1. 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

2. 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: 1T35AG
The American Federation for Aging Research
Konstantin Grigoryan MS:
MSTAR Program:

3. Background Hip fractures common in elderly
Annual incidence: 957.3/100,000 women, /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:
3 Osteoporos Int. 2010;21:S637-46

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

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

6. 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

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

8. 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

9. 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 total of top line total citations were reviewed. With 93 full text articles read in detail. In the end 18articles were identified for inclusion.
18 articles included

10. 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

11. 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]

12. 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

13. Results

14. 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

15. 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)

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

17. 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