Major joint surgery is one of the largest components of Medicare spending in the US and the most frequent major procedure performed in older adults. Increasing age is associated with increasing prevalence of frailty, but the influence of frailty on healthcare expenditures following arthroplasty has yet to be adequately explored.

To explore the association between frailty and healthcare expenditures in the year following total hip and knee arthroplasties.

Retrospective cohort study SETTING: United States population PARTICIPANTS: Medicare beneficiaries 65 and older undergoing total knee or hip arthroplasty (n = 1,152,872) from 2017 through 2018.

Claims-based frailty index (exposure), total 1-year Medicare expenditures broken down by category (primary outcome), in-hospital complications, length of stay, discharge destination, readmission and mortality (secondary outcomes).

Among 435,496 patients who underwent hip (37.8 %) and 717,376 patients who underwent knee arthroplasty (62.2 %), the mean age was 73.7 years and 19.2 % were classified as frail. Median total expenditures in US dollars at one year were higher in those with frailty ($247,503; IQR [$169,400-$391,176]) relative to the prefrail ($179,379 [$127,396-$265,039]) and robust ($130,314 [$85,438-$199,605]) groups. Total expenditures included the index surgical admission, rehospitalization, skilled nursing care, and outpatient care, all of which were higher with increasing frailty. However, the surgical procedure accounted for less than a third of the total 1-year healthcare costs and was the category with the lowest degree of variation between patients. Frailty was also associated with longer lengths of stay, higher risks of complications, readmission, and mortality and lower likelihood of being discharged home after the procedure.

Among older adults undergoing total hip and knee arthroplasty, frailty is associated with higher healthcare expenditures, predominantly driven by longitudinal care during the year following the procedure. More research is needed to test interventions to improve outcomes and reduce cost in this high-risk population.

Fragility hip fractures are a common and often devastating event, and a shared care approach between orthopaedics and geriatrics can improve patient, health service and quality of care outcomes. The aim of this cross-sectional survey, administered to all hospitals caring for patients with acute hip fracture, in New South Wales (NSW), Australia, was to establish current models of care (e.g. shared care or other), and barriers and facilitators of best care.

A combination of quantitative and free-text data was collected. In total, 30/36 (83%) hospitals responded, with representation from all 15 state local health districts.

Overall, 21/30 had a formal orthopedic surgery/geriatric medicine shared care model; orthopaedic surgery admission with routine (ortho)geriatrician input was commonest (13/21). Multiple barriers to optimal hip fracture care were identified along the various stages of the national guideline-recommended care pathway. Common barriers reported included staffing deficits (for pain assessment, fascia iliaca block administration) and gaps in service structure (lack of specialist services for refracture prevention). Multidisciplinary meetings were in place to enable best care and to promote team communication, but were impeded by absence of relevant team members (8/16). Free-text themes of enablers of good practice included clear escalation and hand-over processes, multidisciplinary communication strategies, and guideline-aligned clinical pathways.

Moving forward, addressing common barriers such as staffing and knowledge deficits, and harnessing enablers of good practice such as multidisciplinary communication and support, combined with effective implementation strategies, are likely to optimize care for patients with hip fracture.

To describe and compare the factors that impact initial rehabilitation type after hip fracture surgery.

Retrospective population-based cohort study.

People aged between 50 and 105 with a hip fracture who had a surgical repair in Ontario, Canada, between January 1, 2015, and December 31, 2021.

Descriptive statistics and a multinomial logistic regression model were used to identify factors associated with initial rehabilitation type.

In this study, 63,401 individuals were included with a mean age of 80 years [standard deviation (SD) 10.9], mostly female (67.3%), with 86.3% living in urban areas at the time of hospitalization and most (72.6%) admitted from the community without home care. A total of 24.5% of individuals did not receive any form of rehabilitation. Rurality of residence decreased the odds of having an initial rehabilitation type in complex continuing care [odds ratio (OR), 0.23; 95% CI, 0.21-0.26], in inpatient rehabilitation (OR, 0.26; 95% CI, 0.24-0.28), or in community rehabilitation (OR, 0.54; 95% CI, 0.50-0.58) compared with no rehabilitation. Dementia decreased the odds of having an initial rehabilitation type in complex continuing care (OR, 0.75; 95% CI, 0.69-0.81), in inpatient rehabilitation (OR, 0.44; 95% CI, 0.41-0.47), or in community rehabilitation (OR, 0.88; 95% CI, 0.82-0.95) compared with receiving no rehabilitation. Previous history of fragility fracture decreased the odds of having an initial rehabilitation type in either complex continuing care (OR, 0.30; 95% CI, 0.27-0.34), in inpatient rehabilitation (OR, 0.27; 95% CI, 0.24-0.29), or in community rehabilitation (OR, 0.33; 95% CI, 0.30-0.37) compared with no rehabilitation.

Rurality of residence, dementia, and previous history of fragility fractures reduced the odds of receiving specialized inpatient rehabilitation and increased the odds of receiving no rehabilitation. Future research should focus on achieving more equitable care for individuals living in rural settings, with dementia, or with previous fragility fractures to enhance the quality of care and achieve best outcomes for the overall hip fracture population.

While epidemiology and treatment strategies of proximal humerus fractures have been well studied, post-hospital care is poorly analysed. Corresponding data is available in the context of hip fractures, but the evidence regarding proximal humerus fractures is weak. Aim of this study is to identify risk factors for institutionalisation required after discharge into inpatient aftercare for elderly patients treated for proximal humerus fractures.

For this retrospective single-centre investigation, n = 295 patients (age 70 (58,79) years, 63.7% female) admitted to hospital from home due to proximal humerus fractures were included and divided into two study groups: Patients being discharged home ('Home') vs being discharged into aftercare ('Aftercare'). Differences regarding demographic and clinical data were analysed. Odds ratios (OR) of influencing factors (adjusted for age) were calculated by logistic regression analysis.

Increased age notably increased the likelihood for discharge of patients into 'Aftercare' (OR 1.09 [1.06;1.12] per year of life). Age-independent indicators for 'Aftercare' were higher ASA score (OR 2.16 per ASA point [1.37;3.49]; P < .001), anterior surgical approach (OR 6.05 [1.93,27.1]; P < .006), duration of surgery (OR 1.01 per min [1.00,1.02]; P < .012), non-surgical complications (OR 3.82 [1.60,9.49]; P < .003), length of stay (OR 1.12 per day [1.04,1.22]; P < .005), ICU stay (OR 3.15 [1.71,6.00]; P < .001) and reversely surgery (OR 0.39 [0.19,0.80]; P < .010).

Increased Age and higher ASA score notably increase the likelihood for post-hospital discharge to an inpatient aftercare facility. Available literature in the context of hip fractures is confirmed. The results of this study may assist in identifying patients at risk and may serve as a stepstone in establishing a scoring system for elderly patients with proximal humerus fractures.

Background Hip fractures are a major cause of morbidity and mortality in the growing US geriatric population, with the majority resulting from falls. They are associated with a significant loss of independence and impose a substantial financial burden on healthcare systems worldwide. The Rio Grande Valley (RGV), a medically underserved region with a predominantly Hispanic population, faces high rates of chronic conditions such as diabetes and obesity, which may influence fracture patterns and outcomes. This study examines hip fractures in a predominantly Hispanic geriatric cohort, focusing on the impact of diabetes and obesity on fracture type, with the goal of informing targeted prevention and treatment strategies. Methods This retrospective cohort study was conducted at a Level 1 Trauma Center along the US-Mexico border. The study included hip fracture cases caused by falls in patients aged 65 and older over a three-year period, excluding periprosthetic and pathologic fractures. Fractures were stratified as intracapsular (femoral head/neck) or extracapsular (intertrochanteric, subtrochanteric, and greater/lesser trochanter). Treatment strategies included arthroplasty, osteosynthesis, or conservative management. Outcome measures included one-year all-cause mortality, length of stay (LOS), readmission rates, and complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), fat embolism, pressure ulcers, and surgical site infections (SSIs). Statistical analyses assessed associations between fracture type, patient characteristics, treatment strategies, and outcomes. Results The study included 412 patients, of whom 85.2% (351) were Hispanic and 71.4% (294) were female, with a mean age of 80.6 years and a body mass index (BMI) of 25.5 kg/m2. Higher age (mean: 81.3 years, p=0.033), lower BMI (25.0 vs. 26.2, p=0.019), and Hispanic ethnicity (OR: 1.98, p=0.026) were associated with extracapsular fractures. Non-surgical management was associated with a significantly higher one-year mortality rate (n=6; 20.7%; p=0.004). Surgery performed more than 48 hours after arrival prolonged hospital stay (7.96 vs. 5.73 days for <24 hours, p<0.001). The overall one-year mortality rate was 5.6% (23), with older age (OR: 1.08, p=0.034), COPD (OR: 5.24, p=0.015), and cirrhosis (OR: 8.69, p=0.024) as significant predictors. Prolonged immobilization (OR: 2.68, p=0.016) and diabetes (OR: 3.89, p=0.002) increased complication rates. Conclusion  Aging, comorbidities, and Hispanic ethnicity increased extracapsular fracture risk, while a higher BMI was predictive for intracapsular fractures. The one-year mortality rate of 5.6% highlighted the Hispanic paradox, suggesting a survival advantage despite the presence of multiple comorbidities and risk factors. Ultimately, these findings emphasize the necessity of targeted intervention strategies, including fall prevention programs, bone health education, and culturally tailored healthcare approaches. Addressing ethnic and socioeconomic disparities in osteoporosis screening and fracture management remains essential for improving outcomes and reducing hip fracture occurrence within this high-risk population.

Orthogeriatric hospital care is recommended for hip fra cture patients, but differentiated hospital care has not been evaluated. The aim of this study was to describe physical performance and health-related quality of life for hip fracture patients 1-year after surgery in four treatment pathways. We also report changes in functional outcomes from baseline to 1-year follow-up together with readmission and mortality rates for each pathway.

We included 177 hip fracture patients aged 65 years or older from a single center in Norway. Participants were discharged home, to specialised rehabilitation, regular rehabilitation or nursing home based on orthogeriatric assessment of pre- and postfracture function, mobility level and Ac tivities of Daily Living. Outcome variables included Short Physical Performance Battery, EuroQol-5-dimension-5-level, Barthel-index, Lawton & Brody Instrumental Activities of Daily Living, Lawton & Brody Self-Maintenance Scale, readmission and mortality rates during follow-up.

Participants discharged home and to specialised rehabilitation were younger and healthier than participants discharged to regular rehabilitation and nursing home. All groups had a clinically important improvement in Short Physical Performance Battery score (mean 4.8 points, 95% confidence interval (CI) 4.2, 5.5) from post-surgery to 1-year follow-up and a clinically important decline in EuroQol-5-dimension-5-level (mean -0.12 points, CI -0.16, -0.07) from baseline to 1-year follow-up. The decline in Barthel-index from baseline to 1-year follow-up was greater in the regular rehabilitation group (mean -2.3 points, CI -4.2, -0.2) than in the home group (mean -0.6 points, CI -1.4, 0.2) and specialised rehabilitation group (mean -0.4 points, CI -2.4, 1.6). Participants in the regular rehabilitation group were more frequently readmitted (standardised Pearson residual 4.1) and mortality rates were higher in the nursing home group (standardised Pearson residual 7.8) during the first year.

Orthogeriatric treatment pathways for hip fracture patients entailed differentiation based on factors such as age, mobility, comorbidity and physical function. Participants in all pathways improved in physical performance-scores, yet experienced decline in quality of life-scores during follow-up. Overall readmission and mortality rates were not influenced, but varied between pathways. Further research is needed to investigate the need for differentiated hospital treatment and its potential effects on rehabilitation after discharge.

We compared medication prescription and initiation proportions among high-risk Fracture Screening and Prevention Program patients with multiple chronic conditions. Patients with two conditions were more likely to receive prescriptions and initiate prescribed medication than those with none. Post hoc analysis showed that patients with ≥ 3 conditions were less likely to be prescribed and to initiate medication, compared to those with two conditions. Tailored interventions are important for improving post-fracture care outcomes.

To investigate the association between the number of chronic conditions and pharmacological treatment outcomes in high-risk patients who were screened through the Fracture Screening and Prevention Program (FSPP).

A retrospective cohort study was employed to determine the association between the number of chronic conditions and treatment outcomes. All high-risk patients who were enrolled in the FSPP between June 1, 2017, and June 30, 2022, were included in the study. The number of self-reported chronic conditions available in the FSPP data was classified into four categories: (1) 0 condition; (2) 1 condition; (3) 2 conditions; and (4) ≥ 3 conditions. Multivariable logistic regression models were created with prescription and initiation as outcomes.

In total, 11,245 patients were identified as high-risk for future fracture. Patients with two chronic conditions demonstrated a 26% higher odds of receiving a medication prescription, and those with two chronic conditions and prescribed bone-active medication had a 57% increased odds of initiating the treatment compared to individuals without chronic conditions. No significant differences in medication prescription or initiation were seen in those with 1 or ≥ 3 chronic conditions compared to those without chronic conditions. In post hoc testing, we saw a 25-30% significantly lower odds of medication prescription and initiation in patients reporting ≥ 3 chronic conditions when compared to those who reported only two chronic conditions.

The findings suggest that a large provincial secondary fracture prevention program resulted in higher odds of prescription and initiation of treatment in patients with two chronic conditions compared to those having no chronic conditions. Potential inequities in these treatment outcomes were found with a threshold of three or more chronic conditions. This highlights the need for tailored interventions and comprehensive support systems to improve fracture prevention outcomes for high-risk patients with multiple chronic conditions.

The main objective of this study was to measure the incidence of in-hospital adverse events in older adults presenting to the emergency department (ED) with an isolated traumatic hip fracture. The secondary objective was to identify the risk factors of adverse outcomes in those patients.

Retrospective database analysis.

Adults aged ≥65 years presenting to 1 of the 3 Quebec level 1 adult trauma centers' ED between 2003 and 2017 with an isolated hip fracture.

The main outcome was a composite of any adverse events defined as extended length of stay (LOS) >21 days, in-hospital complications (delirium, pressure ulcers, urinary tract infection, pneumonia, deep venous thrombosis, or pulmonary embolism), and mortality. Outcomes were also analyzed separately. Multivariable logistic regression modeling was used to identify factors associated with adverse events.

We included 4569 patients (female: 74.8%; mean age: 83.7 years). Low energy mechanisms were the most frequent cause of injury (68.4%), and the median LOS was 13 days (interquartile range, 8-21). A total of 1829 patients (40.0%) suffered an in-hospital adverse event: extended LOS (n = 1106; 24.2%), death (n = 365, 8.0%), and ≥1 complications (n = 892, 19.5%). Risk factors of any in-hospital adverse event included aged ≥75 years [75-84 years: adjusted odds ratio (AOR), 1.44; 95% CI, 1.17-1.76; ≥85 years: AOR, 2.11; 95% CI, 1.72-2.58], male sex (AOR, 1.35; 95% CI, 1.17-1.56), cardiovascular disease (AOR, 1.47; 95% CI, 1.23-1.77), major cognitive disorder (AOR, 1.51; 95% CI, 1.26-1.80), and ≥2 comorbidities (AOR, 1.40; 95% CI, 1.02-1.93). Direct admission from ED to the operating room was associated with decreased risk of any adverse event (AOR, 0.87; 95% CI, 0.76-0.99).

Two out of five patients presenting to a level-1 trauma center with an isolated hip fracture suffered from an adverse event. Aged ≥75 years, male sex, cardiovascular diseases, major cognitive disorder, and ≥2 comorbidities were significant risk factors. These factors may guide early identification of high-risk patients in the ED.

Patient-reported outcome measures (PROMs) are widely used in medicine. As older adults, who may rely on a proxy caregiver for answers due to cognitive impairment, are representing an increasing share of the traumatically injured patient population, proxy-reported outcome measures (proxROMs) offer a valuable alternative source of patient-centered information although its association with PROMs is unclear. The objective of this scoping review is to discuss all available literature comparing PROM and proxROMs in adult patients with musculoskeletal trauma to guide future research in this field.

The PRISMA extension for Scoping Reviews was used to guide this review. MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched without date limit for articles comparing PROM and proxROMs in setting of musculoskeletal trauma. Abstract and full-text screening were performed by two independent reviewers. Variables included study details, patient and proxy characteristics, and reported findings on agreement between PROMs and proxROMs.

Of 574 unique records screened, 13 were included. Patient and proxy characteristics varied greatly, while patients' cognitive status and type of proxy perspective were poorly addressed. 18 different PROMs were evaluated, mostly reporting on physical functioning and disability (nine, 50%) or quality of life (six, 33%). Injury- and proxy-specific tools were rare, and psychometric properties of PROMs were often not described. Studies reported moderate to good agreement between PROMs and proxROMs. There is less agreement on subjective outcome measures (e.g., depression score) compared to observable items, and proxy bias results in in worse outcomes compared to patient self-reports.

Current literature, though limited, demonstrates moderate to good agreement between injured patients' self- and proxy-reports. Future studies should be mindful of current guidelines on proxy reporting when developing their studies and consider including neglected populations such as cognitively impaired patients to improve clinical validity.

There is growing evidence on the benefits of integrated models of care between surgeons and physicians in non-orthopaedic surgery. We implemented a new General Surgery/General Medicine care model, for all emergency General Surgery patients aged 75 years and older. We compared rates of goals of care (GOC) documentation, hospital-acquired complications (HAC), mortality, and hospital length of stay (LOS).

This is a non-randomized trial, with data collected prospectively in phase 1 (2021-2022), where patients received the traditional standard of care (case-by-case referral to a General Physician), and in phase 2 (2022-2023) where patients received integrated care. Variables were compared between phase 1 and phase 2 using Generalized Linear Models (GLMs).

Five hundred and forty-nine patients, 188 in phase 1 and 361 in phase 2, participated in the study. On univariate analysis, there was a significant increase in patients treated non-surgically in phase 2 (58.5% vs. 69.0%). Patients treated non-surgically had significantly shorter LOS, experienced less HACs (P < 0.001). Other variables did not significantly differ after implementation of the service. The multivariate GLM revealed a significant reduction in admissions with undocumented GOC in phase 2 (P = 0.037).

This study showed that an integrated care model resulted in a greater proportion of patients being treated non-surgically with a comparable rate of HAC and mortality, as well as better documentation of patients' GOC. As the number of older surgical patients will continue to rise, the call for such service to become standard of care in non-orthopaedic surgery is pressing.

Approximately 320 million surgeries occur annually worldwide, increasingly performed on an ageing, comorbid population in whom postoperative complications contribute significantly to mortality. While anesthesiologists have led advances in perioperative care, the optimal structure of the provision of postoperative care has lacked discourse. In this article, we describe the implementation, structure, role, and benefits of an Anesthesiology Perioperative Outreach Service (APOS) at a Canadian tertiary hospital, providing proactive daily review and management of high-risk surgical patients. The APOS involves routine reviews and care on surgical wards, emphasizing collaboration among anesthesiology, internal medicine, surgery, and geriatric medicine teams, with a specific screening pathway to identify patients experiencing myocardial injury after noncardiac surgery. We discuss case vignettes to illustrate common examples of how the APOS enabled early detection and treatment escalation for deteriorating patients and provide a focused narrative literature review. The anesthesiology-led perioperative outreach model described herein could provide an implementable framework for institutions seeking to enhance their quality of postoperative care-particularly among complex, comorbid patients at risk of postoperative morbidity.

Geriatricians are increasingly involved in the treatment of fragility fractures. In Germany, hospitals that meet specific standards for orthogeriatric co-management (OGCM) are additionally certified as 'geriatric trauma centers.' One responsibility of OGCM is the appropriate management of osteoporosis through medication. We aimed to analyse the association between prescription frequencies of anti-osteoporotic drugs in hospitals with certified OGCM, those with non-certified OGCM, and those with no OGCM at all.

Claims data from nearly 200,000 patients aged 80 and older with an incident index fracture of the humerus, forearm, hip, pelvis, or spine, were obtained from a German health insurance. Hospitals were categorized into three groups: no OGCM, with OGCM, and with certified OGCM. The outcomes were new prescriptions for specific anti-osteoporotic drugs and vitamin D within 180 days after the index fracture. Crude incidences and adjusted incidence rate ratios (IRR) were calculated.

Prescription rates of specific anti-osteoporotic drugs and vitamin D increased from hospitals with no OGCM to hospitals with OGCM and were highest in hospitals with certified OGCM. This pattern was observed across all fracture types, age groups, and both men and women, except for forearm fractures. For example, in hip fractures, the IRR for prescriptions of specific anti-osteoporotic drugs in hospitals with certified OGCM compared to those with no OGCM was 2.17 (95 % CI: 1.90-2.48).

OGCM, especially when coupled with certification as a 'Geriatric Trauma Center,' is associated with higher prescription rates of specific anti-osteoporotic drugs and vitamin D after fragility fractures in Germany.

Background/Objectives: The number of seriously injured elderly patients is continuously rising. Several studies have underlined the benefit of orthogeriatric co-management in treating older patients with a proximal femur fracture. The basis of this orthogeriatric co-management is a certification as a Centre for Geriatric Trauma (ATZ). Data of seriously injured patients are collected in the TraumaRegister DGU® (TR-DGU) from participating trauma centres. We hypothesise that if a certified trauma centre is also a certified Centre for Geriatric Trauma, a benefit can be measured. Methods: Retrospective cohort analysis was conducted from 1 January 2016 to 31 December 2021. The TraumaRegister DGU® collected the data prospectively. This retrospective multicentre registry study included patients 70 years or older with an abbreviated injury scale of ≥3 and intensive care unit treatment from 700 certified Trauma Centres and 110 Centres for Geriatric Trauma in Germany, Austria and Switzerland. The primary outcome was mortality in in-hospital stays. Other outcome parameters were days of intubation, the length of stay in ICU, and in-hospital stays. Furthermore, the discharge target and the Glasgow Outcome Scale (GOS) were analysed. Results: The inclusion criteria were met by 27,531 patients. The majority of seriously injured patients (n = 23,007) were transported to certified trauma centres without certification as ATZ. A total of 4524 patients were transported to a trauma centre with additional ATZ certifications. Mortality and the Revised Injury Severity Classification II (RISC-II) model for prediction of mortality after trauma were higher in ATZ hospitals. Logistic regression analysis showed no effect on mortality by a certification as a centre for geriatric trauma in treating seriously injured elderly patients. Conclusions: We assume that the additional ATZ certification does not positively influence the treatment of seriously injured elderly patients. A potential side effect could not be measured.

To determine whether adherence to hip fracture clinical care quality indicators influences mortality among people who undergo surgery after hip fracture in New South Wales, both overall and by individual indicator.

Retrospective population-based study; analysis of linked Australian and New Zealand Hip Fracture Registry (ANZHFR), hospital admissions, residential aged care, and deaths data.

People aged 50 years or older with hip fractures who underwent surgery in 21 New South Wales hospitals participating in the ANZHFR, 1 January 2015 - 31 December 2018.

Thirty-day (primary outcome), 120-day, and 365-day mortality (secondary outcomes) by clinical care indicator adherence level (low: none to three of six indicators achieved; moderate: four indicators achieved; high: five or six indicators achieved) and by individual indicator.

Registry data were available for 9236 hip fractures in 9058 people aged 50 years or older during 2015-2018; the mean age of patients was 82.8 years (standard deviation, 9.3 years), 5510 patients were women (69.4%). Complete data regarding adherence to clinical care indicators were available for 7951 fractures (86.1%); adherence to these indicators was high for 5135 (64.6%), moderate for 2249 (28.3%), and low for 567 fractures (7.1%). After adjustment for age, sex, comorbidity, admission year, pre-admission walking ability, and residential status, 30-day mortality risk was lower for high (adjusted relative risk [aRR], 0.40; 95% confidence interval [CI], 0.30-0.52) and moderate indicator adherence hip fractures (aRR, 0.61; 95% CI, 0.46-0.82) than for low indicator adherence hip fractures, as was 365-day mortality (high adherence: aRR, 0.59 [95% CI, 0.51-0.68]; moderate adherence: aRR, 0.74 [95% CI, 0.63-0.86]). Orthogeriatric care (365 days: aRR, 0.78; 95% CI, 0.61-0.98) and offering mobilisation by the day after surgery (365 days: aRR, 0.74; 95% CI, 0.67-0.83) were associated with lower mortality risk at each time point.

Clinical care for two-thirds of hip fractures attained a high level of adherence to the six quality care indicators, and short and longer term mortality was lower among people who received such care than among those who received low adherence care.

With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.

Proximal femoral fractures are severe injuries in geriatric patients. Additionally, geriatric patients are at a high risk of death due to coronavirus disease 2019 (COVID-19).

To identify predictors of mortality in geriatric patients with COVID-19 and concurrent proximal femoral fractures.

Patients who underwent surgical treatment for proximal femoral fractures and also tested positive for COVID-19 were included. The age, gender, the American Society of Anesthesiology (ASA) score and the admission from a nursing home were considered as variables. The rate of reoperations, the mortality at 3 months and discharge home were evaluated as outcomes.

In this study 46 patients with COVID-19 (female/male 31/15, median age 87.0 years with an interquartile range [IQR] of 9.8 years) met the inclusion criteria. Of these, 32 patients (69.6%) had to be cared for in the intensive care unit and 26 patients (56.5%) had a severe course of COVID-19 with pneumonia. The median length of hospital stay for survivors was 19 (IQR 17.5) days and 4 of the patients (8.7%) required surgical revision. The in-hospital and 3‑month mortality were 40.0% (n = 17) and 43.5% (n = 20), respectively. The factors which influenced the in-hospital and 3‑month mortality rates were admission from a nursing home, the presence of pneumonia (increased the risk of death) and female gender (protective).

The occurrence of COVID-19 in patients with proximal femoral fractures has a high mortality. Admission from a nursing home and the presence of pneumonia increased the risk of death, whereas women were at lower risk.

Background: Orthogeriatric treatment, which involves a collaborative approach between orthopedic surgeons and geriatricians, is generally considered to be superior to standard care following hip fractures. The aim of this study was to investigate additional effects of a geriatrician-led multidisciplinary rehabilitation program. Methods: In this matched paired observational cohort study, patients aged 70 years and older with a proximal femur fracture requiring surgery were included. Between 1 January 2016 and 31 December 2022 data were recorded from hospital admission to 120-day follow-up in the Registry for Geriatric Trauma (ATR-DGU), a registry of older adults with hip fractures. Out of 60,254 patients, 9580 patients met the inclusion criteria, 4669 patients received early multiprofessional rehabilitation (EMR) and 4911 patients were treated by standard orthogeriatric co-management (OGC). Results: Compared to standard orthogeriatric treatment, multiprofessional therapy significantly lowered the 7-day mortality rate (2.89% vs. 5.11%) and had a significant impact on walking ability seven days after surgery (86.44% vs. 77.78%). Conclusions: In summary, a geriatrician-led multiprofessional rehabilitation program resulted in lower mortality and improved walking ability than standard orthogeriatric care.

Fragility fractures of the hip are one of the most important triggers of poor health outcomes in older adults. They often result in limitations in the ability of patients to care for themselves and mortality remains high. Orthogeriatric co-management may improve outcomes for this high-risk population. However, the impact on long-term results has not yet been definitively clarified. The purpose of this study was to present the influence of orthogeriatric co-management on mortality and self-care ability, as measured by the Barthel score, one year after hip fracture in people ≥ 60 years.A systematic literature search was performed in accordance with the process steps of identification, selection, and evaluation, with a systematic search of the MEDLINE, CINAHL Complete and Cochrane Library databases in the period from February to March 2022. Articles in English and German published between 2012 and 2022 were included. Twelve studies were finally used.Six studies demonstrated a statistically significant reduction in the one-year mortality rate. Only one of four studies evaluating self-care ability showed a significant improvement when the patient was treated on a specialised ward.Orthogeriatric co-management seems to be beneficial in positively influencing one-year mortality and self-care ability. In view of the heterogeneous results, the implementation of this care model can only be recommended to a limited extent.

This systematic review seeks to evaluate the proportion of fragility fracture patients screened in secondary fracture prevention programs who were indicated for pharmacological treatment, received prescriptions for bone-active medications, and initiated the prescribed medication. Additionally, the study aims to analyze equity in pharmacological treatment by examining equity-related variables including age, sex, gender, race, education, income, and geographic location.

We conducted a systematic review to ascertain the proportion of fragility fracture patients indicated for treatment who received prescriptions and/or initiated bone-active medication through secondary fracture prevention programs. We also examined treatment indications reported in studies and eligibility criteria to confirm patients who were eligible for treatment. To compute the pooled proportions for medication prescription and initiation, we carried out a single group proportional meta-analysis. We also extracted the proportions of patients who received a prescription and/or began treatment based on age, sex, race, education, socioeconomic status, location, and chronic conditions.

This review included 122 studies covering 114 programs. The pooled prescription rate was 77%, and the estimated medication initiation rate was 71%. Subgroup analysis revealed no significant difference in treatment initiation between the Fracture Liaison Service and other programs. Across all studies, age, sex, and socioeconomic status were the only equity variables reported in relation to treatment outcomes.

Our systematic review emphasizes the need for standardized reporting guidelines in post-fracture interventions. Moreover, considering equity stratifiers in the analysis of health outcomes will help address inequities and improve the overall quality and reach of secondary fracture prevention programs.

Fragility fractures are a serious and common consequence of falls in older adults. Orthogeriatric models of care reduce mortality and morbidity, but, despite this evidence, orthogeriatric programs (OGPs) are not standardized across Canada. The aim of this study was to better understand the facilitators and barriers of OGPs across Canada.

Data on OGPs across Canada were gathered via email survey to all Canadian Geriatric Society (CGS) members and distributed April 1st to May 1st 2021. Respondents answered 15 questions, using SKIP LOGIC, and data analysis was conducted with QualtricsXM software.

62 CGS members completed the survey. Respondents came from nine provinces/territories, with most being physicians from academic centres. 77% respondents indicated an existing OGP at their site, commonly an optional or automatic geriatrician consult. 23% indicated no formal OGP, of which 56% had an alternative service automatically consulted for older adults with fragility fracture, commonly internal medicine or a hospitalist. Responders indicated the most important factor in establishing an OGP is clinical leadership (56%, 10/18), and the most common barriers are lack of hospital prioritization and lack of funding (41%, 62/153).

The survey found that clinical leadership, hospital prioritization, and available funding are imperative to establishing OGPs. Limitations include the survey being distributed only to CGS members, a lower response rate, and respondents predominantly from academic centres in Ontario. Further qualitative data from other specialties (for example, orthopedics) and greater representation from community hospitals would be helpful to understand additional perceived barriers and facilitators.

Older adults often present with multiple comorbidities and face significant postoperative complications. This study aimed to describe the role of Nurse Practitioner (NP)-led orthogeriatric services in managing hip fracture patients. We conducted a review of health records of older adults with hip and proximal femoral fractures between July 2017 and June 2018, presenting descriptive statistics on patient characteristics, surgical outcomes, and the involvement of orthogeriatric services. A total of 197 participants were included, with a majority being female (n = 132; 67.0%). Most patients (53.8%; n = 106) had between five and nine pre-existing conditions. Among the 192 patients who underwent surgery, 69.8% (n = 134) experienced up to four surgical complications. The Nurse Practitioner provided care to 89.1% (n = 163) of the patients within the orthogeriatric service, with half of the patients (n = 82) requiring at least five NP interventions to manage complex pre- and postoperative needs. Refining the NP-led model could potentially help reduce the burden on physicians and surgeons in treating complex medical conditions, especially in settings where geriatricians may not be readily available.

Background/Objectives: Integrated orthogeriatric care has demonstrated benefits in hip fracture management for older patients. Comprehensive care pathways are essential for effective integrated care delivery, yet local variability in care pathways persists. We assessed the current hip fracture care pathways in the Netherlands, focusing on the variability between these care pathways and the degree of implementation of orthogeriatric care. Methods: A nationwide inventory study was conducted. A survey was sent to all hospitals in the Netherlands to collect the care pathways or local protocols for hip fracture care. All care elements reported in the care pathways and protocols were systematically analyzed by two independent researchers. Furthermore, an assessment was performed to determine which model of orthogeriatric care was applied. Results: All 71 Dutch hospitals were contacted, and 56 hospitals responded (79%), of which 46 (82%) provided a care pathway or protocol. Forty-one care elements were identified in total. In the care pathways and protocols, the variability in the description of these individual care elements ranged from 7% to 87%. Twenty-one hospitals had an integrated care model with shared responsibility, while an equal number followed an orthopedic trauma surgeon-led care model. Conclusions: These findings provide a detailed description of the hip fracture care pathways in the Netherlands. Variations were observed concerning the care elements described in the care pathways, the structure of the care pathway, and the specification of several elements. The implementation of integrated care with shared responsibilities, as recommended by the international literature, has not been achieved nationwide. The clinical implications of the variability between care pathways, such as the influence on the quality of care, need to be further investigated.

Orthogeriatric co-management (OGCM) addresses the special needs of geriatric fracture patients. Most of the research on OGCM focused on hip fractures while results concerning other severe fractures are rare. We conducted a health-economic evaluation of OGCM for pelvic and vertebral fractures.

In this retrospective cohort study, we used German health and long-term care insurance claims data and included cases of geriatric patients aged 80 years or older treated in an OGCM (OGCM group) or a non-OGCM hospital (non-OGCM group) due to pelvic or vertebral fractures in 2014-2018. We analyzed life years gained, fracture-free life years gained, healthcare costs, and cost-effectiveness within 1 year. We applied entropy balancing, weighted gamma and two-part models. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves.

We included 21,036 cases with pelvic (71.2% in the OGCM, 28.8% in the non-OGCM group) and 33,827 with vertebral fractures (72.8% OGCM, 27.2% non-OGCM group). 4.5-5.9% of the pelvic and 31.8-33.8% of the vertebral fracture cases were treated surgically. Total healthcare costs were significantly higher after treatment in OGCM compared to non-OGCM hospitals for both fracture cohorts. For both fracture cohorts, a 95% probability of cost-effectiveness was not exceeded for a willingness-to-pay of up to €150,000 per life year or €150,000 per fracture-free life year gained.

We did not obtain distinct benefits of treatment in an OGCM hospital. Assigning cases to OGCM or non-OGCM group on hospital level might have underestimated the effect of OGCM as not all patients in the OGCM group have received OGCM.

There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes.

This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality.

Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services.

Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.

Orthogeriatric co-management (OGCM) describes a collaboration of orthopedic surgeons and geriatricians for the treatment of fragility fractures in geriatric patients. While its cost-effectiveness for hip fractures has been widely investigated, research focusing on fractures of the upper extremities is lacking. Thus, we conducted a health economic evaluation of treatment in OGCM hospitals for forearm and humerus fractures.In a retrospective cohort study with nationwide health insurance claims data, we selected the first inpatient stay due to a forearm or humerus fracture in 2014-2018 either treated in hospitals that were able to offer OGCM (OGCM group) or not (non-OGCM group) and applied a 1-year follow-up. We included 31,557 cases with forearm (63.1% OGCM group) and 39,093 cases with humerus fractures (63.9% OGCM group) and balanced relevant covariates using entropy balancing. We investigated costs in different health sectors, length of stay, and cost-effectiveness regarding total cost per life year or fracture-free life year gained.In both fracture cohorts, initial hospital stay, inpatient stay, and total costs were higher in OGCM than in non-OGCM hospitals. For neither cohort nor effectiveness outcome, the probability that treatment in OGCM hospitals was cost-effective exceeded 95% for a willingness-to-pay of up to €150,000.We did not find distinct benefits of treatment in OGCM hospitals. Assigning cases to study groups on hospital-level and using life years and fracture-free life years, which might not adequately reflect the manifold ways these fractures affect the patients' health, as effectiveness outcomes, might have underestimated the effectiveness of treatment in OGCM hospitals.

Introduction Orthogeriatric patients with femur fractures, despite their multiple comorbidities and associated healthcare costs, have a promising new approach. This approach suggests that most patients should be hospitalized in the geriatric department, with daily orthopedic follow-up. The potential for lower mortality rates through orthogeriatric co-management and dual care is a reason for hope in our field. Methods This study is retrospective and involved 285 patients with proximal hip fractures. Two treatment models were compared: hospitalization in orthopedic and geriatric departments with different treatment protocols. The study analyzed demographic data and postoperative outcomes. It also included an analysis of 26 patients who received conservative treatment. Results Our study revealed significant differences between patients hospitalized in the orthopedic and geriatric departments. Geriatric department patients, who were significantly older and had higher comorbidities, experienced extended hospitalization and higher mortality rates during hospitalization, at 30 days, and at one-year follow-up (p<0.05). Notably, a significantly higher proportion of geriatric patients were discharged to home rehabilitation at the end of hospitalization compared to orthopedic patients (17.5% vs. 7.4%; p<0.01). Among non-operated patients, the mortality rate was 57.7% compared to 16.5% in patients who underwent surgery during the one-year follow-up. Discussion Our study suggests that elderly patients with hip fractures may benefit from management in the geriatric department. Despite experiencing significantly longer hospital stays, these patients have a higher likelihood of being discharged home compared to those managed in the orthopedic department. These findings have important implications for the care of orthogeriatric patients and may help guide future treatment strategies.

The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture.

Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients.

A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients.

A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.

The surgical management of older patients is complex due to age-related underlying comorbidities and decreased physiological reserves. Comanaged care models, such as the Geriatric Trauma Unit, are proven effective in treating the complex needs of patients with fall-related injuries. While patient-centered care is an important feature of these comanaged care models, there has been minimal research dedicated to investigating the patient experience within Geriatric Trauma Units. Therefore, it remains uncertain whether the Geriatric Trauma Unit's emphasis on a patient-centered approach truly manifests in these interactions. This study explores how patients with fall-related injuries admitted to a Geriatric Trauma Unit perceive and experience patient-centered care during hospitalization.

This qualitative generic study was conducted in three teaching hospitals that integrated the principles of comanaged care in trauma care for older patients. Between January 2021 and May 2022, 21 patients were interviewed.

The findings highlight the formidable challenges that older patients encounter during their treatment for fall-related injuries, which often signify a loss of independence and personal autonomy. The findings revealed a gap in the consistent and continuous implementation of patient-centered care, with many healthcare professionals still viewing patients mainly through the lens of their injuries, rather than as individuals with distinct healthcare needs. Although focusing on fracture-specific care and physical rehabilitation aligns with some patient preferences, overlooking broader needs undermines the comprehensive approach to care in the Geriatric Trauma Unit.

Effective patient-centered care in Geriatric Trauma Units requires full adherence to its core elements: patient engagement, strong patient-provider relationships, and a patient-focused environment. This study shows that deviations from these principles can undermine care, emphasizing the need for a holistic approach that extends beyond treating immediate medical conditions.

Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79-92), and a median FI-CGA of 0.48 (IQR 0.43-0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.

In Germany, geriatricians deliver acute geriatric care during acute hospital stay and post-acute rehabilitation after transfer to a rehabilitation clinic. The rate patients receive acute geriatric care (AGC) or are transferred to post-acute rehabilitation (TPR) differs between hospitals. This study analyses the association between the two geriatric treatment systems (AGC, TPR) and second hip fracture in patients following an index hip fracture.

Nationwide health insurance data are used to identify the rate of AGC and TPR per hospital following hip fracture surgery in patients aged ≥ 80 years. Outcomes are a second hip fracture after surgery or after discharge within 180 or 360 days and new specific anti-osteoporotic drugs. Cox proportional hazard models and generalised linear models are applied.

Data from 29,096 hip fracture patients from 652 hospitals were analysed. AGC and TPR are not associated with second hip fracture when follow-up started after surgery. However, during the first months after discharge patients from hospitals with no AGC or low rates of TPR have higher rates of second hip fracture than patients from hospitals with high rates of AGC or high rates of TPR (Hazard Ratio (95% CI) 1.35 (1.01-1.80) or 1.35 (1.03-1.79), respectively). Lower rates of AGC are associated with lower probabilities of new prescriptions of specific anti-osteoporotic drugs.

Our study suggests beneficial relationships of geriatric treatment after hip fracture with a) the risk of second hip fractures during the first months after discharge and b) an improvement of anti-osteoporotic drug treatment.

➤ Hospitalist comanagement of patients undergoing orthopaedic surgery is a growing trend across the United States, yet its implementation in an academic tertiary care hospital can be complex and even contentious.➤ Hospitalist comanagement services lead to better identification of at-risk patients, optimization of patient care to prevent adverse events, and streamlining of the admission process, thereby enhancing the overall service efficiency.➤ A successful hospitalist comanagement service includes the identification of service stakeholders and leaders; frequent consensus meetings; a well-defined standardized framework, with goals, program metrics, and unified commands; and an occasional satisfaction assessment to update and improve the program.➤ In this article, we establish a step-by-step protocol for the implementation of a comanagement structure between orthopaedic and hospitalist services at a tertiary care center, outlining specific protocols and workflows for patient care and transfer procedures among various departments, particularly in emergency and postoperative situations.

Hip fractures globally are associated with high levels of morbidity, mortality, and significant financial burden. This audit aimed to assess the impact of orthogeriatric liaison care on post-operative outcomes following surgical management of neck or femur fractures.

Here, 258 patients who underwent hip fracture surgery over 1-year were included. Data were collected as an audit following the transition to an orthogeriatric liaison care model, involving regular orthogeriatric review (thrice weekly ward rounds, daily board rounds), superseding orthogeriatric review as requested. The audit is meant to assess the development of post-operative non-surgical site infection (NSSI) and mortality and duration of inpatient stay. Outcomes were compared to previous data from our hospital site in 2015/2016.

Patients with severe cognitive impairment and systemic disease (Abbreviated Mental Test Score (AMTS) < 7 and American Society of Anesthesiologists (ASA) grade ≥ 3) showed significantly elevated NSSI risk, consistent across the study periods. Both periods demonstrated an increased risk of NSSI associated with admission from nursing homes. Despite the 2021/2022 cohort being notably older, NSSI risk decreased from 40.6% to 37.2% after implementing the orthogeriatric care model. NSSI risk was notably reduced for severe cognitive impairment (51.6% vs. 71%), and the p-value was 0.025. Average hospital stay decreased post-intervention (2.4 days shorter), with a notable reduction for NSSI patients (3.4 days shorter). Overall mortality rates were similar, although mortality due to infection was significantly reduced in 2021/2022 (44.4% vs. 93.3%), and the p-value was 0.003.

The orthogeriatric liaison care model significantly decreased NSSI only in individuals with severe cognitive impairment and infection-associated mortality. This highlights the integral role of orthogeriatricians in the care of elderly hip fracture patients.

Both dementia and frailty have been associated with worse outcomes in patients with hip fractures. However, the interrelation and predictive value of these two entities has yet to be clarified. The current study aimed to investigate the predictive relationship between dementia, frailty, and in-hospital mortality after hip fracture surgery.

All patients registered in the 2019 National Inpatient Sample Database who were 50 years or older and underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. Logistic regression (LR) models were constructed with in-hospital mortality as the response variables. One model was constructed including markers of frailty and one model was constructed excluding markers of frailty [Orthopedic Frailty Score (OFS) and weight loss]. The feature importance of all variables was determined using the permutation importance method. New LR models were then fitted using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models.

An estimated total of 216,395 patients were included. Dementia was the 7th most important variable for predicting in-hospital mortality. When the OFS and weight loss were included, they replaced dementia in importance. There was no significant difference in the predictive ability of the models when comparing the model that included markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.81)] with the model that excluded markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.80)].

Dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients. This finding highlights the importance of early frailty screening for improvement of care pathways and discussions with patients and their families in regard to expected outcomes.

Geriatric trauma continues to rise, corresponding with the continuing growth of the older population. These fractures continue to expand, demonstrated by the incidence of hip fractures having grown to 1.5 million adults worldwide per year. This patient population and their associated fracture patterns present unique challenges to the surgeon, as well as having a profound economic impact on the health care system. Pharmacologic treatment has focused on prevention, with aging adults having impaired fracture healing in addition to diminished bone mineral density. Intraoperatively, novel ideas to assess fracture reduction to facilitate decreased fracture collapse have recently been explored. Postoperatively, pharmacologic avenues have focused on future fracture prevention, while shared care models between geriatrics and orthopaedics have shown promise regarding decreasing mortality and length of stay. As geriatric trauma continues to grow, it is imperative that we look to optimize all phases of care, from preoperative to postoperative.

Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures.

All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding.

A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001].

There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.

The number of older people hospitalised with major trauma is rapidly increasing. New models of care have emerged, such as co-management, and trauma centres dedicated to delivering geriatric trauma care. The aim of this scoping review was to explore in-hospital models of care for older adults who experience physical trauma.

The search was conducted in accordance with the PRISMA- SC (preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews) reporting guidelines. The National Heart Lung, and Blood Institute (NIH) study quality assessment tool was used to evaluate risk of bias in before and after non-randomised experimental studies.

Of 2127 records returned from the database search, 43 papers were included. We identified five types of care models investigated in the reviewed studies: centralised trauma management, consultation services, co-management, patient care protocols, and alert and triage systems. The majority of patients were admitted under a specialised trauma service, intervention teams were for the most part multidisciplinary, and follow-up of patients post-discharge was seldom reported. Consultation services more often had advanced care and discharge planning as treatment objectives. In contrast, patient care protocol and alert systems commonly had management of anticoagulation as a treatment objective. Overall, the impact of the five models of care on patient outcomes was mixed.

Given the variability in patient characteristics and capabilities of health services, models of care need to be matched to the local profile of older trauma patients. However, some standards should be incorporated into a care model, including identifying goals of care, medication review and follow up post-discharge.

Fragility fractures occur because of low-impact trauma or even spontaneously in individuals with osteoporosis. Caring for older persons with fragility fractures can present several challenges due to the unique needs and vulnerabilities of this population. Older individuals commonly have multiple medical conditions, such as osteoporosis, arthritis, cardiovascular diseases, and diabetes. These comorbidities can complicate fracture management and increase the risk of complications. Fracture repair through surgery may be more complex in older patients due to poor bone quality, decreased tissue elasticity, and higher chances of anesthesia complications. In addition, mobility and functional limitations post-fracture are highly prevalent in this population, affecting their independence and increasing their risk of institutionalization. Addressing these challenges requires a multidisciplinary approach involving orthopedic surgeons, geriatricians, physical and rehabilitation physicians, physiotherapists, occupational therapists, dieticians, social workers, and caregivers. Preventive measures, such as fall prevention strategies and osteoporosis management, can also play a vital role in reducing the incidence of fragility fractures in older persons.

Orthogeriatric co-management (OGCM) may provide benefits for geriatric fragility fracture patients in terms of more frequent osteoporosis treatment and fewer re-fractures. Yet, we did not find higher costs in OGCM hospitals for re-fractures or antiosteoporotic medication for most fracture sites within 12 months, although antiosteoporotic medication was more often prescribed.

Evidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence for other fractures is rare. The aim of our study was to conduct an evaluation of economic and health outcomes after the German OGCM for geriatric fragility fracture patients.

This retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a fragility fracture in 2014-2018, and were treated in hospitals certified for OGCM (ATZ group), providing OGCM without certification (OGCM group) or usual care (control group). Healthcare costs from payer perspective, prescribed medications, and re-fractures were investigated within 6 and 12 months. We used weighted gamma and two-part models and applied entropy balancing to account for the lack of randomization. All analyses were stratified per fracture site.

We observed 206,273 patients within 12-month follow-up, of whom 14,100 were treated in ATZ, 133,353 in OGCM, and 58,820 in other hospitals. Total average inpatient costs per patient were significantly higher in the OGCM and particularly ATZ group for all fracture sites, compared to control group. We did not find significant differences in costs for re-fractures or antiosteoporotic medication for most fracture sites, although antiosteoporotic medication was significantly more often observed in the OGCM and particularly ATZ group for hip, pelvic, and humerus fractures.

The observed healthcare costs were higher in ATZ and OGCM hospitals within 12 months. Antiosteoporotic medication was prescribed more often in both groups for most fracture sites, although the corresponding medication costs did not increase.

Geriatrics-surgery co-management (GSCM) programs have improved patient outcomes, but little is known about how they change care and whether their value varies by surgical specialty. We aimed to assess GSCM's effects as perceived by Orthopedic Trauma, Trauma, and Neurosurgery clinicians.

We conducted a mixed-methods study utilizing electronic survey and virtual interviews at Penn Presbyterian Medical Center, an academic trauma center, in Philadelphia, PA. Participants included physicians, advanced practice providers, nurses, social workers, and case managers in the aforementioned specialties. Key measures were perspectives on value of GSCM, its facilitators, specialty most appropriate to manage specified medical issues, and factors affecting use.

Of 71 eligible clinicians, 45 (63%) completed the survey and 12 (21%) of 56 purposefully sampled for specialty-role diversity were interviewed. Clinicians across specialties valued GSCM highly and similarly for impact on personal management of older adults (grand mean [standard error, SE] = 4.33 [0.24] out of 5; p = 0.80 for specialty means comparisons), patient care (mean [SE] = 4.47 [0.21]; p = 0.27), patient outcomes (mean [SE] = 4.26 [0.22]; p = 0.51), and specialty overall (mean [SE] = 4.55 [0.23]; p = 0.25) but less so for knowledge growth (mean [SE] = 3.47 [0.29]; p = 0.11). Interviewees across specialties reported that value derived from improved understanding of patient history, management of complex medical conditions, goals of care support, communication with families, and patient discharge facilitation. Interviewees also agreed on program facilitators: aligned stakeholders, shared data-driven goals, champion/administrative support, continuity and availability of geriatricians, and thorough communication. Specialties differed on three issues: (1) who should manage some medical concerns; (2) whether GSCM makes their job easier (significantly easier for Orthopedic Trauma: mean [SE] = 4.75 [0.29] vs. Trauma: mean [SE] = 4.01 [0.19]; p = 0.05); and (3) whether GSCM increases coordination difficulty (more for Neurosurgery: mean [SE] = 2.18 [0.0.58] vs. Orthopedic Trauma: mean [SE] = 0.51 [0.42]; p = 0.03 and Trauma: mean [SE] = 0.89 [0.28]; p = 0.07). Orthopedic Trauma had the most positive impression of GSCM overall.

Clinicians across diverse surgical specialties valued GSCM. Hospitals considering implementation or expansion of GSCM should attend to identified facilitators and may need to tailor to specialty.