Knobe M, Böttcher B, Coburn M, Friess T, Bollheimer L C, Heppner H J, Werner C J, Bach J-P, Wollgarten M, Poßelt S, Bliemel C, Bücking B
Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Aachen, Deutschland.
Unfallchirurg. 2019 Feb;122(2):134-146. doi: 10.1007/s00113-018-0502-y.
Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable.
The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU).
A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model).
In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035).
There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.
以往关于老年骨科护理模式的研究表明，老年护理在患者管理中的整合方式存在很大差异，且老年护理所需的强度也值得怀疑。
当前这项前瞻性队列研究的目的是，按照德国创伤协会（DGU）的指南，对老年创伤中心实施前后的脆性骨折治疗路径进行临床和经济评估。
对三种不同的治疗模式（各6个月）进行了比较：A：骨科创伤的标准治疗；B：改进质量管理体系并实施标准操作程序的特殊护理路径；C：采用护理路径并与老年病科医生合作的多学科治疗（查房模式）。
在151例接受检查的患者中（男/女47/104；83.5（70 - 100）岁；A组：n = 64，B组：n = 44，C组：n = 43），老年骨科联合管理（C组）的路径提高了术后活动频率（p = 0.021）、骨质疏松预防频率（p = 0.001）以及出院流程（p = 0.024）。与标准治疗（A组）相比，老年骨科联合管理（C组）的死亡率（9%对2%；p = 0.147）和心肺并发症发生率（39%对28%；p = 0.235）有降低趋势。在此背景下，心肌梗死发生率较低（6%对0%）、脱水发生率较低（6%对0%）、心律失常发生率较低（8%对0%）、肺功能失代偿发生率较低（28%对16%）、电解质失衡发生率较低（34%对19%）以及肺水肿发生率较低（11%对2%）。重症监护病房的住院时间分别为29小时（A组）和18小时（C组）（p = 0.205），成本随之降低。仅为老年髋部骨折患者建立特殊护理路径（B组）显示心肌梗死发生率较低（A组：11%，B组：0%，C组：0%；p = 0.035）。
采用老年骨科联合管理查房模式接受多学科老年骨科治疗的患者，总体结果有明显改善的趋势，心肺并发症发生率和死亡率较低。虽然特殊护理路径可降低髋部骨折患者的心肌梗死发生率，但在所有评估的护理模式中，成本和收益并无差异。然而，髋部骨折或假体周围骨折患者在临床和经济方面也存在风险。
