title: Impact of an Integrated Hip Fracture Inpatient Program on Length of Stay and Costs.
abstract: BACKGROUND
  Hip fractures are associated with significant morbidity and mortality. Co-management models pairing orthopaedic surgeons with hospitalists or geriatricians may be effective at improving processes of care and outcomes such as length of stay (LOS) and cost. We set out to determine the effect of an integrated hip fracture co-management model on LOS, cost, and process measures.
  
  
  METHODS
  We conducted a single-center pre-post study of 571 patients admitted to an academic medical center with hip fractures between January 2009 and December 2013. The group receiving an integrated medical-surgical co-management incorporating continuous improvement methodology was compared with a control population. Primary outcome was LOS. Secondary outcomes included cost per case, time to surgery, osteoporosis (OP) treatment, preoperative echocardiogram utilization, mortality, and readmission.
  
  
  RESULTS
  LOS decreased from 18.2 (1.1) to 11.9 (1.5) days, a reduction of 6.3 days (P < 0.001). Mean cost decreased by $4953 (P < 0.001) per case. Mean time to surgery decreased from 45.8 (66.8) to 29.7 (17.9) hours (P < 0.001). Initiation of OP treatment increased from 55.8% to 96.4% (P < 0.001). Preoperative echocardiogram use decreased from 15.8% to 9.1% (P < 0.05). There was a nonsignificant difference in mortality rate (5.0% vs. 2.1%, P = 0.06). Readmission rate remained unchanged (4.6% vs. 6.0%, P = 0.56).
  
  
  CONCLUSIONS
  An integrated medical-surgical co-management model incorporating continuous improvement methodology was associated with reduced LOS, costs, time to surgery, and increased initiation of appropriate OP treatment.
  
  
  METHODS
  Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Division of General Internal Medicine and Geriatrics, Mount Sinai Hospital and University Health Network, Toronto, Canada;†Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Canada;‡Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada;§Faculty of Medicine, University of Toronto, Toronto, Canada;‖Department of Medicine, University Health Network, Toronto, Canada;¶Mount Sinai Hospital, Toronto, Canada;**Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; and††Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, Canada.
authors.forename: Christine
authors.initials: C
authors.lastname: Soong
authors.forename: Peter
authors.initials: P
authors.lastname: Cram
authors.forename: Ksenia
authors.initials: K
authors.lastname: Chezar
authors.forename: Faiqa
authors.initials: F
authors.lastname: Tajammal
authors.forename: Kathleen
authors.initials: K
authors.lastname: Exconde
authors.forename: John
authors.initials: J
authors.lastname: Matelski
authors.forename: Samir K
authors.initials: SK
authors.lastname: Sinha
authors.forename: Howard B
authors.initials: HB
authors.lastname: Abrams
authors.forename: Christopher
authors.initials: C
authors.lastname: Fan-Lun
authors.forename: Christina
authors.initials: C
authors.lastname: Fabbruzzo-Cota
authors.forename: David
authors.initials: D
authors.lastname: Backstein
authors.forename: Chaim M
authors.initials: CM
authors.lastname: Bell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019033:Delivery of Health Care, Integrated / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006620:Hip Fractures / Q000191:economics* / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000191:economics* / Q000706:statistics & numerical data; D008297:Male; D009864:Ontario / Q000453:epidemiology; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome