`Aims

Background

Methods Results

Results

Acknowledgements

Conclusions1) Comparepost- andpre-GFPpatientgroups

characteristicsandoutcomes.2) Applyapredictivemodeldevelopedfromtwo

yearsofGeriatricFractureProgram(GFP)patientstopre-GFPpatientstoaccountforpatientcomplexityinanalyzingtheoutcomesoftheUCDavisGFP.

• >300,000geriatrichipfracturesperyearintheUnitedStates,incidenceexpectedtoincrease1,2

• Highratesofcomplications,leadingtoprolongedhospitalizations3.

• $9-15bn/yr ofinpatientcosts4.• $26,000-$35,000average

hospitalizationcostalone

References1:Morris,A.H.,Zuckerman,J.D.,&AAOSCouncilofHealthPolicyandPractice,USA.AmericanAcademyofOrthopaedicSurgeons.(2002).NationalConsensusConferenceonImprovingtheContinuumofCareforPatientswithHipFracture. TheJournalofBoneandJointSurgery.AmericanVolume, 4,84.2:Cummings,S.R.,Rubin,S.M.,&Black,D.(1990).ThefutureofhipfracturesintheUnitedStates.Numbers,costs,andpotentialeffectsofpostmenopausalestrogen. ClinicalOrthopaedics andRelatedResearch, 252,163-6.Kates,S.L.(2016).Hipfractureprograms:aretheyeffective?. Injury, 47.3: Braithwaite,R.S.,Col,N.F.,&Wong,J.B.(2003).EstimatingHipFractureMorbidity,MortalityandCosts. JournaloftheAmericanGeriatricsSociety, 51, 3,364-370.4:Kates,S.L.(2016).Hipfractureprograms:aretheyeffective?. Injury, 47.

• Programsofcoordinatedcarehavebeendevelopedwithmarkedlyimprovedoutcomes4.

• InJanuary2014,UCDMCintroducedthemulti-disciplinaryGeriatricFractureProgram(GFP).

• Retrospectivechartreviewof2012-2013(pre-GFP,n=119)and2014-2015(post-GFPn=174)withthefollowingdataabstracted:

• ApredictiveLOS(PLOS)modelwascreatedbyamultivariateregressionanalysiswithpost-GFPdata.

• Themodelwasretroactivelyappliedtothepre-GFPgrouptoassessimprovements.

• AthresholdofPLOS+1.5daysasaclinically-relevantcutoffforestimatingiftheGFPcouldhaveimprovedeachpatientsactualLOS

Variable Parameterestimate

P-value

TimetoSurgery(Eachmidnight) +0.14 0.0016*

ASAScore(onepointincrease) +0.12 0.0689

CCI<4 - 0.02 0.8058Age(eachdecade>82) +0.002 0.5590

Gender(Female) - 0.04 0.5522Cohorted onD14(Orthoward) - 0.08 0.2319InitialINR<1.5 - 0.18 0.0844Nodelirium - 0.19 0.0082*

Pre-GFP2012-2013(N=119)

Post-GFP2014-2015(N=174)

P-value

Age 81.2± 8.4 82.0± 7.9 0.4585

Sex 83F(69.8%) 118F(67.8%) 0.7264

CCI<4 89(74.8%) 133(76.4%) 0.7466

ASAScore2:17(14.3%)3:71(59.7%)4:31(26.1%)

2:18(10.7%)3:117(69.2%)4:34(19.5%)

0.2862

TimetoSurgery(Midnights)

0:3(2.5%)1:87(73.1%)2+:29(23.6%)

0:8(4.6%)1:113(64.9%)2:53(30.6%)

0.5331

INR(initial) INR<1.5:109(91.6%)

INR<1.5:149(85.6%) 0.1221

Delirium 27(22.7%) 74(42.5%) 0.0004 *

OrthoWard 66(55.5%) 100(57.5%) 0.7332

Complications(notdelirium) 42(35.3%) 31(17.8%) 0.0007*

LengthofStay 7.8± 6.0 5.9± 3.1 0.0023*

Delaytosurgery(>2midnights) 26(21.9%) 52(29.9%) 0.1264

• ActualLOSandcomplicationssignificantlydeclinedafterinitiationoftheGFP;deliriumwasdetectedmuchmorecommonly

• UsingthePLOSmodel,49.5%ofpatientsinthepre-GFPgroupwouldhavehaddecreasedLOSundertheGFPmanagement(Figure1).

• Lengthofstayisausefulproxyforbothqualityofcare,complications,andcosteffectivenessinourgeriatricfractureprogram.

• ThistypeofmodelingisnovelinthispopulationandimportantforQIfocusandhospitalresourceallocation.

• ClinicallymodifiablevariablesthatsignificantlyimpactedLOSincludeddeliriumpreventionanddecreasingtimetosurgery.

• OurpredictivemodelindicatesthatiftheGFPwasretroactivelyappliedtothe2012-2013patientsnearlyhalfwouldcouldhavehadapredictedLOSatleast1.5daysshorter.

• Thereweredecreasedcomplications,excludingdelirium,andlengthofstayaftertheGFPwasappliedtosimilarpatients.

• TheapparentincreaseindeliriumislikelyaneffectoftheincreasedeffortplacedonnursingreportingofConfusionAssessmentMethod(CAM)scoresmandatedbytheGFP.

DischargeED

Table1:UnadjustedRegressionAnalysisofLOSbyDemographicsandClinicalCharacteristics.*statisticalsignificance

Table2.DemographicandClinicalCharacteristicsofGeriatricFractureProgramPatients.*statisticalsignificance

EmergencyDepartment• QuickDiagnosisto

initiateGFPprotocol• FasciaIliaca (IF)Block• ConsultOrtho/Med

Pre-opAdmission• OptimizeforOR• MedicineTeam• DischargePlanningstarts

onhospitalday1• FamilyEducationProvided

PostOpCare• PT/OT– early/often• OrthopaedicNursingCare• Deliriumprevention• DischargePlanning

OR– ideallyonday1• Orthopaedicsurgeryallows

immediateweight-bearing• Anesthesiaisspinalversus

generalandrepeatIFblock

Figure1: PredictiveLengthofStayModelAppliedtopre-GFPPatientswithPLOS+1.5DayssetasThresholdforClinicalRelevance

• Charlson ComorbidityIndex(CCI)• Timetosurgery(TtoS)• Delaystosurgery(DTS)• Delirium• OtherComplications

• LOS• INR• ASAscore• OrthoWard• Demographics

-2

0

2

4

6

8

10

12

14

16

18

Diffe

renceinActualLOS–P

redicted

LOS(days)

Affiliations1:UCDavisSchoolofMedicine,Sacramento,CA958172:DepartmentofOrthopaedics,UCDavisMedicalCenter,Sacramento,CA958173:QualityandSafety,UCDavisMedicalCenter,Sacramento,CA95817PrimaryProjectMentorsPhilipWolinsky MDandGarinHechtMD

PredictiveModelingforaGeriatricHipFractureProgramasaMethodofAssessingOutcomesParkerGoodell1 MPH,GarinHecht2 MD,TrevorShelton2 MD,ChristinaSlee3 MPH,andPhilipWolinsky2 MD

Patients>+1.5dofpredictedLOS

Patients<+1.5dofpredictedLOS

ClinicalThreshold+1.5days