Abstract
Objective
Patients with hip fractures tend to have a poor prognosis. Although guideline-compliant practices are known to improve patient outcomes, there is a lack of evidence regarding the use of intervention to improve guideline adherence in hip fracture patients. The objective of our study was to evaluate guideline adherence by internists providing care to patients with hip fractures, using a protocol developed based on various guidelines.
Method
Protocol-driven care for hip fracture patients by internists began in April 2018 at our hospital. After its initiation, orthopedic surgeons performed the surgery, and the internists provided all other medical care. A controlled interrupted time-series analysis was used to evaluate the effects of protocol-driven care on guideline adherence to compare our hospital with other hospitals, using data extracted from a nationwide Japanese inpatient database covering the period April 2014 to March 2023.
Results
A total of 221,620 inpatients from 373 hospitals were included in the study. The initiation of protocol-driven care was associated with the guideline-recommended prescriptions: osteoporosis medication (incidence rate ratio (IRR): 8.09; 95% confidence interval (CI) 4.02-17.7), acetaminophen (IRR: 2.11; 95% CI 1.55-2.90), non-steroidal anti-inflammatory drugs (IRR: 0.16; 95% CI 0.11-0.24), and opioids (IRR: 5.96; 95% CI 3.14-12.2). However, there was no effect on the proportion of benzodiazepine prescriptions, surgery within 48 hours, deep venous thrombosis prophylaxis, or other perioperative outcomes, including medical fees.
Conclusion
The initiation of protocol-driven care by internists resulted in improved adherence to osteoporosis medication prescriptions and postoperative analgesic use compared with orthopedic care. This approach can be used as an effective method of care for elderly patients undergoing surgery.
Keywords: clinical practice guideline, hip fracture, perioperative care, guideline adherence, protocol, internist
Introduction
Hip fractures, which frequently occur in individuals aged 65 years and older (1), are associated with a significant functional decline, morbidity, and mortality (2,3). It results in a loss of physical function in approximately half of all patients compared to before suffering the fracture (4), and it also increases the time spent living in nursing homes (1). The 1-year mortality rate is reported to be as high as 22% (5). Patients with hip fractures often have many comorbidities (6) and their management should therefore be multidisciplinary (7).
Clinical practice guidelines (CPGs) are evidence-based and have been developed to achieve the desired outcomes (8,9). Adherence to CPGs leads to improved health outcomes (10). CPGs for hip fracture management include not only surgery but also internal medical practices, such as avoidance of surgical delay, pain control, and prophylaxis of deep venous thrombosis (DVT), secondary fracture, and complications (7,11-15). In Scottish and Danish studies, high adherence to CPGs for hip fracture patients was associated with a reduced 30-day mortality, readmission, and discharge to a high care setting (16,17).
However, adherence to CPGs for hip fracture management varies among institutions. Previous studies have reported CPG adherence rates of 0-60% (18-21). Multiple factors prevent adherence to CPGs, including a lack of protocols, additional workload, and little familiarity with such CPG recommendations (22). Thus, developing a protocol that clarifies the content of CPGs and their implementation by internists may have the potential to improve CPG adherence in patients with hip fractures. A protocol is effective for improving the clarity of CPG contents, and managing elderly patients with many comorbidities by internists is efficient and leads to a reduction in the workload of orthopedic surgeons. However, there is insufficient evidence regarding the effects of protocol-driven care provided by internists on CPG adherence.
Therefore, we aimed to evaluate the effects on CPG adherence and the perioperative outcomes due to the initiation of guideline-based protocol-driven care by internists.
Materials and Methods
Data sources
We utilized Diagnosis Procedure Combination (DPC) data from the Quality Indicator/Improvement Project's (QIP) database in Japan. It consists of data from acute care hospitals representing various sizes and geographical areas. Participating QIP hospitals regularly provide DPC data, which are also submitted to the Ministry of Health, Labour and Welfare. A list of hospitals participating in the QIP that consented to public disclosure is available on the website (http://med-econ.umin.ac.jp/QIP/sanka_byouin.html).
The DPC data consist of several data files, including Forms 1, 3, and 4, and Files D, E, F, H, and K (23). For this study, we used Form 1 and Files E and F. Form 1 contains discharge summaries, which include patient characteristics such as sex, age, height, and weight, as well as the primary diagnosis, trigger diagnosis, most and second-most medical-resource-intensive diagnoses, comorbidities, and complications using the codes from the International Classification of Diseases, Tenth Revision (ICD-10). Files E and F contain details regarding the medical services provided, medications, and equipment. These files also include the number of earned points based on the tariff of the National Health Insurance system, with one point equivalent to 10 JPY. This allowed us to calculate the claimed charges.
Study population
The patients included in this study met the following criteria: (1) a trigger diagnosis of ICD-10 Codes of S72.00 and S72.10; (2) underwent surgery (open reduction with internal fixation, total hip arthroplasty, or hemiarthroplasty) for hip fracture; (3) were admitted and discharged between April 1, 2014, and March 31, 2023; and (4) were aged 65 years or older.
Intervention
Intervention was defined as the initiation of protocol-driven care at Takatsuki General Hospital (TGH), an acute care hospital in Japan. Patients with hip fractures were admitted to the orthopedic surgery department at the TGH. However, since April 2018, internists in the general internal medicine (GIM) department have primarily treated patients with hip fractures as attending physicians. Orthopedic surgeons performed the surgery, and the internists provided all other medical care using a protocol (Table 1). The protocol was constructed by the internists themselves based on six CPGs (7,11-15), which included perioperative management of comorbidities, pain control, prophylaxis and management of perioperative complications, and management of osteoporosis and fall risk medications (Table 2).
Table 1.
Role of the Orthopedic Surgeon and Internist in Takatsuki General Hospital for Patients with Hip Fractures.
| Orthopedic surgeon | Internist | |
|---|---|---|
| Position of physicians | Member of medical staff | Attending physician |
| At admission | ||
| Obtaining patient information such as medical history | ○ | |
| Physical examination | Examination of hip fracture | General examination |
| Image evaluation | ○ | |
| Obtaining consent for surgery | ○ | |
| Explanation of medical condition to patient and the family | ○ | ○ |
| Entry of medical record | Related to hip fracture | Hospitalization summary |
| Paperwork required for hospitalization | ○ | |
| Entry of hip fracture care pathway | ○ | Modification in the path as necessary (Adjustment of perioperative fluids and antibiotics for surgical site infection prophylaxis) |
| Ordering rehabilitation | ○ | |
| Entry order set (such as meals, instructions) | ○ | |
| After hospitalization | ||
| Preoperative evaluation | Subspecialty medical consultation if considered necessary by the attending physician | |
| Ordering operating room and anesthesia | ○* | |
| Instructions for postoperative resting level | ○ | |
| Daily physical examination | ○ | |
| Daily medical record | ○ | |
| Prescription, and management of complications and comorbidities | ○ (Table 2) | |
| Wound treatment | ○ | |
| Routine postoperative image evaluation | ○ | |
| Discharge planning | ○ | |
| Explanation of medical condition to patient and the family | ○ | |
| At discharge | ||
| Paperwork required for discharge | ○ | |
| Preparing forms of patient information for discharge destination and primary care physician | ○ | |
| Prescription for discharge | ○ | |
| Completing discharge summary | ○ |
*The date of surgery is proposed, taking into account the availability of surgeons, anesthesiologists, and operating rooms.
If patients’ medical condition is expected to be difficult to stabilize until the day, the internist will recommend delaying the surgery.
Table 2.
Detailed Content Provided in Protocol-driven Care in the Intervention Group.
| Care process | Description |
|---|---|
| Perioperative management and evaluation | |
| Heart disease | Conduct risk assessment for individual cases and consider consultation with an expert if needed based on JCS guidelines. |
| Lung disease | Conduct risk assessment for individual cases and consider consultation with an expert if needed based on ACP guidelines. |
| Liver disease | Conduct risk assessment for individual cases and consider consultation with an expert if needed based on AGA recommendations. |
| Antithrombotic drug | Discontinuation and restarting based on ACC guidelines. |
| Comorbidities and complications | Identifying and treating correctable comorbidities and complications to prevent delays in surgery. |
| Collaboration with anesthesiologist | Sharing the information on patients identified as high risk by an internist in advance based on the patient’s comorbidities and complications. |
| Pain control | |
| Assess daily and prescribe sufficient analgesics to enable patients to perform movements necessary for nursing care and rehabilitation. | |
| Use acetaminophen as first choice if no contraindications and titrate depending on the patient’s condition (age, liver disease). | |
| Use NSAIDs: use with caution in patients with inadequate control with acetaminophen and (eGFR>30 mL/min/1.73m2 as recommended in KDIGO guidelines) or opioids in patients where acetaminophen is insufficient. | |
| Evaluate the possibility and necessity of reducing or discontinuing the analgesics and reducing or discontinuing the medication if possible. | |
| Anemia | |
| The target Hb level for stable patients is 8g/dL, and RBC transfusion given if the Hb level is lower than 8g/dL. | |
| The threshold for RBC transfusion is set higher for symptomatic patients, including those with myocardial ischemia and hemodynamic instability. | |
| Management of postoperative complications and comorbidities | |
| At the attending physician’s discretion. | |
| Prophylaxis of complications | |
| DVT prophylaxis | Patients with high padua prediction score and without anticoagulant drugs: pharmacological prophylaxis if no contraindications If there are contraindications: mechanical prophylaxis |
| Preventing falls | Reduce or stop medications that are linked to falls, when possible, in accordance with deprescribing algorithm. Remove unnecessary devices. Give instructions for use of alarms and restraints as needed. |
| Delirium prophylaxis | Avoid factors known to cause or aggravate delirium (such as consideration of cessation or reduction of drugs that are linked to delirium using deprescribing algorithm, pain control, and removal of unnecessary devices.) |
| Prophylaxis of nosocomial infections | Early removal of urinary catheters/intravenous route. Aspiration prevention (oral care, intervention by speech therapist, avoidance of antacids if not indicated). |
| Preventing gastrointestinal bleeding | Prescribe antacids if at least one of the following is met: coagulation abnormalities, platelet count <50,000/μL, history of gastrointestinal ulcer, antiplatelet drug use, anticoagulant drug use, corticosteroid use, SSRI use. Decrease use of sedatives to improve instability. |
| Preventing pressure ulcer | Prescribe preemptive dressings on areas of risk. If oral intake is low, try to find the cause and increase energy intake |
| Prophylaxis of refracture (based on CDC guidelines) | |
| Patient education | Guidance on quitting smoking and excessive drinking. |
| Nutrition | Evaluate calorie, calcium and vitamin D intake and consult with dietitian for dietary guidance. Prescribe vitamin D if intake is insufficient. |
| Management of comorbidities that increase fall risk | Management of chronic diseases that are linked to falls, such as cognitive dysfunction and neurological, cardiovascular, and musculoskeletal conditions. |
| Interventions for home hazards | Improve footwear and home environment. |
| Osteoporosis assessment | Bone mineral density testing. |
| Osteoporosis medication | Initiate bisphosphonate, anti-receptor activator of NFκB ligand antibody (denosumab), or human parathyroid hormone (teriparatide) if no contraindications, or arrange for initiation of humanized anti-sclerostin monoclonal antibody (romosozumab) after discharge. |
| Orthostatic hypotension | If recognized, establish the cause and intervene. |
| Assess visual impairment | If the patient cannot read more than a newspaper headline, refer to an ophthalmologist. |
| Management of medications that increase fall risk | Review prescribed drugs and reduce or stop medications that are linked to falls, when possible, in accordance with deprescribing algorithm. |
| Discharge planning | |
| Daily physiotherapy and occupational therapy assessment and comprehensive geriatric assessment by physicians are provided, and appropriate discharge destination is decided by multidisciplinary team, sharing the assessment results. | |
Items in bold are those relevant to the present study
JCS: Japanese Circulation Society, ACP: American College of Physicians, AGA: American Gastroenterological Association, ACC: American College of Cardiology, NSAIDs: Non-steroidal anti-inflammatory drugs, KDIGO: Kidney Disease Improving Global Outcomes, Hb: Hemoglobin, RBC: red blood cell, SSRI: Selective Serotonin Reuptake Inhibitor, CDC: Centers for Disease Control and Prevention, NF-κB: nuclear factor-kappaB
JCS guideline [24], ACP guideline [25], AGA recommendation [26], ACC guidelines [27], KDIGO guideline [28], Deprescribing algorithm [29], CDC guidelines [30]
Medications linked to falls: anticonvulsants, benzodiazepines, antidepressants, opioids, antipsychotics, sedative-hypnotics, anticholinergics, medications affecting blood pressure, antihistamines, muscle relaxants [30,31]
Medications linked to delirium: Benzodiazepines, opioids, dihydropyridines, and antihistamines [32]
Control
The control group comprised of hospitals registered in the QIP database, excluding TGH.
Outcomes
The primary outcomes and definitions are presented in Table 3. We reviewed the Japanese guidelines related to the management of patients with hip fractures requiring surgery. The guidelines include “the Femoral neck/trochanteric fracture clinical practice guidelines, revised 2nd edition (2011),” “the Japanese Orthopaedic Association (JOA) clinical practice guideline on the prevention of venous thromboembolism 2017,” and “the Guidelines for Perioperative Infection Prevention in Bone and Joint Surgery 2015” (7,15,34). Four contents related to the prophylaxis of secondary fractures, a multidisciplinary team approach, DVT prophylaxis, and prophylaxis of surgical site infection (SSI), were strongly recommended as internal medical care in these guidelines. Because a multidisciplinary team approach was achieved with the involvement of internists and SSI prophylaxis was achieved with the clinical pathway in our hospital, prophylaxis of secondary fractures and DVT prophylaxis were selected as indicators of CPG adherence. Regarding the prophylaxis of secondary fractures, because prescriptions can be extracted from the DPC database, we focused on the recommendations related to medication, including osteoporosis treatment, and minimizing the use of medications associated with an increased fall risk (35). Several medications are associated with falls, particularly benzodiazepine; therefore, we focused on the prescription of benzodiazepine during hospitalization (31). There were no specific recommendations on pain control or surgical timing in the Japanese guidelines, so we referred to the National Institute for Health and Care Excellence hip fracture management guidelines, which recommend surgery within 48 h, offer paracetamol unless contraindicated, and offer additional opioids if necessary and it does not recommend non-steroidal anti-inflammatory drugs (NSAIDs) use (13).
Table 3.
The Definitions of the Primary Outcomes.
| Primary outcomes | Definition |
|---|---|
| The proportion of osteoporosis medication prescriptions | Proportion of patients with an osteoporosis medication prescription including bisphosphonates, anti-receptor activator of NFκB ligand antibody (denosumab), human parathyroid hormone (teriparatide), and humanized anti-sclerostin monoclonal antibody (romosozumab) each week during hospitalization (33). |
| The proportion of benzodiazepine prescriptions | Proportion of patients with a benzodiazepine prescription each week during hospitalization. |
| The proportion of DVT prophylaxis performed | Proportion of patients with a prophylactic anticoagulant or therapeutic anticoagulant and/or mechanical prophylaxis each week during hospitalization. |
| The proportion of surgery within 48h | Proportion of patients with the duration from admission to operation being within 2 days. |
| The proportion of postoperative analgesics prescriptions | Proportion of patients with a postoperative acetaminophen, NSAIDs, or opioids prescription each week. |
DVT: deep venous thrombosis, NFκB: nuclear factor-kappa B, NSAIDs: non-steroidal anti-inflammatory drugs
Secondary outcomes were the proportion of major complications and their breakdown, in-hospital mortality, 30-day readmission, 90-day readmission, length of stay (LOS), and medical fee. Conditions that are especially life-threatening and can be reliably extracted from DPC data were defined as major complications, referring to a previous study: myocardial infarction, stroke, venous thromboembolism requiring thrombolytic therapy or procedure, and life-threatening cardiovascular events (36). Because an incomplete report was expected due to the lack of incentives for hospitals to register complications, we identified complications using the data of drug prescriptions and medical procedures based on various guidelines to prevent underestimation (37,38). Japan's statutory health insurance system covers all medical expenses in Japan, and a national fee schedule, which is the same regardless of hospital, is paid by Japan's statutory health insurance. The medical fee is the total hospitalization fee (i.e., the national fee schedule) per patient.
Statistical analysis
A controlled interrupted time series (CITS) approach was used (39) to compare the effect of protocol-driven care at TGH before and after its initiation, with other hospitals as controls, considering that CPG adherence tends to increase naturally over time.
We examined the changes in the outcomes over the entire study period and divided the period into before and after the initiation of protocol-driven care in our hospital on April 1, 2018. A generalized linear model with a Poisson or quasi-Poisson distribution, considering the overdispersion of the data, and a log-link function were used. We added the weekly number of patients as offset terms in this model to evaluate the proportion of events [Supplementary material 1(a)]. A simple linear model was used to evaluate the number of events (Supplementary material 2b).
We modeled calendar week as a continuous variable to estimate secular trends. We examined differences in the immediate change in the proportion or number of each outcome between the intervention and control groups before and after April 1, 2018.
All statistical analyses were performed using the R version 3.6.0 software program (R Foundation for Statistical Computing, Vienna, Austria).
We conducted a sensitivity analysis to assess the consistency of the CITS analysis by considering lag periods of four and eight weeks, recognizing the possibility that patients admitted before the change point could be analyzed as patients admitted after the change point.
Ethical consideration
This study was approved by the Ethics Committee of the Graduate School of Medicine, Kyoto University (approval number: R0135), and was conducted in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects of the Ministry of Health, Labour and Welfare, Japan. Informed consent was waived for this research, as it did not utilize human biological specimens, and any information utilized in the research was anonymized.
Results
A total of 221,620 inpatients from 373 hospitals were included (Fig. 1). The characteristics of the two groups are presented in Table 4. There were no significant differences between the two groups.
Figure 1.
Flow of case selection.
Table 4.
Patient Characteristics.
| Characteristic | Control (n=220,432) | Intervention (n=1,188) | ||
|---|---|---|---|---|
| Female, n (%) | 172,082 | (78.1) | 940 | (79.1) |
| Admission on weekends and holidays, n (%) | 56,169 | (25.5) | 339 | (28.5) |
| Age, n (%) | ||||
| 65-74 | 27,749 | (12.6) | 158 | (13.3) |
| 75-84 | 74,130 | (33.6) | 430 | (36.2) |
| 85- | 118,553 | (53.8) | 600 | (50.5) |
| BMI (median [IQR]) | 20.33 | [18.07, 22.77] | 20.55 | [18.09, 22.66] |
| Ambulation status at admission (after injury), n (%) | ||||
| Dependent | 187,780 | (85.2) | 1,061 | (89.3) |
| Independent | 14,860 | (6.7) | 85 | (7.2) |
| Ambulation status at discharge, n (%) | ||||
| Dependent | 162,709 | (73.8) | 856 | (72.1) |
| Independent | 45,710 | (21.1) | 233 | (20.8) |
| Comorbidities, n (%) | ||||
| Cardiovascular disease | 25,874 | (11.7) | 156 | (13.1) |
| Dementia | 51,528 | (23.4) | 189 | (15.9) |
| Pulmonary disease | 9,810 | (4.5) | 19 | (1.6) |
| Diabetes mellitus | 43,394 | (19.7) | 201 | (16.9) |
| Hypertension | 87,354 | (39.6) | 151 | (12.7) |
| Renal failure | 12,468 | (5.7) | 68 | (5.7) |
| Liver disease | 8,292 | (3.8) | 43 | (3.6) |
| Coagulation abnormality | 750 | (0.3) | 1 | (0.1) |
| Anemia | 11,560 | (5.2) | 36 | (3.0) |
| Japan Coma Scale at admission, n (%) | ||||
| 0 | 179,691 | (81.5) | 1,085 | (91.3) |
| 1-3 | 40,741 | (18.5) | 103 | (8.7) |
| Japan Coma Scale at discharge, n (%) | ||||
| 0 | 184,975 | (85.2) | 1,054 | (89.5) |
| 1-3 | 32,027 | (14.5) | 124 | (10.4) |
| Trochanteric fracture, n (%) | 105,023 | (47.6) | 501 | (42.2) |
| Surgical procedure, n (%) | ||||
| Hemiarthroplasty | 79,972 | (36.3) | 417 | (35.1) |
| Internal fixation | 138,189 | (62.7) | 770 | (64.8) |
| Total hip arthroplasty | 2,271 | (1.0) | 1 | (0.1) |
| Medications at admission, n (%) | ||||
| Anticoagulant | 10,803 | (4.9) | 60 | (5.1) |
| Antiplatelet | 19,136 | (8.7) | 107 | (9.0) |
| Osteoporosis medication | 4,967 | (2.3) | 22 | (1.9) |
The results of the CITS analyses are shown in Fig. 2, and the immediate changes in the outcomes by the initiation of protocol-driven care are shown in Table 5. The CITS analysis showed a higher proportion of osteoporosis medication prescriptions from 6.47% to 43.7% [incidence rate ratio (IRR) 8.09; 95% confidence interval (CI) 4.02-17.7], a higher proportion of acetaminophen prescriptions from 47.1% to 98.2% (IRR 2.11; 95% CI 1.55-2.90), a higher proportion of opioid prescriptions from 7.22% to 44.5% (IRR 5.96; 95% CI 3.14-12.2), and a lower proportion of NSAIDs prescriptions from 90.7% to 14.7% (IRR 0.16; 95% CI 0.11-0.24) by the initiation of protocol-driven care in the intervention group compared to the control group. The proportion of benzodiazepine prescriptions, surgery within 48 hours, and DVT prophylaxis performed in the intervention group were not different from those in the control group [from 13.8% to 7.94% (IRR 0.58; 95% CI 0.26-1.28), from 39.8% to 46.8% (IRR 1.15; 95% CI 0.78-1.69), and from 99.5% to 100% (IRR 1.01; 95% CI 0.80-1.28), respectively]. There was no immediate change in the secondary outcomes, including the proportion of major complications, in-hospital mortality, 30-day readmission, 90-day readmission, LOS, and medical fee.
Figure 2.
Results of the controlled interrupted time series analysis for primary and secondary outcomes. Solid lines show the fitted results for the intervention and control group, and dashed lines show the 95% confidence intervals on the model. The black vertical dahsed line shows the point of initiation of protocol-driven care in the intervention group. DVT: deep venous thrombosis, LOS: length of stay
Table 5.
Controlled Interrupted Time Series Analysis for Primary and Secondary Outcomes.
| Primary outcomes | Incidence rate ratio | 95% CI |
| Proportion of osteoporosis medication prescription | 8.09 | 4.02-17.7 |
| Proportion of benzodiazepine prescription | 0.58 | 0.26-1.28 |
| Proportion of DVTa prophylaxis | 1.01 | 0.80-1.28 |
| Proportion of surgery within 48h | 1.15 | 0.78-1.69 |
| Proportion of postoperative analgesics | ||
| Acetaminophen | 2.11 | 1.55-2.90 |
| NSAIDsb | 0.16 | 0.11-0.24 |
| Opioids | 5.96 | 3.14-12.2 |
| Secondary outcomes | Incidence rate ratio | 95% CI |
| Proportion of major complications | 10.1 | 0.94-198 |
| In-hospital mortality | 15.8 | 0.26-5.05×104 |
| Proportion of 30-day readmission | 0.52 | 0.16-1.61 |
| Proportion of 90-day readmission | 1.13 | 0.53-2.46 |
| Secondary outcomes | Risk difference | 95% CI |
| Length of stay | -0.41 | -3.48 to 2.66 |
| Medical fee | -7,464 | -21,781 to 6,853 |
Bold font indicates statistical significance.
aDVT: deep venous thrombosis, bNSAIDs: non-steroidal anti-inflammatory drugs
The weekly changes in the outcomes are shown in Supplementary material 3. The outcomes for each major complication are shown in Supplementary materials 2 and 4. The outcomes with sensitivity analyses showed the same trends as the results of the main analyses (Supplementary materials 5-8).
We fitted the CITS models assuming quasi-Poisson distributions for the proportion of osteoporosis medication prescriptions, proportion of major complications, proportion of myocardial infarction, and proportion of life-threatening vascular events because of the overdispersion of the data, assuming Poisson distributions for the other outcomes, and assuming Poisson distributions for the remaining outcomes where the proportion was the outcome.
Discussion
This study suggested that protocol-driven care by internists significantly improved adherence to CPGs regarding the prescription of osteoporosis medication and postoperative analgesic use compared to the control group. It did not have a significant positive effect on other CPG adherence measures or on the perioperative outcomes. This result was consistent with previous studies evaluating the impact of standardized protocols for patients with hip fractures requiring surgery, which also showed improvements in CPG adherence regarding osteoporosis medication prescription and DVT prophylaxis (40). However, our findings differ from previous studies that evaluated the effectiveness of standardized protocols for patients with hip fractures requiring surgery and showed a significant reduction in the waiting time for surgery (41-43), LOS (41-44), readmission rates (40), and cost (43,44).
The reported proportion of osteoporosis medication prescription at discharge for patients with hip fractures under standard orthopedic care is reported to be 11.8-39.6% (45-47), which is consistent with the proportion observed in the control group at the change point. In previous studies, the low prescription proportion was reported to be due to the lack of clarity on clinical responsibility and low physician priority for osteoporosis management. These studies suggest that a clear definition of roles and the development of protocols are necessary (48-50). Moreover, physicians' hesitancy to start medications in the presence of contraindications or comorbidities is reported to be a reason for non-initiation (48). In the intervention group, specifying that medication should be initiated by internists during hospitalization may have addressed these issues, thus resulting in a higher proportion of osteoporosis medication prescriptions.
The estimate for the proportion of osteoporosis medication prescriptions by our CITS analysis increased to 49.1% at the end of the study period in the intervention group; however, the remaining 51% of the patients did not receive osteoporosis medication prescriptions. In a previous study conducted in Japan, a low proportion of osteoporosis medication prescriptions, even with a protocol, was attributed to patient barriers, such as their desire to be treated after consultation with their primary care physicians after discharge, a scheduled dental procedure, severe renal dysfunction, and a limited prognosis (51). Naik-Panvelkar et al. reported that doubts about the necessity or benefits of the medicine, concerns about adverse events, unique and complex dosage instructions, and the cost were patient barriers to initiation (48). Although the reasons why osteoporosis medication was not prescribed were not evaluated in our study, there may have been either some patient factors or medication-related factors, as has been reported in previous studies, which could not be eliminated by protocol initiation.
It has been reported that the proportion of anxiolytics, including benzodiazepine prescription, for patients aged 65 to 74 years in 2018 was 6.6% using a Japanese commercial database (52), and the proportion of prescriptions increased with age for outpatients in the U.S. (53). Although there was a difference in the patient backgrounds, whether they were inpatients or outpatients, the proportion in the control group at the change point was consistent with that in previous studies. The proportion of benzodiazepine prescriptions in the intervention group after the initiation of protocol-driven care was estimated to be lower than in the control group, although there was no difference in the proportion between the two groups before the initiation of protocol-driven care. The fact that the protocol specified to reduce or stop benzodiazepine, if possible, because it is linked to falls and delirium, may have been a possible reason for the result, just as previous studies have shown that the STOPP criteria, a screening tool for potentially inappropriate medications, including benzodiazepine, have reduced benzodiazepine prescription (54,55). Moreover, because knowledge about medication is required for deprescribing, care provided by internists in the intervention group may also have led to fewer prescriptions of benzodiazepine.
Although a decreasing trend in benzodiazepine prescriptions by protocol-driven care was observed, it was not statistically significant. This may be because a benzodiazepine prescription is recommended to gradually reduce the dosage of medication, even if the drug is deemed unnecessary to prevent withdrawal (56).
The proportion of DVT prophylaxis administered in the intervention group showed no significant difference between the two groups at the change point after the initiation of protocol-driven care (100% vs. 93.4%) in our CITS analysis. The proportion of DVT prophylaxis performed was already high without protocol-driven care, thus suggesting that protocol-driven care did not show any negative effect.
The proportion of hip fracture patients undergoing surgery within 48 h across OECD countries was reported to be 80% in 2021, which was higher than that in our study at the change point. It has been reported that a low proportion in Japan is strongly related to operating room availability, surgical procedures, and hospitalization days of the week (57,58).
The proportion of surgery within 48 h before the initiation of protocol-driven care was estimated to be lower in the intervention group than in the control group; however, protocol-driven care increased the proportion in the intervention group to a level comparable to that in the control group. Meyer et al. reported that a comprehensive multidisciplinary preoperative protocol involving collaboration with an anesthesiologist resulted in a decreased time to surgery from 28.2 h to 20.6 h (59). Our protocol, which specified collaboration with an anesthesiologist for high-risk patients, may have contributed to the increased proportion of patients in the intervention group. It has also been reported that care provided by physicians specializing in geriatric care resulted in significantly fewer consultations with internal medicine specialists other than cardiologists per patient for hip fracture patients (60). Because internists have knowledge about care for elderly patients and perioperative optimization of comorbidities and complications by internists themselves were specified in the protocol, which may have led to fewer consultations, protocol-driven care may have resulted in an increased proportion of surgery within 48 h in the intervention group. Moreover, the increased proportion in the intervention group by protocol-driven care may be attributed to the ability of internists to provide timely identification and early optimal treatment for correctable preoperative acute medical issues accompanying hip fracture, as specified in the protocol. This would ensure that patients could undergo surgery as soon as surgical resources became available.
There have been no previous studies on analgesic prescriptions for patients like those in our study in Japan, but a previous study on outpatients with osteoarthritis in Japan reported that the proportion of oral NSAIDs prescriptions was 71%, the proportion of acetaminophen prescriptions was 21.4%, and the proportion of weak opioid prescriptions was 10.7% (61). Although a simple comparison cannot be made due to the different settings, the proportions of NSAIDs and opioid prescriptions in the control group were 61.2% and 12.7%, respectively, which were comparable to those in the previous study. The proportion of acetaminophen prescriptions in the control group was estimated to increase during the study period from 29% to 80%. This increase was in line with the gradual increase in the proportion of acetaminophen prescriptions from 2013 to 2017 reported in a previous study on outpatients with osteoarthritis in Japan (61). One reason for this is thought to be that the approved acetaminophen dosage in Japan was less than the global standard dosage; however, the use of the global standard dosage has been approved since 2011, and the analgesic efficacy of acetaminophen for postoperative patients in Japan has been reported since then (62). In contrast, in our protocol-driven care, because the protocol specified the use of acetaminophen as the first choice for patients with no contraindications, an immediate increase in the proportion of acetaminophen prescriptions was shown.
The estimated lower proportion of NSAIDs prescriptions by protocol-driven care was consistent with a previous study reported by Gleich et al., thus indicating that orthogeriatric treatment decreased the proportion of NSAIDs prescriptions compared to standard orthopedic care (8.5% vs. 35.1%) (63). This result may be attributed to several factors. First, because avoiding the use of NSAIDs for patients with estimated glomerular filtration rate (eGFR)＜30 mL/min/1.73 m2 was clearly described in the protocol in accordance with the recommendations in kidney disease: improving global outcomes, inappropriate prescription of NSAIDs may have been decreased (28). Second, the evaluation of medical history by internists identified patients with comorbidities, such as cardiovascular disease and gastrointestinal bleeding, who were at risk of side effects by NSAIDs, and prescription for these high-risk patients may have been withheld. Lastly, because a sufficient dosage of acetaminophen was prescribed in accordance with the protocol, it is supposed that NSAIDs were not required or that opioids were used as additional analgesics, as described in the protocol.
The proportion of major complications was lower than the breakdown of the proportion of major complications in a previous study (36). It is difficult to assess our results because the lower proportion in our study might be due to underestimation resulting from undercoding, which is a major issue for administrative health data (64). Our CITS analysis estimated that the proportion of 30-day readmissions in the intervention group was 5.88% to 3.34%, and the proportion of 90-day readmissions in the intervention group was slightly higher (9.18% to 11.3%), although there was no significant difference between the groups. Previous studies reported that care by internists for hip fracture patients undergoing surgery showed no effect on readmission, which is consistent with our results (65,66).
Regarding in-hospital mortality, a statistically meaningful assessment could not be made because of the low incidence in our study. A previous review reported that orthogeriatric care for hip fracture patients showed lower in-hospital mortality than orthopedic surgeons' care (67), but the mechanism of action is unclear.
In this study, it was shown that initiating a protocol based on various CPGs by internists can improve adherence to CPG-recommended practices for elderly patients undergoing surgery without any negative effects. Additionally, these findings suggest the importance of involving internists in the care of elderly hip fracture patients with multimorbidities when providing protocol-driven care.
Strengths and limitations
We performed a CITS analysis, which is a quasi-experimental design with a good control group, using a large-scale inpatient database to evaluate the effects of protocol-driven care provided by internists in our hospital. However, our study is associated with several limitations. First, some hospitals in the control group may have adopted protocol-driven care by their internists. However, this influence would be biased toward the null hypothesis; hence, our results would be robust if this influence existed. Second, the use of an administrative database could have led to underestimation of complications due to undercoding (64). However, the diagnosis at admission and complications after admission were entered separately into the DPC database, and complications were extracted using disease-specific procedures and medications recommended in the CPGs to compensate for this limitation. Even if a limitation exists, the results would be biased in the same direction for both groups. Finally, this protocol was only a single-center initiative; therefore, its generalizability is limited. Additionally, the study reflects the outcomes of care provided by internists using the protocol, without comparison to the care provided by orthopedic surgeons using the same protocol. However, considering the mechanisms by which protocol-driven care influenced the outcomes, the usefulness of protocol-driven care was supported.
Conclusion
The initiation of care by internists using a protocol based on various CPGs for hip fracture patients undergoing surgery showed improved adherence to recommended practice in CPGs, particularly in prescribing osteoporosis medication and initiating acetaminophen first with sparing the use of NSAIDs in comparison to standard orthopedic care without compromising perioperative outcomes. Protocol-driven care by internists is therefore considered to be an effective method of care for elderly patients undergoing surgery.
The authors state that they have no Conflict of Interest (COI).
Financial Support
This study was supported by a Health and Labour Sciences Research Grant (Grant Numbers JPMH21IA1005 and JPMH22AA2003) from the Ministry of Health, Labour and Welfare and JSPS KAKENHI (Grant Number JP23H00448) from the Japan Society for the Promotion of Science (to Yuichi Imanaka). The funders had no role in the study design, data collection and analysis, decision to publish, or manuscript preparation.
Supplementary Material
The model and parameters in a CITS analysis.
Slope changes in the controlled interrupted time series analysis for primary and secondary outcomes.
Results of the controlled interrupted time series analysis of breakdown of major complications.
Results of sensitivity analysis of controlled interrupted time series analysis.
Results of sensitivity analysis of controlled interrupted time series analysis for the breakdown of major complications.
Results of the controlled interrupted time series analysis for the breakdown of major complications.
Results of the sensitivity analysis of controlled interrupted time series analysis.
Results of the sensitivity analysis of controlled interrupted time series analysis for the breakdown of major complications.
Acknowledgments
The authors would like to thank the hospitals that participated in the QIP for sharing their data.
References
- 1.Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 51: 364-370, 2003. [DOI] [PubMed] [Google Scholar]
- 2.Bentler SE, Liu L, Obrizan M, et al. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol 170: 1290-1299, 2009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Melton LJ 3rd. Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res 18: 1139-1141, 2003. [DOI] [PubMed] [Google Scholar]
- 4.Maggi S, Siviero P, Wetle T, Besdine RW, Saugo M, Crepaldi GHip Fracture Study Group . A multicenter survey on profile of care for hip fracture: predictors of mortality and disability. Osteoporos Int 21: 223-231, 2010. [DOI] [PubMed] [Google Scholar]
- 5.Downey C, Kelly M, Quinlan JF. Changing trends in the mortality rate at 1-year post hip fracture - a systematic review. World J Orthop 10: 166-175, 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Liow MHL, Ganesan G, Chen JDY, et al. Excess mortality after hip fracture: fracture or pre-fall comorbidity? Osteoporos Int 32: 2485-2492, 2021. [DOI] [PubMed] [Google Scholar]
- 7.Japanese Orthopaedic Association (JOA); Japanese Society for Fracture Repair (JSFR) . Femoral Neck/trochanteric Fracture Clinical Practice Guidelines revised 2nd ed. Nankodo, Tokyo, 2011. [Google Scholar]
- 8.Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ 318: 593-596, 1999. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Jackson R, Feder G. Guidelines for clinical guidelines. BMJ 317: 427, 1998. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 342: 1317-1322, 1993. [DOI] [PubMed] [Google Scholar]
- 11.McGlasson R, Zellermeyer V, MacDonald V, et al. National Hip Fracture Toolkit [Internet]. [cited 2023 Nov 7]. http://boneandjointcanada.com/wp-content/uploads/2014/05/National-hip-fracture-toolkit-June-2011.pdf
- 12.O'Connor MI, Switzer JA. AAOS Clinical Practice Guideline Summary: Management of Hip Fractures in Older Adults. J Am Acad Orthop Surg 30: e1291-e1296, 2022. [DOI] [PubMed] [Google Scholar]
- 13.Swift C, Sahota O, Johansen A, et al. Hip fracture: management. Clinical guideline [CG124] [Internet]. [cited 2023 Nov 7]. https://www.nice.org.uk/guidance/cg124
- 14.Orimo H, Iki M, Ishibashi H, Hajime O, Masayuki I, Hideaki I, et al. Osteoporosis Prevention and Treatment Guidelines 2015. Life Science Publishing, Tokyo, 2015. [Google Scholar]
- 15.Japanese Orthopaedic Association . Japanese Orthopaedic Association (JOA) Clinical Practice Guideline on the Prevention of Venous Thromboembolism 2017. Nankodo, Tokyo, 2017. [Google Scholar]
- 16.Farrow L, Hall A, Wood AD, et al. Quality of care in hip fracture patients: the relationship between adherence to national standards and improved outcomes. J Bone Joint Surg 100: 751-757, 2018. [DOI] [PubMed] [Google Scholar]
- 17.Kristensen PK, Thillemann TM, Søballe K, Johnsen SP. Are process performance measures associated with clinical outcomes among patients with hip fractures? A population-based cohort study. Int J Qual Health Care 28: 698-708, 2016. [DOI] [PubMed] [Google Scholar]
- 18.Seys D, Sermon A, Sermeus W, et al. Recommended care received by geriatric hip fracture patients: where are we now and where are we heading? Arch Orthop Trauma Surg 138: 1077-1087, 2017. [DOI] [PubMed] [Google Scholar]
- 19.Frandsen CF, Glassou EN, Stilling M, Hansen TB. Poor adherence to guidelines in treatment of fragile and cognitively impaired patients with hip fracture: a descriptive study of 2,804 patients. Acta Orthop 92: 544-550, 2021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Sunol R, Wagner C, Arah OA, et al.; DUQuE Project Consortium . Implementation of departmental quality strategies is positively associated with clinical practice: results of a multicenter study in 73 hospitals in 7 European countries. PLoS ONE 10: e0141157, 2015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 348: 2635-2645, 2003. [DOI] [PubMed] [Google Scholar]
- 22.Correa VC, Lugo-Agudelo LH, Aguirre-Acevedo DC, et al. Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview. Health Res Policy Syst 18: 74, 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Ministry of Health, Labour and Welfare . Guidelines for “A Survey for Assessing the Effects of Introducing DPC" in fiscal year 2022 [Internet]. [cited 2023 Nov 17]. https://www.mhlw.go.jp/content/12404000/000923138.pdf
- 24.Hiraoka E, Tanabe K, Izuta S, et al.; the Japanese Society Joint Working Group . JCS 2022 guideline on perioperative cardiovascular assessment and management for non-cardiac surgery. Circ J 87: 1253-1337, 2023. [DOI] [PubMed] [Google Scholar]
- 25.Qaseem A, Snow V, Fitterman N, et al.; the Clinical Efficacy Assessment Subcommittee of the American College of Physicians . Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med 144: 575-580, 2006. [DOI] [PubMed] [Google Scholar]
- 26.Newman KL, Johnson KM, Cornia PB, Wu P, Itani K, Ioannou GN. Perioperative evaluation and management of patients with cirrhosis: risk assessment, surgical outcomes, and future directions. Clin Gastroenterol Hepatol 18: 2398-2414.e3, 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 69: 871-898, 2017. [DOI] [PubMed] [Google Scholar]
- 28.Eknoyan G, Lameire N, Eckardt K, et al. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl 3: 5-14, 2013. [DOI] [PubMed] [Google Scholar]
- 29.Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 175: 827-834, 2015. [DOI] [PubMed] [Google Scholar]
- 30.Rogers S, Haddad YK, Legha JK, et al. Best Practices for Developing an Inpatient Program to Prevent Older Adult Falls after Discharge [Internet]. [cited 2022 Jan 27]. https://www.cdc.gov/steadi/pdf/STEADI-inpatient-guide-508.pdf
- 31.Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 169: 1952-1960, 2009. [DOI] [PubMed] [Google Scholar]
- 32.Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age Ageing 40: 23-29, 2011. [DOI] [PubMed] [Google Scholar]
- 33.Camacho PM, Lewiecki EM, Petak SM, et al. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis- 2020 update. Endocr Pract 26（Suppl 1）: 1-46, 2020. [DOI] [PubMed] [Google Scholar]
- 34.Japanese Orthopaedic Association . Clinical Practice Guideline on the Prevention of Surgical Site Infections in Bone and Joint, 2015. Nankodo, Tokyo, 2015. [Google Scholar]
- 35.Conley RB, Adib G, Adler RA, et al. Secondary fracture prevention: consensus clinical recommendations from a multistakeholder coalition. J Bone Miner Res 35: 36-52, 2020. [DOI] [PubMed] [Google Scholar]
- 36.HIP ATTACK Investigators . Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet (Lond, Engl) 395: 698-708, 2019. [DOI] [PubMed] [Google Scholar]
- 37.Japanese Circulation Society Joint Working Group . Guidelines for the Diagnosis, Treatment and Prevention of Pulmonary Thromboembolism and Deep Vein Thrombosis (JCS 2017) [Internet]. [cited 2023 Nov 17]. https://js-phlebology.jp/wp/wp-content/uploads/2020/08/JCS2017.pdf
- 38.Kimura K, Kimura T, Ishihara M, et al.; the Japanese Circulation Society Joint Working Group . JCS 2018 Guideline on Diagnosis and Treatment of Acute Coronary Syndrome. Circ J 83: 1085-1196, 2019. [DOI] [PubMed] [Google Scholar]
- 39.Bernal JL, Cummins S, Gasparrini A. The use of controls in interrupted time series studies of public health interventions. Int J Epidemiol 47: 2082-2093, 2018. [DOI] [PubMed] [Google Scholar]
- 40.Arshi A, Rezzadeh K, Stavrakis AI, Bukata SV, Zeegen EN. Standardized hospital-based care programs improve geriatric hip fracture outcomes: an analysis of the ACS NSQIP targeted hip fracture series. J Orthop Trauma 33: e223-e228. [DOI] [PubMed] [Google Scholar]
- 41.Jackson K, Bachhuber M, Bowden D, Etter K, Tong C. Comprehensive hip fracture care program: successive implementation in 3 hospitals. Geriatr Orthop Surg Rehabil 10: 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Roberts HJ, Rogers SE, Ward DT, Kandemir U. Protocol-based interdisciplinary co-management for hip fracture care: 3 years of experience at an academic medical center. Arch Orthop Trauma Surg 142: 1491-1497, 2022. [DOI] [PubMed] [Google Scholar]
- 43.Soong C, Cram P, Chezar K, et al. Impact of an integrated hip fracture inpatient program on length of stay and costs. J Orthop Trauma 30: 647-652, 2016. [DOI] [PubMed] [Google Scholar]
- 44.Della Rocca GJ, Moylan KC, Crist BD, Volgas DA, Stannard JP, Mehr DR. Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study. Geriatr Orthop Surg Rehabil 4: 10-15, 2013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Baroni M, Serra R, Boccardi V, et al. The orthogeriatric comanagement improves clinical outcomes of hip fracture in older adults. Osteopor Int 30: 907-916, 2019. [DOI] [PubMed] [Google Scholar]
- 46.Gosch M, Roth T, Kammerlander C, et al. Treatment of osteoporosis in postmenopausal hip fracture patients after geriatric rehabilitation: changes over the last decade. Z Gerontol Geriatr 44: 381-386, 2011. [DOI] [PubMed] [Google Scholar]
- 47.Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM. Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 20: 172-180, 2006. [DOI] [PubMed] [Google Scholar]
- 48.Naik-Panvelkar P, Norman S, Elgebaly Z, et al. Osteoporosis management in Australian general practice: an analysis of current osteoporosis treatment patterns and gaps in practice. BMC Fam Pract 21: 32, 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15: 767-778, 2004. [DOI] [PubMed] [Google Scholar]
- 50.Sheehan J, Mohamed F, Reilly M, Perry IJ. Secondary prevention following fractured neck of femur: a survey of orthopaedic surgeons practice. Ir Med J 93: 105-107, 2000. [PubMed] [Google Scholar]
- 51.Tsunemitsu A, Tsutsumi T, Inokuma S, Kobayashi T, Imanaka Y. Effects of hospitalist co-management on rate of initiation of osteoporosis treatment in patients with vertebral compression fractures: retrospective cohort study. J Orthop Sci 28: 1359-1364, 2023. [DOI] [PubMed] [Google Scholar]
- 52.Okada Y, Akazawa M. Effects of medical service fee revision on reducing irrational psychotropic polypharmacy in Japan: an interrupted time-series analysis. Soc Psychiatry Psychiatr Epidemiol 57: 411-422, 2022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry 72: 136-142, 2015. [DOI] [PubMed] [Google Scholar]
- 54.Dalleur O, Boland B, Losseau C, et al. Reduction of potentially inappropriate medications using the STOPP criteria in frail older inpatients: a randomised controlled study. Drugs Aging 31: 291-298, 2014. [DOI] [PubMed] [Google Scholar]
- 55.Gallagher P, O'Connor M, O'Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 89: 845-854, 2011. [DOI] [PubMed] [Google Scholar]
- 56.Clinical Guidelines for withdrawal Management and Treatment of Drug Dependence in Closed Settings. World Health Organization, Geneva, 2009 [Internet]. [cited 2023 Nov 17]. https://iris.who.int/bitstream/handle/10665/207032/9789290614302_eng.pdf?sequence=1＆isAllowed=y. [PubMed]
- 57.Hagino H, Endo N, Harada A, et al. Survey of hip fractures in Japan: recent trends in prevalence and treatment. J Orthop Sci 22: 909-914, 2017. [DOI] [PubMed] [Google Scholar]
- 58.OECD (2023), Health at a Glance 2023: OECD Indicators, OECD Publishing, Paris [Internet]. [cited 2023 Nov 17]. https://doi.org/10.1787/7a7afb35-en.
- 59.Meyer JR, Earnest RE, Johnson BM, Steffensmeier AM, Vyas DA, Laughlin RT. Implementation of a multidisciplinary preoperative protocol for geriatric hip fractures improves time to surgery at a level III trauma center. Geriatr Orthop Surg Rehabilitation 14: 21514593231181990, 2023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.Folbert ECE, Smit RS, van der Velde D, Regtuijt EM, Klaren MH, Hegeman JH. Geriatric fracture center: a multidisciplinary treatment approach for older patients with a hip fracture improved quality of clinical care and short-term treatment outcomes. Geriatr Orthop Surg Rehabil 3: 59-67, 2012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Akazawa M, Mimura W, Togo K, et al. Patterns of drug treatment in patients with osteoarthritis and chronic low back pain in Japan: a retrospective database study. J Pain Res 12: 1631-1648, 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.Ohkura Y, Haruta S, Shindoh J, Tanaka T, Ueno M, Udagawa H. Effectiveness of postoperative intravenous acetaminophen (Acelio) after gastrectomy: a propensity score-matched analysis. Medicine (Baltimore) 95: e5352, 2016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 63.Gleich J, Pfeufer D, Zeckey C, et al. Orthogeriatric treatment reduces potential inappropriate medication in older trauma patients: a retrospective, dual-center study comparing conventional trauma care and co-managed treatment. Eur J Med Res 24: 4, 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 64.Quan H, Li B, Saunders LD, et al.; the IMECCHI Investigators . Assessing validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions in a unique dually coded database. Health Serv Res 43: 1424-1441, 2008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65.Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a comanaged geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med 169: 1712-1717, 2009. [DOI] [PubMed] [Google Scholar]
- 66.Phy MP, Vanness DJ, Melton LJ 3rd, et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med 165: 796-801, 2005. [DOI] [PubMed] [Google Scholar]
- 67.Heghe AV, Mordant G, Dupont J, Dejaeger M, Laurent MR, Gielen E. Effects of orthogeriatric care models on outcomes of hip fracture patients: a systematic review and meta-analysis. Calcif Tissue Int 110: 162-184, 2022. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The model and parameters in a CITS analysis.
Slope changes in the controlled interrupted time series analysis for primary and secondary outcomes.
Results of the controlled interrupted time series analysis of breakdown of major complications.
Results of sensitivity analysis of controlled interrupted time series analysis.
Results of sensitivity analysis of controlled interrupted time series analysis for the breakdown of major complications.
Results of the controlled interrupted time series analysis for the breakdown of major complications.
Results of the sensitivity analysis of controlled interrupted time series analysis.
Results of the sensitivity analysis of controlled interrupted time series analysis for the breakdown of major complications.