, controlled trial. J Am Geriatr Soc 2005;53(9):1476-1482.
- Sharma G, Fletcher KE, Zhang D, Kuo YF, Freeman JL, Goodwin JS: Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults. JAMA 2009;301(16):1671-1680.
- Kammerlander C, Roth T, Friedman SM, et al: Ortho-geriatric service: A literature review comparing different models. Osteoporos Int 2010;21(Suppl 4):S637-S646.
- Zidén L, Kreuter M, Frändin K: Long-term effects of home rehabilitation after hip fracture: 1-year follow-up of functioning, balance confidence, and health-related quality of life in elderly people. Disabil Rehabil 2010;32(1):18-32.
- Gregersen M, Zintchouk D, Borris LC, Damsgaard EM: A geriatric multidisciplinary and tailor-made hospital-at-home method in nursing home residents with hip fracture. Geriatr Orthop Surg Rehabil 2011;2(4):148-154.
- Holt-Lunstad J, Smith TB, Layton JB: Social relationships and mortality risk: A meta-analytic review. PLoS Med 2010;7(7):e1000316.
- Hung WW, Egol KA, Zuckerman JD, Siu AL: Hip fracture management: Tailoring care for the older patient. JAMA 2012;307(20):2185-2194.
- Mahure SA, Hutzler L, Yoon RS, Bosco JA: Economic impact of nonmodifiable risk factors in orthopaedic fracture care: Is bundled payment feasible? J Orthop Trauma 2017;31(3):175-179.