Orthogeriatric Co-management of Spine, Arm, Forearm, and Pelvis Fractures

Care models have been developed to address the specific needs of very old patients with fragility fractures where care is provided jointly between trauma surgery and geriatrics. A number of observational studies from various countries are available which show that this type of orthogeriatric co-management (OGCM) of patients with hip fractures reduces mortality (1, 2, 3). This has also been confirmed by data from Germany (4). The extent to which the structure provided by OGCM might also have an impact on mortality with other fracture sites such as the pelvis and spine has not yet been investigated for larger data sets. The aim of the present study was to compare, with the aid of routine data, mortality of very old patients who had been treated in hospitals with and without OGCM for fractures of the proximal humerus, forearm, spine, and pelvis.

Methods

This observational study is based on nationwide health insurance claims data from a large general statutory health insurance fund (AOK) relating to patients aged 80 years and over who had been admitted to hospital with proximal humerus, forearm, pelvic, and spinal fractures between 2014 and 2018. Whether or not a hospital had OGCM in place was defined by the entry of Operations and Procedure code OPS8–550 (early complex geriatric rehabilitation therapy [GRT]) in at least ten billings per year, regardless of the type of fracture (e.g., hip fracture) for which the invoice was issued. GRT is provided by a multidisciplinary team under the direction of a geriatrician. Outcome variables were 30-day and 180-day mortality. Administration of GRTs served as an indication of the general availability of OGCM at the respective hospital. The study investigated whether patients benefited from the structure of OGCM provided by the treating hospital, regardless of whether they themselves actually received GRT or not. Proportional hazards regression analyses were performed. Only patients who had received operative management were included in a sensitivity analysis.

Results

The data set comprised 117 708 hospital admissions with fractures of the proximal humerus, forearm, pelvis, and spine (84% females, average age 86.4 years). Around 70% of the patients were treated in hospitals with OGCM in place. In these hospitals, the incidence of documented GRT ranged between 9.2% for forearm fractures and 33.3% for pelvic fractures. The incidence of operative management was lowest for pelvic fractures (5.3%) and highest for forearm fractures (85.0%) (Table 1). The risk of dying within 180 days ranged between 7.1% for forearm fractures and 19.8% for pelvic fractures. Treatment in hospitals with OGCM was associated with a higher 30-day mortality for forearm fractures ([HR] 1.23 95% CI [1.01; 1.50]). For all other fracture types, there was no association between the availability of OGCM and 30-day mortality or 180-day mortality (Table 2). If only those patients were analyzed who had received operative management, then a reduction in mortality by 10% was observed in patients with proximal humerus fractures for hospitals with OGCM after 180 days (HR 0.90 [0.82; 0.999]). However, no association with OGCM was observed for operatively treated forearm, pelvic, and spinal fractures.

Table 1

Table 2

Discussion

We observed no association between the mere availability of OGCM in the treating hospital and mortality after proximal humerus, spinal, and pelvic fractures. There was even higher 30-day mortality for patients with forearm fractures treated in hospitals with OGCM, although this was not evident when analyzing only operated patients. Although some studies are available on hip fractures that investigated the association between OGCM and mortality, no study has so far been conducted on other fragility fractures. OGCM for hip fractures in Germany is usually provided in the form of GRT. Our hypothesis was that the other fragility fractures also benefit from this structure provided in the form of standardized processes and available expertise, regardless of whether GRT was implemented. However, this hypothesis was not confirmed. GRT rates of between 9% for forearm fractures and 33% for pelvic fractures were possibly too low to have any impact on mortality. Unlike the fracture types we investigated, hip fractures are almost always operated on, and it is also conceivable that patients who underwent surgery benefited in particular from OGCM. However, a sensitivity analysis which included only operated patients showed an association between OGCM and a 10% reduction in 180-day mortality only for proximal humerus fractures. A strength of this study is its large sample size and the systemic approach by which not so much the individual effect of GRT was analyzed but rather the structural effect of the availability of OGCM in the treating hospital, which reduced the risk of selection bias. In summary, our results demonstrated no reduction in mortality in hospitals with OGCM for proximal humerus, forearm, spinal, and pelvic fractures. It could be argued that a higher GRT rate is required to be able to demonstrate the known benefit of OGCM for hip fractures also in other fracture types.

Kilian Rapp, Clemens Becker, Patrick Roigk, Claudia Konnopka, Hans-Helmut König, Thomas Friess, Dietrich Rothenbacher, Gisela Büchele

Funding

Federal Joint Committee (grant number 01VSF19028)

Conflict of interest statement
The authors declare that they have no conflicts of interests.

Manuscript received on 4 October 2023, revised version accepted on 8 February 2024

Translated from the original German by Dr Grahame Larkin.

Cite this as:
Rapp K, Becker C, Roigk P, Konnopka C, König HH, Friess T, Rothenbacher D, Büchele G: Orthogeriatric co-management of spine, arm, forearm, and pelvis fractures. Dtsch Arztebl Int 2024; 121: 438–9. DOI: 10.3238/arztebl.m2024.0035

References

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