Interdisciplinary Care Programs

While the 2014 AAOS CPG on Interdisciplinary Care focused on patients with mild to moderate dementia, four high quality studies (Berggren 2008, Duncan 2006, Marcantonio 2001, Naglie 2002) and 15 moderate quality studies (Crotty 2019, Heltne 2017, Huusko 2000, Huusko 2002, Majumdar 2007, Olsson 2007, Prestmo 2015, Shyu 2008, Shyu 2010, Shyu 2013, Shyu 2013, Shyu 2013, Shyu 2016, Stenvall 2007, Vidan 2005) now provide strong evidence that interdisciplinary management of geriatric hip fractures improves overall outcomes in all geriatric fracture patients. 

Interdisciplinary care refers to programs that involve providers from multiple disciplines working together to co-manage individuals with hip fracture. This may include geriatric and orthopedic providers, and nursing, dietary, and rehabilitation providers such as occupational and physical therapists. Co-management often includes workup and initiation of therapy for osteoporosis, pain, functional, nutritional and medication management, and prevention of complications (e.g. falls, delirium, and constipation).

Although the outcomes delineated in the studies do not allow for head-to-head comparisons, certain critical themes have emerged from our updated analysis.

Decreased mortality and complications: One high quality study (Duncan 2006) and three moderate studies (Vidan 2005, Olsson 2006, Shyu 2016) found that early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in older adult patients with hip fractures. One high quality study (Naglie 2002) and two moderate quality studies (Huusko 2000, Majumdar 2007) found no difference in mortality for intensive geriatric rehabilitation and case management respectively. However, the findings from these studies all trended toward benefit of intervention.

Functional outcomes, reduction of falls, quality of life, and return to the community: Two high quality studies (Berggren 2008, Naglie 2002) found no significant difference in falls, fractures and functional outcomes for interdisciplinary care. One moderate study (Vidan 2005) found no difference in functional recovery. However, the findings from these studies all trended toward benefit of intervention. While most authors reported a trend toward increased mobility, decreased falls and/or failure to lose mobility, significant improvements were noted in eight moderate studies (Crotty 2019, Prestmo 2015, Huusko 2002, Olsson 2007, Huusko 2000, Shyu 2016, Stenvall 2007, both a and b). There was evidence of benefits for reduction in falls and improved quality of life and return to the community.  Three studies, Naglie?(2002) Huusko (2000) and Stenvall (2007) found improvements in functional outcomes for subgroups with mild to moderate cognitive impairment or dementia.

Initiation of Osteoporosis Management: Only Majumdar (2007) compared case management focused on evidence-based osteoporosis treatment with usual care. They found that the intervention group had substantially higher proportion of appropriate care (bone mineral density testing, bisphosphonate therapy). The average intervention cost was $50.00 per patient. 

Nutritional outcomes: Duncan (2006) noted that Dietetic assistant supported patients had higher energy intake and decreased in-hospital and 4-month post-operative mortalities. Stenvall (2007) found fewer nutritional problems for postoperative geriatric assessment and rehabilitation intervention compared to conventional care. 

Delirium: Marcantonio (2001) found that cumulative incidence was significantly lower for delirium and severe delirium in the group who had geriatric consultation compared to the usual care group. Both groups experienced a similar drop in prevalence so that there was no significant difference by discharge. Stenvall (2007a) found significantly better outcomes for postoperative delirium and number of days of delirium for the postoperative geriatric assessment and rehabilitation intervention compared to conventional care. There was also no difference between groups in the number days of delirium per episode. Crotty (2019) found that the control group was favored at 4 weeks, but at 12 weeks there was no difference.

Cognitive status: Whereas one high quality study (Berggren 2008) found no difference in Mini-Mental State Exam (MMSE) between intervention and control groups, two high quality studies found significant differences in favor of interdisciplinary care. Prestmo (2015) found significant improvement in MMSE and Clinical Dementia Rating scale for comprehensive geriatric care compared to orthopaedic trauma ward care. Shyu (2013) found a non-significant outcome for general mental health as measured by the SF-36 Mental Component Summary score for interdisciplinary comprehensive compared to usual care.

Depression: Berggren (2008) found that the Geriatric Depression scale scores favored conventional orthopaedic care group compared to multi-disciplinary multi-factorial care at 4 and 12 months after hospitalization. Prestmo (2015) found significant difference in depression symptoms in favor for comprehensive geriatric care. Shyu and colleagues (2008, 2010, 2013, 2013, 2013, 2016) followed 2 cohorts of hip fracture patients recruited in 2001-2003 and 2005-2010, respectively. The team tracked interdisciplinary versus usual care in the first cohort and noted reduction of depression in those treated with interdisciplinary care. They then added comprehensive care for their second cohort which included depression management and reduced depression even further.

Improved medical care: This issue was particularly addressed by Heltne (2017) who conducted a secondary analysis of the Trondheim Hip Fracture Trial, which compared acute inpatient comprehensive geriatric care (CGC) with traditional orthopaedic care. They found that at discharge the group had more prescribed medications, related to the treatment of conditions related to the fracture (e.g., pain, constipation, osteoporosis). In addition, the CGC group had more drugs withdrawn, such as cardiovascular and CNS-active drugs.

Length of stay: Results on hospital length of stay varied. Whereas Vidan (2005) found that early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in older adult patients with hip fractures, there was no significant effect on length of hospital stay or functional recovery.  Two studies also found no significant difference in length of stay between intervention and control groups (Mercantonio 2001, Duncan 2006), Moreover, while Prestmo (2015) found?improved mobility, activities of daily living, and more frequent direct discharge home at 12 months for comprehensive geriatric care compared with usual orthopaedic care, they also found increased hospital length of stay. However, between 4 and 12 months, the comprehensive care group required fewer short-term nursing home stays. There was no difference between groups in hospital readmissions or permanent nursing home stay during the 4-12-month period. Similarly, Stenvall (2007 a and b) found shorter length of stay for the intervention group. Huusko (2000) conducted a secondary analysis of a RCT of intensive geriatric rehabilitation compared to usual care for 2 groups of patients with mild and moderate dementia. For both groups, the intervention resulted in substantially shorter length of hospital stay and a higher percent of patients returning to living in the community.

Benefits/Harms of Implementation

Interdisciplinary care programs for patients with hip fracture have a longstanding record of use with few identified safety risks. Relative benefits and harms of specific program elements should be considered individually to guide design and implementation.

Cost Effectiveness/Resource Utilization

Available studies provide limited information on the cost-effectiveness of interdisciplinary care programs overall or aspects of specific programs that may increase or decrease their cost effectiveness.

Acceptability

Dedicated care programs are likely to be acceptable to patients and providers, although acceptability may vary depending on specific components.

Feasibility

Available studies demonstrate feasibility of program implementation overall across diverse settings; feasibility of implementation/use is likely to vary depending on program eligibility criteria and the specific components.

Future Research

Future research should compare the relative advantages of different intervention components and their timing, intensity, frequency, and duration. Additional research is needed to characterize the cost-effectiveness of interdisciplinary hip fracture programs from the perspective of different stakeholders (e.g., patient/family, hospital, payer, society).