Konstantin Grigoryan MS Houman Javedan MD James L. Rudolph MD Ortho-Geriatric Models and Optimal Outcomes: A Systematic Review and Meta-Analysis Konstantin Grigoryan MS Houman Javedan MD James L. Rudolph MD

Disclosures Houman Javedan MD: James L. Rudolph MD: Current geriatrician in trauma/orthopedic-geriatric service at Brigham and Women’s Hospital James L. Rudolph MD: VA Rehabilitation Research CDA VA Patient Safety Center of Inquiry MSTAR Program NIH Grant: 1T35AG038027-02 The American Federation for Aging Research Konstantin Grigoryan MS: MSTAR Program:

Background Hip fractures common in elderly Annual incidence: 957.3/100,000 women, 414.4/100,00 men1 High 1 year mortality 20-30%2 Geriatricians specialize in medical care of older patients Orthopedic-geriatric collaboration increasing in frequency and may improve outcomes3 Incidence from 1986 to 2005 1 JAMA. 2009;302:1573-9 2 J Am Geriatr Soc. 2002;50:1644-50 3 Osteoporos Int. 2010;21:S637-46

Objective Systematic Review and Meta-Analysis to determine if ortho-geriatric care models improve in-hospital outcomes and long- term mortality

Methods Systematic Literature Search Databases MEDLINE CINAHL EMBASE Cochrane Central Register Two independent reviewers

Methods Inclusion Criteria Exclusion Criteria Hip fractures Collaboration between geriatricians and orthopedic surgeons Focus on inpatient care Contain a control or standard care group Not published in English or Spanish No control group Published more than 20 years ago Published as Letter or Abstract only

Methods Outcomes In-hospital Mortality Length of Stay Time to surgery Long-term mortality (6m to 1yr)

Methods Statistics Random effects meta-analysis Minimum of three studies required for meta-analysis Other sources of bias: Heterogeneity Publication Bias Small Study Bias Used to manage any heterogeneity that may have been introduced by varying conitions of different studies. A Other sources of Bias

75 Did not meet inclusion/exclusion criteria Results Systematic Review 1480 Citations 1387 Not Relevant 93 Full-Text articles reviewed 75 Did not meet inclusion/exclusion criteria This is just a flow cart of the search process. 1729 total of top line. 1480 total citations were reviewed. With 93 full text articles read in detail. In the end 18articles were identified for inclusion. 18 articles included

Results Care Models Of 18 included studies, three models of care emerged 1. Routine geriatric consultation on orthopedic ward – 10 studies 2. Geriatric ward with orthopedic consultation – 3 studies 3. Shared care or co-management model within an orthopedic ward – 5 studies Shared care- both surgeon and geriatrician share responsibility, geriatrician integral part of the team 2. = ACE unit

Results In-hospital Mortality Model (n) RR ( 95%CI) Heterogeneity All Three Models (n=9) 0.60 [0.43, 0.84] No Specific Models Routine Geriatric Consult (n=5) 0.51 [0.38, 0.69] Geriatric Ward (n=1) N/A Shared Care (n=3) 0.61 [0.16, 2.28]

Results Length of Stay Model (n) SMD (95%CI) Heterogeneity All Three Models (n=18) -0.25 [-0.44, -0.05] Yes Specific Models Routine Geriatric Consult (n=10) -0.03 [-0.20, 0.14] Geriatric Ward (n=3) -0.33 [-1.06, 0.41] Shared Care (n=5) -0.61 [-0.95, -0.28] SMD standardized mean difference

Results

Results Time To Surgery Model (n) SMD (95%CI) Heterogeneity All Three Models (n=9) -0.10 [-0.22, 0.02] Yes Specific Models Routine Geriatric Consult (n=4) -0.13 [-0.23, -0.03] No Geriatric Ward (n=1) -0.33 [-1.06, 0.41] Shared Care (n=4) -0.15 [-0.44, 0.15] Yes + Publ. bias Highlight Publication Bias SMD standardized mean difference

Results Long-term Mortality Model (n) RR (95%CI) Heterogeneity All Three Models (n=11) 0.83 [0.74, 0.94] No Specific Models Routine Geriatric Consult (n=7) 0.78 [0.65, 0.95] Geriatric Ward (n=2) N/A Shared Care (n=2)

Limitations Several studies were not randomized trials Control groups varied (hospitalist consult, PRN geriatric consult, etc) Some heterogeneity and publication bias present

Conclusion Routine Geriatric interventions seem to have a positive outcome including reduced mortality As the number of collaborative programs increases, it is important to measure other outcomes (function, quality of life) to further clarify the benefit of geriatric input