The orthogeriatric service in Malta started in
2012 and expanded in 2014. From admission, the
patient is offered a ward based hip fracture
programme that includes orthogeriatric assessment,
management and co-ordinated multidisciplinary
review.
457 patients were seen by the orthogeriatric
service when this study was done. Mean age was 83
and 69% of patients were female. The Nottingham
Hip Fracture Score (NHFS) is a scoring system that
reliably predicts 30-day and 1-year mortality for
patients after hip fracture. It is made up of seven
independent predictors of postoperative mortality
that have been incorporated into a risk score. The
score ranges from 0-10 and the mean score for this
cohort was 5.1. There was a statistically significant
correlation between age and high NHFS scores. 30
day mortality was 5.9% and 1 year mortality was
24.4%. Compared with the Nottingham data both
30 day and 1 year mortality were less for the
orthogeriatric department in Malta.
The orthogeriatric service in Malta achieved
better results when comparing mortality with the
UK. In the future expansion of data collected should
be considered to better evaluate standards of care in
the department.peer-reviewe

Bugeja, Vincent

Cordina, John

Dalli, Stephanie

Ferry, Peter

Muscat, Jeffrey

Vassallo, Mark

Vella, Antoine

Zammit, Kristian

Zammit, Paul

English

OAR@UM

dRe    Original Article    Malta Medical Journal    Volume 28 Issue 01 2016    Abstract The orthogeriatric service in Malta started in 2012 and expanded in 2014. From admission, the patient is offered a ward based hip fracture programme that includes orthogeriatric assessment, management and co-ordinated multidisciplinary review. 457 patients were seen by the orthogeriatric service when this study was done. Mean age was 83 and 69% of patients were female. The Nottingham Hip Fracture Score (NHFS) is a scoring system that reliably predicts 30-day and 1-year mortality for patients after hip fracture. It is made up of seven independent predictors of postoperative mortality that have been incorporated into a risk score. The score ranges from 0-10 and the mean score for this cohort was 5.1. There was a statistically significant correlation between age and high NHFS scores. 30 day mortality was 5.9% and 1 year mortality was 24.4%. Compared with the Nottingham data both 30 day and 1 year mortality were less for the orthogeriatric department in Malta. The orthogeriatric service in Malta achieved better results when comparing mortality with the UK. In the future expansion of data collected should be considered to better evaluate standards of care in the department.  Keywords Orthogeriatrics; Hip fractures; Mortality; Older people.                                                                      Orthogeriatrics in Malta: a 3 year experience   Paul Zammit, Peter Ferry, John Cordina, Mark Vassallo,  Stephanie Dalli,  Antoine Vella,  Vincent Bugeja,  Jeffrey Muscat,  Kristian Zammit Paul Zammit* MD M.Ger. MRCP (UK) Dip.Ger Department of Geriatrics Karen Grech Hospital Pieta, Malta pzamm@hotmail.com  Peter Ferry MD MSc FRCP Dip. Ger Dip ORT  Department of Geriatrics Karen Grech Hospital Pieta, Malta  John Cordina MD MRCP (UK) Department of Geriatrics Karen Grech Hospital Pieta, Malta  Mark Vassallo MD MA (Bioethics) MRCP (UK) Department of Geriatrics Karen Grech Hospital Pieta, Malta  Stephanie Dalli MD MRCP (UK)  Department of Geriatrics Karen Grech Hospital Pieta, Malta  Antoine Vella MD MBA MRCP (UK) Department of Geriatrics Karen Grech Hospital Pieta, Malta  Vincent Bugeja MD MRCP (UK) Department of Geriatrics Karen Grech Hospital Pieta, Malta  Jeffrey Muscat MD MRCP (UK) Department of Geriatrics Karen Grech Hospital Pieta Malta  Kristian Zammit MD MRCP (UK) DGM Department of Geriatrics Karen Grech Hospital Pieta, Malta  *Corresponding Author  38dRe    Original Article    Malta Medical Journal    Volume 28 Issue 01 2016    Introduction Hip fractures are associated with significant morbidity and mortality. Approximately 10% of patients who have a neck of femur fracture die within a month from the traumatic event, and 30% within a year. About half of these patients do not return to their pre-fracture level of mobility and only half eventually return home. 80% of older women say they would rather die than experience the loss of independence and quality of life associated with a hip fracture. It is common as well as expensive with 80,000 hip fractures and direct costs of 2 billion pounds each year in the United Kingdom.1 Orthogeriatrics is the subspeciality area in geriatrics involved in the care of older people with fragility fractures.2 It was introduced when it was found that that there was a need to improve the efficiency and quality of hip fracture injury treatments and care of patients involved with such injuries. To this end, the geriatricians and orthopaedic surgeons organized an effort toward forming so called “orthogeriatrics” collaboration in various countries.  Orthogeriatrics offers to fragility fracture patients’ pre-operative assessment/optimisation, management of peri-operative complications, rehabilitation, as well as falls and bone health assessments.3 It has been shown that a good service reduces mortality, complications, length of stay and improves functional outcomes such as mobility and return to independence.1  Orthogeriatrics in Malta The orthogeriatric service in Malta was started in January 2012 with the introduction of a 6 bedded unit within an acute orthopaedic ward. Elderly over the age of 60 with a proximal fracture femur were eligible for this unit. The service was run by the geriatric department in collaboration with orthopaedic department.  Daily proactive ward rounds by the geriatricians were done and the patient was seen till discharge to their home or to a rehabilitation unit.  The service was expanded in February 2014. All older people with a proximal hip fracture over the age of 70 present in any orthopaedic ward were eligible to be under the care of an orthogeriatrician. The aim of the study was to assess NHFS scores and mortality statistics in the orthogeriatric service in Malta and compare these with the United Kingdom.  Data Data was collected for all patients seen by the orthogeriatric service from its introduction till January 2015.  Descriptive data including age and sex was collected from the. Mortality data and Nottingham hip fracture scores (NHFS) were also collected retrospectively. The NHFS is a weighted score of 7 independent admission variables that reliably predicts 30-day, 1-year postoperative mortality and functional outcome. The variables are sex, age, admission haemoglobin, abbreviated mental test score, living in institution, number of co-morbidities and malignancy. This data was taken from the patient’s history and the total score calculated. Informed consent from patients was done and the data protection team approved this study. The range for the score is 0-10.4 The score calculation can be seen in Table 1.  Data was analysed by using SPSS 13.0.0.  Table 1: Nottingham Hip Fracture Score Variable Value Score Age <66 0  66–85 yr 3  ≥86 yr 4 Sex Male 1 Admission Hb ≤10 g dl−1 1 MMTS ≤6 out of 10 1 Living in an institution Yes 1 Number of co-morbidities ≥2 1 Malignancy Yes 1  Results There were a total of 457 patients seen. 318 (69.5%) were female whilst 139 (30.5%) were male. Mean and median age of the patients was 83 years with a 6.6 standard deviation (SD). Age range varied between 61 and 98 years. Till January 2014 monthly admissions seen by the orthogeriatric service ranged from 6 to 15. From the expansion of the orthogeriatric service this went up with monthly admissions seen ranging from a minimum of 17 to a maximum of 44.  Mean levels for NHFS were 5.1 with a median of 5.0, 1.3 SD and range was 0 to 8. Univariate analysis found a significant link between mortality 39dRe    Original Article    Malta Medical Journal    Volume 28 Issue 01 2016    and increasing NHFS (p=value <0.01). One way ANOVAs found a significant link between increasing age and higher NHFS (p-value <0.01). There were a total of 27 deaths out of the 457 (5.9%) patients seen by orthogeriatrics in the first 30 days from admission. 50 patients out of 209 (data of patients from admission till March 2014) died within 1 year of admission to orthogeriatrics which was 23.9% of total. The mean death rate was 135.2 days whilst the median date rate was 68.0 days.  Discussion The current results show that compared to studies done in the United Kingdom and Denmark admissions in Malta tend to be older (83 vs 82 years) and there is a higher percentage of males with fractures (30.5% in Malta vs 21.7% in the United Kingdom).2,4-5 The NHFS scores in Malta tend to be higher than in the United Kingdom (5.1 vs 3.9).2,4 This suggests that patients been seen by the orthogeriatric service in Malta tend to be older and frailer than in other European countries. As regards mortality various studies and metanalyses have shown that the overall 1 month mortality in hip fracture patients is 13.3%.6 The overall 1 year mortality is 24.5% but ranges between 18.8-33%.6-7 The result from our data show that our 1 month mortality is very low when compared with these studies. As for the 1 year mortality this is marginally lower with data found in these studies. Patients in the orthogeriatric service in Malta who die tend to do this within the first 3 months.8-9 This is similar to data in other studies.  Conclusion In conclusion data collected during the first 3 years of the orthogeriatric service in Malta shows that it is doing well as regards mortality compared with other countries despite having frailer patients. Despite this, more data needs to be collected to view performance in reducing length of stay in hospital, discharge destination and independence level on discharge post rehabilitation.   References 1.  British Orthopaedic Association Blue book (2007) The care of patients with fragility fracture. Available via DIALOG. http://www.boa.ac.uk. Accessed June 2015. 2.  Aw D, Sahota O. Orthogeriatrics moving forward. Age Ageing. 2014 May;43(3):301-5. doi: 10.1093/ageing/afu011. 3.  Gregersen M,  Mørch M, Hougard K, and  Damsgaard EM. Geriatric intervention in elderly patients with hip fracture in an orthopedic ward. J Inj Violence Res. 2012 Jul; 4(2): 45-51 doi:10.529/jivr.v4i2.96. 4. Moppett IK, Wiles MD, Moran CG, Sahota O The Nottingham Hip Fracture Score as a predictor of early discharge following fractured neck of femur. Age Ageing 2012;41:322-6. 5.  Wiles MD, Moran CG, Sahota O, Moppett IK. Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fracture neck of femur. Br J Anaesth 2011;106:501-4. 6.  Hu F, Jiang C, Shen J, Tang P, Wang, Y. Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis. Injury. 2012;43:676–85. 7.  Schnell S, Friedman SM, Mendelson DA, Bingham  KW, Kates SL. "The 1-Year Mortality of Patients Treated in a Hip Fracture Program for Elders". Geriatric Orthopaedic Surgery & Rehabilitation. 2010; 1(1): 6-14. 8.  Haentjens P, Magaziner J, Colon-Emeric CS, Vanderschueren D, Milisen K, Velkeniers B et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152:380–90. 9.  Richmond J, Aharonoff GB, Zuckerman JD, Koval KJJ.  Mortality Risk after Hip Fracture. Orthopaedics and Trauma, 2003;17, 53-6.  40

Geriatric intervention in elderly patients with hip fracture in an orthopedic ward. J Inj Violence Res.

Metaanalysis: excess mortality after hip fracture among older women and men. Ann Intern Med.

Mortality Risk after Hip Fracture. Orthopaedics and Trauma,

Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fracture neck of femur.

Orthogeriatrics moving forward. Age Ageing.

Orthopaedic Association Blue book (2007) The care of patients with fragility fracture. Available via DIALOG. http://www.boa.ac.uk. Accessed

Preoperative predictors for mortality following hip fracture surgery: a systematic review and metaanalysis.

The 1-Year Mortality of Patients Treated in a Hip Fracture Program for Elders&quot;. Geriatric Orthopaedic Surgery & Rehabilitation.

The Nottingham Hip Fracture Score as a predictor of early discharge following fractured neck of femur.

Orthogeriatrics in Malta : a 3 year experience

https://www.um.edu.mt/library/oar/bitstream/handle/123456789/9710/Orthogeriatrics%20in%20Malta.pdf?sequence=1&isAllowed=y

Orthogeriatrics in Malta : a 3 year experience

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