Analysis of the experience of the geriatric fracture program in two institutions in Colombia: a reproducible model?

Background: hip fracture is the major cause of morbidity and mortality. Geriatric fracture programs promise to improve the quality of care, health outcomes and reduce costs. Objective: To describe the results related to the Geriatric fracture programs implementation in two Colombian institutions to assess reproducibility.
Methods: We performed A retrospective descriptive study of the patients treated under the Geriatric fracture programs in two institutions in Colombia. The information was collected from the initial year of implementation until 2018. Demographic characteristics, length of stay, hospitalization complications, readmissions and mortality were described. Consumption of healthcare resources was defined using base cases determined with local experts and costs were estimated using standard methods.
Results: 475 patients were included in the Geriatric fracture programs. We observed an increase in the number of patients. The length of stay decreased between 8.5% and 26.1% as did the proportion of total complications, with delirium having the greatest reduction. A similar situation was seen for first year mortality (from 10.9% to 4.7%), in-hospital deaths and readmissions. Estimates of costs of stay and complications showed reductions in all scenarios, varying between 22% and 68.3%. Conclusions: The present study presents the experience of two institutions that implemented the Geriatric fracture programs with increase in the number of patients treated and reductions in the time of hospital stay, the proportion of complications, readmissions, mortality and estimated costs. These are similar between both institutions and with other published implementations. This could hint that geriatric fracture program may be implemented with reproducible results.

Remark

Introduction

Hip fractures are considered a worldwide health problem , as they are associated with high mortality and morbidity rates , . Demographic changes have increased the incidence of this type of fracture, which increases exponentially with age , . Likewise, the highest mortality rates occur in the elderly, with an annual mortality of 8% to 26% and greater values for patients over 80 years with hip fracture .

In recent years the incidence of hip fracture has increased in several Latin American countries. Aziziyeh R et al. , estimated by 2020 an increase in the number of hip fractures in adults between 50 and 89 years of 7.3%, 17%, 19.1% and 15.3% in Argentina, Brazil, Colombia and Mexico, respectively, due to the aging population.

In Colombia, osteoporosis and hip fractures result in high morbidity and mortality. Its prevalence increases dramatically after the age of 50 and its management requires, in most cases, surgical intervention. These fractures are related to a deterioration in the quality of life, disability, higher mortality and a high cost . The estimated annual cost for osteoporosis-related fractures in Mexico, Argentina, Brazil and Colombia is 411, 360, 310 and 94 million dollars, respectively . Several studies have shown that between 44% and 57% of the total hospital cost is associated with hip fracture care - .

Due to the above, comprehensive care programs have been developed worldwide, called geriatric fracture programs. These programs are defined by a multidisciplinary joint management system, early surgical intervention, patient-centered care using standardized protocols, and early discharge planning to reduce the length of hospital stay , . Their objectives are to improve the quality of care, health outcomes and reduce costs. These programs have shown various positive effects for patients, professionals and health systems , . In 2008, a geriatric fracture program was implemented at the University Children's Hospital of San José in Bogotá. They showed reductions in mortality and hospital stay in 298 patients in the program in the initial four years of implementation .

The objective of this study was to describe the results related to the implementation of geriatric fracture programs in two Colombian health institutions. The end goal is to compare them with previous implementation of geriatric fracture programs in Colombia to assess reproducibility. If similar positive results can be achieved when implementing the program in other institutions, this could hint to reproducibility of the model.

Materials and Methods

A retrospective descriptive study was carried out using information from patients older than 65 years who had fractures resulting from fragility, who were treated in two health institutions that recently implemented geriatric fracture programs. These institutions are highly complex institutions with long-term care programs for fracture patients. Institution A is in Bogota and had 230 general inpatient, 5 intermediate care and 21 intensive care beds for adults. Institution B is in Cali had 168 general inpatient, 17 intermediate care and 31 intensive care beds for adults.

Geriatric fracture program description

The implemented model is based on the Rochester orthopedic management model , which has been previously implemented in another institution in Colombia . In summary, the model is a multidisciplinary joint management system to produce a comprehensive care plan. Target patients were at least 65 years of age and suffered from hip fracture requiring surgical intervention. The program considered two components (Figure 1S). The first one was related to inpatient care. This phase was triggered whenever a target patient was admitted though the Emergency Room and was referred to the orthopedics and geriatrics services. They defined the initial diagnosis, appropriate treatment according to patient status and fracture type, and initial rehabilitation strategies. The second component considered outpatient care during the first postsurgical year. Orthopedics controls were performed at 15 days, 1 month, 3 months, 6 months and 12 months after surgical intervention and focused on rehabilitation and osteoporosis treatment. Additional follow ups could be scheduled if necessary. Geriatrics consultations were also performed, focusing on general health status, comorbidity management, functionality assessments, fall prevention and osteoporosis treatment. Scheduling for geriatric care was defined on a per-case base depending on individual situation and evolution.

Figure S1

The program considered two components. One was related to inpatient care. The second component considered outpatient care during the first postsurgical year

One of the model’s objectives were to minimize the time before and after the surgical procedure, reducing the total time of stay. In this way, was is expected that complications and mortality should be reduced, and the patients’ rehabilitation improved.

Data collection

The institutions following the model carried out a systematic compilation of clinical and process indicators in order to monitor the performance of the program. Each institution collected the following information:

Demographic data: number of patients admitted, age, sex.

Procedure variables: type of procedure.

Variables of hospital stay: time from admission to surgery, time of pre-surgical stay, time of post-surgical stay, total time of stay.

Follow-up outcome variables: in-hospital death, death in the first month after surgery, death in the first year after surgery, hospital readmission in the first 30 days after discharge.

Intrahospital complications: delirium, pneumonia, urinary tract infection, surgical site, pressure ulcers, deep vein thrombosis, pulmonary thromboembolism, cardiovascular events, neurological events.

This information was originally collected at the individual level. Each institution provided a month-by-month report summarizing the continuous variables with average and standard deviation (SD) and categorical variables such as event counts. These accumulated data were reported from the beginning of the program in each institution up until June 2018, including all patients included in the program. Since the institutions were integrated into the program at different times, the calendar year in which the institution was integrated into the Geriatric fracture programs was defined as the base year, and following years were defined as follow-up years.

Data analysis

Because the data came from different institutions, we performed a stratified description for each institution, with the objective of assessing possible systematic differences between them which could skew the grouped description. It is important to point out that the scope of this description was to view the trend in the indicators comparing the initial point of implementation against the last one available and did not include an explicit comparison between the institutions. Likewise, given the descriptive scope of the study and the absence of control of confounding variables, the trends should be interpreted only at the descriptive level and not in terms of causation. All procedures and graphs were performed using the statistical program R, version 3.5.0.

Initially, the number of patients treated in the institutions and their demographic characteristics were characterized, describing the trend of different types of hospital stay over time. These were calculated by hours and summarized using averages and SD. Subsequently, the complications registered in each institution were described, discriminating them by type of complication, and the trends of the outcome variables in the medium and long term. Considering the variability over time with respect to the total number of patients admitted to each institution, these results were expressed in terms of proportions. It was not possible to estimate the annual mortality rate for 2018 since the data were obtained in early 2019.

Economic estimation

A theoretical estimate was made of the possible economic impact of the program, focusing on the possible differences related to hospital stays and complications. This implies that surgical procedures costs were not considered. All costs were calculated in Colombian pesos and converted to United States dollars (USD) using the current exchange rate (1 USD = 3,301 Colombian pesos). Clinical experts from the institutions were consulted for the construction of the resource consumption scenarios for the different complications. The costs of these events were estimated using the standard methodology of the Institute of Health Technological Assessment (IETS in Spanish). Costs were estimated from the perspective of the third-party payer, considering direct medical costs. Drug prices were obtained from the drug price information database (SISMED) of the last reported quarter and, where necessary, from the latest available regulated prices set by the Ministry of Health. Final drug prices were estimated as a weighted average by the market share of the average values recorded for each formulation. The costs of procedures were extracted from the tariff manual of the Social Security Institute in 2001, with an increase of 30% in accordance with the methodology proposed by IETS. Monetary values for the required consumables were consulted in the public tender documentation or in the Colombia Compra Eficiente database. For the hospital stay, a day-cost sensitivity analysis was performed, taking as a lower limit the cost of hospitalization of high complexity, and as an upper limit the cost of hospitalization in the adult intensive care unit. In this way the average price of the hospital stay was calculated, considering the observed lengths of stay from the institutions. Regarding complications, the estimated average cost per capita of all complications in the cohort of patients in the program was calculated from their proportions in each institution. By combining these two costs and viewing the trend over time, the average cost of the stay was estimated, plus the complication of a patient in the program.

With this information, the costs associated with stay and complications for each institution in each year of implementation were estimated, and the baseline was compared with the last year available to estimate the variation in the cost associated with the stay and complications over time.

Exploratory analyses

Finally, in an exploratory manner, statistical comparisons were made between the first and last year of available data for total length of stay and number of complications. These analyses were hypothesis generating. For the time of stay a Student’s t-test was performed to compare two unpaired samples assuming different variances. For complications, the comparison was made using the Z-test for two proportions.

Compliance with ethical standards and ethical approval

This study was approved by the Ethics Committee of the Santa Fe de Bogotá Foundation (Agreement No. 20 with the approval number CCEI-9941-2018 on November 19, 2018). It was thus conducted according to ethical standards applicable for this type of study. Under that protocol and approval, the study was performed in both institutions.

Results

General description

A total of 475 patients were identified between the two institutions. Institution A presented a total of three years of data with 190 patients (63.3 patients/year) and B a total of five years and 285 patients (57 patients/year). The main baseline characteristics of the patients identified are shown in Table 1. There was an increase in the total number of patients over the years of program implementation (A: from 55 to 71 + 29%; B: from 44 to 77 + 75%) in both institutions. Close to 78% of all patients were women, consistently across the institutions, and around 80% were older than 76 years. The procedure performed in most patients was nail osteosynthesis or compression device.

Table 1

Demographic characteristics of the patients identified in the three institutions. The percentages are relative to the total of each institution.

Variable	Institution
	A(%)	B(%)
Total patients	190	285
Patients according to year of implementation
Base year	55 (28.9)	44 (15.4)
1	64 (33.7)	49 (17.2)
2	71 (37.4)	56 (19.6)
3	NA (NA)	59 (20.7)
4	NA (NA)	77 (27)
Patients by sex
Male	41 (21.6)	64 (22.5)
Female	149 (78.4)	221 (77.5)
Patients by age group (years)
65-75	45 (23.7)	51 (17.9)
76-85	82 (43.2)	117 (41.1)
>85	63 (33.2)	117 (41.1)
Patients by procedure type
Osteosynthesis with nails or with compression device	115 (60.5)	164 (57.5)
Open reduction with osteosynthesis with cannulated screws	10 (5.3)	27 (9.5)
Joint replacement	65 (34.2)	94 (33)

Hospital length of stay

The average total hospital length of stay had reductions between the base year throughout the implementation (Figure 1). When comparing the base year with the last available implementation year both institutions had reductions although of different magnitude (A: from 152.2 to 139.4, -8.5%; B: from 137.3 to 101.5, -26.1%). Institution B had a change between baseline and the second year of implementation of -3.4%, which was similar to the one achieved in institution A in the same timeframe.

Figure 1

Average total hospital length of stay in hours, according to year of implementation and institution (A and B). The error bars represent ± 1 SD

When separating the total stay by type (admission-to-surgery, pre-surgical, post-surgical and total), it can be observed that there is a trend in reduction of the total and post-surgical hospital stay. In contrast, the pre-surgical stay remained relatively stable. This trend was similar in both institutions (Figure 2). In both institutions, the pre-surgical stay time was less than 48 hours.

Figure 2

Average duration of the different times of stay in hours, according to year of implementation and institution (A and B)

Complications

The proportion of total complications was reduced in both institutions following the Geriatric fracture programs implementation (Figure 3). For institution A, the exploratory analysis found a difference of -35.1% between the base year and the last year available, which was statistically significant (74.5% vs. 39.4%, p <0.001, 95% CI: -52.9% to -17.3%). For institution B, the exploratory analysis found a difference of -33.4% between the base year and the last year available, which was statistically significant (56.8% vs. 23.4%, p <0.001, 95% CI: -52.7% to -14.2%). Table 1S shows the details of the proportions of each type of complication over time. By individually evaluating each institution, some differences in behavior can be observed. For institution A, the reduction of total complications coincided with the reduction in pressure ulcers (from 3.6% to 1.6%), cardiovascular events (from 12.7% to 1.4%), surgical site infections (from 9.1% to 2.8%), urinary tract infections (from 10.9 to 5.6%), pneumonia (from 7.3% to 2.8%) and pulmonary thromboembolism (from 10.9% to 1.4%). In institution B, the decrease was mainly related to a decrease in the proportion of delirium (from 38.6% to 13%), surgical site infections (from 2.3% to 1.7%), urinary tract infection (from 4.5% to 2.6%), pneumonia (6.8% to 1.3%) and pressure ulcers (4.5% to 2.6%).

Figure 3

Proportion of patients with complications, by type of complication, by institution (A and B) and year of implementation

Table 1S

Proportion of each type of complication, by institution and year of implementation.

Variable	Year of implementation	Total	A	B
Number of patients with delirium	Base	0.273	0.182	0.386
	1	0.142	0.156	0.122
	2	0.26	0.239	0.286
	3	0.203	NR	0.203
	4	0.13	NR	0.13
Number of patients with cardiovascular events	Base	0.071	0.127	0
	1	0.009	0.016	0
	2	0.016	0.014	0.018
	3	0.017	NR	0.017
	4	0.013	NR	0.013
Number of patients with neurological events	Base	0.01	0.018	0
	1	0	0	0
	2	0.008	0.014	0
	3	0	NR	0
	4	0	NR	0
Number of patients with surgical site infection	Base	0.061	0.091	0.023
	1	0.027	0.047	0
	2	0.016	0.028	0
	3	0.017	NR	0.017
	4	0	NR	0
Number of patients with urinary tract infection	Base	0.081	0.109	0.045
	1	0.071	0.078	0.061
	2	0.039	0.056	0.018
	3	0.034	NR	0.034
	4	0.026	NR	0.026
Number of patients with pneumonia	Base	0.071	0.073	0.068
	1	0.018	0.031	0
	2	0.024	0.028	0.018
	3	0.034	NR	0.034
	4	0.013	NR	0.013
Number of patients with pulmonary thromboembolism	Base	0.061	0.109	0
	1	0.035	0.062	0
	2	0.008	0.014	0
	3	0	NR	0
	4	0.013	NR	0.013
Number of patients with deep vein thrombosis	Base	0	0	0
	1	0.009	0.016	0
	2	0	0	0
	3	0	NR	0
	4	0.013	NR	0.013
Number of patients with pressure ulcers	Base	0.04	0.036	0.045
	1	0.009	0.016	0
	2	0.016	0	0.036
	3	0.051	NR	0.051
	4	0.026	NR	0.026

Follow-up results

In institution A, lower proportions of patients were evident for all outcomes, when comparing the base year with the last available (readmissions from 14.5% to 7%, in-hospital deaths from 3.6% to 2.8%, deaths within the first month of 1.8 % to 1.4% and deaths within the first year from 10.9% to 4.7%) (Figure 4). Regarding institution B, there was a trend towards a reduction in readmissions (18.2% vs. 15.6%), in-hospital deaths (4.5% vs. 2.6%) and deaths within the first year (11.4% vs. 5.1%). However, there was an increase in deaths within the first month (0% vs. 2.6%), although no deaths were reported during the first observation (Figure 4). Detailed data is presented in Supplementary Table 2S.

Figure 4

Proportion of patients with each type of outcome, according to institution (A and B) and year of implementation

Table 2S

Proportion of patients achieving each type of outcome, according to institution and year of implementation.

		Institution
Variable	Year of implementation	Total	A	B
30-days-readmissions	Base	0.162	0.145	0.182
	1	0.124	0.125	0.122
	2	0.118	0.07	0.179
	3	0.085	NR	0.085
	4	0.156	NR	0.156
In-hospital mortality	Base	0.04	0.036	0.045
	1	0.009	0.016	0
	2	0.024	0.028	0.018
	3	0.034	NR	0.034
	4	0.026	NR	0.026
First-month-mortality	Base	0.01	0.018	0
	1	0.035	0.047	0.02
	2	0.024	0.014	0.036
	3	0	NR	0
	4	0.026	NR	0.026
First-year-mortality	Base	0.111	0.109	0.114
	1	0.053	0.047	0.061
	2	0.055	NR	0.071
	3	0.051	NR	0.051
	4	NR	NR	NR

Estimation of health resources and costs

In supplementary 3Sand 4S, we report the estimation of health resources for each event of interest, made with the help of clinical experts. The estimated per-hospitalization-day and per-event costs are detailed in the supplementary table 4S. The individual complications with the highest estimated costs per event were pulmonary embolism (USD 3,891.6), cardiovascular event (USD 3,186.4) and pressure ulcers (USD 1,560.2). The ones with the lowest estimated cost were surgical site infection (USD 205.6), delirium (USD 276.5) and urinary tract infection (USD 485.9). There was also an important difference in the daily cost of stay between the lower and upper sensitivity scenarios (USD 22.1 vs USD 164.5).

Table 3S

Estimated resources for hospitalization and complication for each event, with prices in USD.

		Unitary Price (USD)
S11303	Ward hospitalization - 3 beds - high complexity	22.1
S12103	Adult intensive care unit	164.5
CUPS	Laboratories, consultations, procedures	5.5	Number	% Patients
890702	Emergency consultation, specialized medicine	3.3	8	100
902210	Type IV hemogram	3.8	3	100
903839	Arterial blood gases	0.9	2	100
903825	Creatinine in the blood	80.4	4	100
901314	Mycobacterium, identification by PCR	6.3	2	50
871121	Chest X-ray	2.5	2	100
939400	Respiratory therapy	33.6	40	100
879301	Chest CT scan	5.5	1	100
CUPS	Medications		Daily dose	# days	% Patients
	Sultamicillin, taken orally 375 mg (# tab/day)		750	7	40
	Clarithromycin, taken orally (mg/day)		1000	7	70
	Oxygen (L/day)		4320	7	60
	Ampicillin + Sulbactam, intravenous (g/day)		12	10	60
	Clarithromycin, intravenous (mg/day)		1000	7	70
	Paracetamol, taken orally (mg/day)		3000	7	80
	Omeprazole, taken orally (mg/day)		40	7	100
	Enoxaparin subcutaneous (mg/day)		40	7	100
	Ipratropium bromide inhaler (puff/day)		8	7	80
	Cefepime, intravenous (mg/day)		3000	10	30
	Piperacillin - Tazobactam, intravenous (mg/day)		18000	10	40
	Methylprednisolone, intravenous (mg/day)		375	5	50
			Ward (%)	ICU (%)
	In what percentage of patients is hospitalization required for care regarding the event?		80	20
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		7	5
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890702	Emergency consultation, specialized medicine	5.5	9	100
902210	Type IV hemogram	3.3	2	100
903825	Creatinine in the blood	0.9	2	100
903856	BUN in the blood	1.1	2	100
903703	Vitamin B12 [Cyanocobalamin]	9.9	1	100
903706	Vitamin D25 Hydroxy Total [D2-D3] [Calciferol]	13.8	1	100
904902	TSH	7.3	1	100
903864	Sodium in the blood	1.8	1	100
903859	Potassium in the blood	2.5	1	100
871121	Chest X-ray (PA or AP and lateral, lateral decubitus, oblique or lateral with barium)	6.3	1	100
907107	Urine test	1.1	1	100
879111	Brain CT	29.4	1	70
CUPS	Medications		Daily dose	# days	% Patients
	Haloperidol, taken orally (mg/day)		3	5	70
	Quetiapine, taken orally (mg/day)		100	5	50
	Olanzapine, taken orally (mg/day)		10	5	30
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		80%	0%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		5	0
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890702	Emergency consultation, specialized medicine	5.5	6	100
902210	Type IV hemogram	3.3	2	100
903825	Creatinine in the blood	0.9	2	60
901221	Blood culture	9.2	2	100
881332	Ultrasound of urinary tract	9.1	1	100
907107	Urine test	1.1	1	100
901236	Urine culture	8.8	1	100
550401	Percutaneous nephrostomy	75.6	1	10
879420	CT urography	40.3	1	30
CUPS	Medications		Daily dose	# days	% Patients
	Ampicillin + Sulbactam, intravenous (g/day)		12	7	10
	Ceftriaxone, intravenous (mg/day)		2000	7	80
	Piperacillin - Tazobactam, intravenous (mg/day)		18000	10	4
	Ciprofloxacin, intravenous (mg/day)		800	7	1
	Ertapenem, intravenous (g/day)		1	10	2
	Meropenem, intravenous (mg/day)		3000	10	3
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		90%	10%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		5	10
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890702	Emergency consultation, specialized medicine	5.5	1	70
902210	Type IV hemogram	3.3	1	100
906913	Automated high precision C-reactive protein test	4.7	1	100
902205	Automated erythrocyte sedimentation rate (ESR)	0.4	1	100
862803	Non-excisional debridement of devitalized tissue, between 10% and 20% of body surface	0.0	1	30
S23202	Treatment - S23202	16.8
S41101	Surgical or gyneco-obstetric clinical specialists	0.4
S41201	Anesthesiology specialists	0.3
S41301	Surgical assistant	0.1
S55104	Suture material	13.7
901217	Microorganism culture in any sample other than bone marrow, urine and feces (#2)	4.3	1	100
901209	Sample of intrasurgical cultures	3.8	1	100
901107	Gram staining and reading for any sample	0.9	1	100
CUPS	Medications		Daily dose	# days	% Patients
	Cefalexin, taken orally (mg/day)		4000	7	70
	Amikacin, intravenous (mg/day)		500	7	30
	Paracetamol, taken orally (mg/day)		1500	3	70
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		100%	0%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		2	0
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890702	Emergency consultation, specialized medicine	5.5	8	70
902210	Type IV hemogram	3.3	3	100
906913	Automated high precision C-reactive protein test	4.7	2	100
902205	Automated erythrocyte sedimentation rate (ESR)	0.4	2	100
862803	Non-excisional debridement of devitalized tissue, between 10% and 20% of body surface	0.0	2	100
901217	Microorganism culture in any sample other than bone marrow, urine and feces (#2)	4.3	2	100
901209	Sample of intrasurgical cultures	3.8	2	100
901107	Gram staining and reading for any sample	0.9	2	100
862601	Debridement with placement of subatmospheric pressure device	552.1	1	100
862602	Subatmospheric pressure device replacement	318.5	7	100
965902C	Enterostomal therapy (wound care)	2.0	8	100
CUPS	Medications		Daily dose	# days	% Patients
	Ampicillin + Sulbactam, intravenous (g/day)		12	7	1
	Zinc oxide (30 g of active agent)		1	1	60
	Collagenase 120 UI (40 g)		1	1	10
	Hydrocolloid dressing	8.7	1	1	10
	Saline solution		250	1	90
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		90%	10%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		15	0
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890701	Emergency consultation, general medicine	3.8	1	100
S20201	Emergency observation unit (service for highly complex cases)	11.1	1	100
902104	D-dimer	9.0	1	100
890302	Specialized medicine consultation	3.8	3	100
871121	Chest X-ray	6.3	1	100
879301	Chest CT	33.6	1	90
920304	Gammagraphy of pulmonary ventilation and perfusion	41.1	1	10
882333	Duplex scanning of the lower extremity arteries	24.8	1	100
895101	Electrocardiogram of the rhythm or the surface	4.1	1	100
881234	M-mode and two-dimensional echocardiogram	50.1	1	100
895001	Dynamic electrocardiography (Holter)	37.6	1	40
902045	PT	2.3	2	100
902049	PTT	2.8	1	100
902210	Type IV hemogram	3.3	1	100
903839	Arterial gases	3.8	1	100
903066	Brain natriuretic peptide (BNP)	43.9	1	100
903439	Troponin T, quantitative	11.9	1	100
CUPS	Medications		Daily dose	# days	% Patients
	Enoxaparin, subcutaneous (mg/day)		120	180	85
	Warfarin, taken orally (mg/day)		5	180	80
	Apixaban, taken orally (mg/day)		10	180	10
	Rivaroxaban, taken orally (mg/day)		20	180	10
	Dabigatran, taken orally (mg/day)		300	180	10
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		95%	5%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		3	8
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Use
890701	Emergency consultation, general medicine	3.8	1	100
S20201	Emergency observation unit (service for highly complex cases)	11.1	1	100
902104	D-dimer	9.0	1	100
890302	Specialized medicine consultation	3.8	10	100
894402	6-minute walk	16.7	1	30
871121	Chest X-ray	6.3	1	100
879301	Chest CT	33.6	1	90
920304	Gammagraphy of pulmonary ventilation and perfusion	41.1	1	10
882333	Duplex scanning of the lower extremity arteries	24.8	1	100
895101	Electrocardiogram of the rhythm or the surface	4.1	5	100
881234	M-mode and two-dimensional echocardiogram	50.1	1	100
895001	Dynamic electrocardiography (Holter)	37.6	1	60
902045	PT	2.3	1	100
902049	PTT	2.8	5	100
902210	Type IV hemogram	3.3	1	100
903839	Arterial gases	3.8	1	100
903066	Brain natriuretic peptide (BNP)	43.9	1	100
903439	Troponin T, quantitative	11.9	1	100
CUPS	Medications		Daily dose	# days	% Patients
	Enoxaparin, subcutaneous (mg/day)		120	180	95
	Warfarin, taken orally (mg/day)		5	180	80
	Apixaban, taken orally (mg/day)		10	180	10
	Rivaroxaban, taken orally (mg/day)		20	180	10
	Dabigatran, taken orally (mg/day)		300	180	10
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		30%	70%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		10	15
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Use
890701	Emergency consultation, general medicine	3.8	1	100
890701	Interconsultation by specialized medicine (internal medicine, family medicine or cardiology)	5.1	10	100
903426	Glycated hemoglobin	5.9	1	100
903818	Total cholesterol	1.3	1	100
903815	HDL cholesterol	1.7	1	100
903816	LDL cholesterol	1.7	1	100
903868	Triglycerides	1.6	1	100
895101	Electrocardiogram	4.1	10	100
881232	Transthoracic echocardiogram (M-mode and two-dimensional)	24.9	1	100
372301	Cardiac catheterization of the right and left sides of the heart with electrophysiological study	227.0	1	100
C40558	Coronary angioplasty with balloon	1,378.2	1	60
	Medicated stent		1	100
871121	Chest X-ray	6.3	1	100
903841	Glycemia	0.9	10	100
902045	PT	2.3	5	100
902049	PTT	2.8	5	100
903439	Troponin T	11.9	5	100
904902	Thyroid stimulating hormone (TSH)	7.3	1	100
903825	Creatinine in the blood	0.9	4	100
903856	Blood urea nitrogen (BUN)	1.1	4	100
907107	Urinary sediment and density analysis	1.1	2	100
902210	Type IV hemogram	3.3	3	100
933600	Cardiac rehabilitation therapy	5.9	10	100
CUPS	Medications		Daily dose	# days	% Patients
	Losartan, taken orally (mg/day)		100	10	90
	Metoprolol tartrate, taken orally (mg/day)		300	10	50
	Atorvastatin, taken orally (mg/day)		80	10	100
	Aspirin, taken orally (mg/day)		100	10	100
	Clopidogrel, taken orally (mg/day)		75	10	100
	Oxygen (L/day)		4320	5	100
	Morphine, intravenous (mg/day)		10	5	70
	Metoclopramide, taken orally (mg/day)		30	5	50
	Bisacodyl, taken orally (mg/day)		10	10	100
	Nitroglycerine, intravenous (mg/day)		50	3	100
	Carvedilol, taken orally (mg/day)		25	10	20
	Bisoprolol, taken orally (mg/day)		10	10	30
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		10%	90%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		5	7
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Use
890701	Emergency consultation, general medicine	3.8	1	100
890701	Interconsultation by specialized medicine (internal medicine, family medicine or neurology)	5.1	10	100
903426	Glycated hemoglobin	5.9	1	100
903818	Total cholesterol	1.3	1	100
903815	HDL cholesterol	1.7	1	100
903816	LDL cholesterol	1.7	1	100
903868	Triglycerides	1.6	1	100
903841	Glycemia	0.9	7	100
902045	PT	2.3	3	100
902049	PTT	2.8	3	100
903439	Troponin T	11.9	1	100
904902	Thyroid stimulating hormone (TSH)	7.3	1	100
903825	Creatinine in the blood	0.9	2	100
903856	Blood urea nitrogen (BUN)	1.1	2	100
907107	Urinary sediment and density analysis	1.1	2	90
903605	Ionogram (chlorine, sodium, potassium and bicarbonate or calcium)	6.6	3	100
902210	Type IV hemogram	3.3	2	100
902109	Glucose-6-phosphate dehydrogenase, quantitative	8.1	1	20
895101	Electrocardiogram	4.1	1	100
881232	Transthoracic echocardiogram (M-mode and two-dimensional)	24.9	1	100
881233	Echocardiogram, M-mode and two-dimensional with Doppler	39.2	1	100
881235	Transoesophageal echocardiogram	63.7	1	50
871121	Chest X-ray	6.3	1	100
879111	Brain CAT	29.4	1	100
882110	Carotid Doppler test (vertebral arteries and jugular vein)	21.1	1	100
883101	Nuclear magnetic resonance of the brain	80.6	1	100
931000	Complete physical therapy	3.9	7	100
938300	Complete occupational therapy	1.8	5	100
937000	Complete phonoaudiological therapy	1.8	5	100
S41501	Daily enteral or parenteral nutritional management of the hospitalized patient	1.2	3	100
CUPS	Medications		Daily dose	# days	% Patients
	Losartan, taken orally (mg/day)		100	8	90
	Metoprolol tartrate, taken orally (mg/day)		300	8	50
	Atorvastatin, taken orally (mg/day)		80	8	90
	Aspirin, taken orally (mg/day)		100	8	100
	Clopidogrel, taken orally (mg/day)		75	8	100
	Oxygen (L/day)		4320	5	100
	Bisoprolol, taken orally (mg/day)		10	8	30
	Carvedilol, taken orally (mg/day)		25	8	20
	Enalapril, taken orally (mg/day)		40	8	10
	Enoxaparin, subcutaneous (mg/day)		120	8	50
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		50%	50%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		5	3

Table 4S

Per-event and per-day estimated costs in USD for hospitalization and complications

Event	Average
Pneumonia/event	$ 882.0
Delirium/event	$ 276.5
Urinary tract infection/event	$ 485.9
Surgical site infection/event	$ 205.6
Pressure ulcers/event	$ 1,560.2
Deep vein thrombosis/event	$ 1,519.9
Pulmonary embolism/event	$ 3,891.6
Cardiovascular event/event	$ 3,186.4
Neurological event/event	$ 986.9
Hospitalization floor - high complexity/ day	$ 22.1
Adult intensive care unit/ day	$ 164.5

The results of the estimated cost variations for hospital stay and complications are found in Table 2. Considering the duration and frequency of complications observed in the institutions, we estimated a general reduction in the costs associated with stay and complications throughout the implementation of the program. The absolute decrease in estimated costs related to stay and complications varied between USD 94 and USD 966. The relative variation ranged between -22.0% and -68.3%. Similar results were observed in the cost differences considering only the stay or only complications, although the latter were generally of greater magnitude.

Table 2

Estimated costs related to stay (with minimum and maximum sensitivity scenario), complications, and stay plus complications (with minimum and maximum sensitivity scenario) for each institution in each year of implementation. With these data, absolute and relative variations were calculated. NR = not reported.

Implementation year	Institution
	A	B
Hospital stay cost - minimum sensitivity scenario
Base	$182	$164
1	$173	$139
2	$167	$159
3	NR	$149
4	NR	$122
Absolute variation	-$15	-$43
Relative variation	-8.4%	-26.0%
Hospital stay cost - maximum sensitivity scenario
Base	$1,356	$1,223
1	$1,289	$1,037
2	$1,242	$1,182
3	NR	$1,112
4	NR	$904
Absolute variation	-$113	-$319
Relative variation	-8.4%	-26.0%
Cost of complications
Base	$1,089	$263
1	$460	$63
2	$237	$217
3	NR	$240
4	NR	$212
Absolute variation	-$853	-$51
Relative variation	-78.3%	-19.4%
Average patient cost - minimum sensitivity scenario
Base	$1,271	$428
1	$633	$203
2	$404	$376
3	NR	$389
4	NR	$334
Absolute variation	-$868	-$94
Relative variation	-68.3%	-22.0%
Average patient cost - maximum sensitivity scenario
Base	$2,445	$1,487
1	$1,749	$1,100
2	$1,479	$1,400
3	NR	$1,352
4	NR	$1,117
Absolute variation	-$966	-$370
Relative variation	-39.5%	-24.9%

Discussion

This study describes the experience of two Colombian healthcare institutions that have adopted the Geriatric fracture programs. This type of model seeks to achieve a comprehensive and multidisciplinary patient care program . One of the priorities is to carry out the surgical procedure within the first 48 hours after the fracture. Longer presurgical time has been associated with a greater total length of stay, mortality and morbidity . These experiences, along with the experience previously implemented and published in Colombia , represent the first reports of experiences with these models in Latin America.

During the implementation of the model, trends are identified in the various measured indicators by comparing the base values with those present at the end of the observation.

Firstly, there is an increase in the number of patients treated, which may be relevant to the extent that it may signify a greater ability to offer these services. This is valuable in countries with problems of installed capacity for specialized services.

A reduction in the length of stay was observed, particularly after surgery, and in the proportion of in-hospital complications. These reductions are desirable for patients and institutions and the health system in general. In the previously performed implementation , a reduction in the time of stay was reported between the patients treated in the first two years of the program (5.3 days of stay on average) and those treated in the subsequent two years (3.42 days). Overall, it can be seen how the total length of stay is reduced during the Geriatric fracture programs, replicating the direction of the results previously obtained in Colombia.

Reductions in outcomes such as readmissions and deaths were also observed. Based on these data, the theoretical estimate of costs showed savings related to stays and complications during the program. In the implementation of the previously published Geriatric fracture programs, a reduction in mortality was found throughout the implementation (year 1: 22.99%, year 2: 16.22%, year 3: 9.09%, year 4: 12.68%) that was statistically significant when comparing the first two years with the second two . Therefore, the general outlook of the Geriatric fracture programs shows a trend towards the reduction in mortality and readmissions, which replicate the results achieved in previous implementations.

It is worth highlighting some interesting aspects. In general, similar trends were evidenced in both institutions. In addition, the institutions also registered decreases in the variance of the total stays, possibly indicating homogenization of these times. This point is very interesting, to the extent that it may reflect greater homogeneity in the health requirements of these patients.

Although the two institutions presented similar trends, there were some differences between them, both in the baseline indicators and in the magnitude of the changes seen during the implementation of the program. This is evident in the variations in the frequency of complications, which were very different in magnitude in each institution. This effect may be due to differences inherent in the institutions or to the patients treated. One possible explanation is that the impact of the Geriatric fracture programs is not complication-specific, but affects complications in general, obtaining different results according to the baseline of each institution. This hypothesis should be assessed in a later study.

Finally, these results replicated those previously seen for mortality and hospital stay in the first implementation, made more than 10 years ago with 298 patients treated over a period of 4 years . This shows that GFPs can produce similar results in different institutions in Colombia. Replicating both the implementation and the results obtained is thus feasible in this context.

The trends seen in this characterization reflect some data seen in other studies. Two studies in the United States evaluated a similar program. They found that outcomes of hospital stay (between 4.2 and 4.6 days) and total cost of the event (USD 15,188) were substantially better than those shown in other cohorts presented in the literature , . Another comprehensive management program implemented in three institutions in the United States also showed a hospital stay reduction from 5.6 days in 826 patients before implementation to 4.7 days in 2,069 patients after implementation . These results are consistent with the trends seen in the three institutions where the program has been implemented in Colombia.

The study displays some limitations derived from its design. Since it is an observational study, it is not possible to ensure complete control of the confounding variables. Thus, the observed variations in the indicators cannot be causally attributed to the Geriatric fracture programs. The descriptive nature of the study implies that the trends seen do not involve statistically significant changes and, when performed, the exploratory analyses are intended to generate hypotheses. The retrospective use of information collected routinely in institutions introduces the potential for information bias, particularly for measuring results that require external monitoring, such as mortality per year. Nevertheless, given that the institutions use this same information as an internal indicator, there are information verification processes that exist which help to alleviate this issue. All these aspects limit the extrapolation of the data but do not invalidate the observed results.

Conclusion

The present study describes the experience of 475 patients treated in two institutions with the Geriatric fracture programs. Throughout the years of implementation, the institutions displayed an increase in number of patients treated, and decreases in length of stay, proportion of complications, proportion of readmissions, and deaths. The theoretical estimate of cost shows possible savings related to the reduction in stay and the proportion of complications. Results were generally similar between the two institutions. They are also very similar to other experiences of implementation in Colombia and at the international level. Both situations suggest that other institutions can replicate the program and its results at the national level.

Contribución del estudio

Introducción

Las fracturas de cadera son consideradas un problema de salud global , por su asociación con alta mortalidad y morbilidad ,. Los cambios demográficos en la población han aumentado la incidencia de este tipo de fracturas, que aumenta exponencialmente con la edad ,. Asimismo, la mortalidad más elevada por esta causa ocurre en los adultos mayores, con mortalidad anual entre 8%-26% y con valores aún más altos en mayores de 80 años con fractura de cadera .

En años recientes, la incidencia de fracturas de cadera ha aumentado en paises de Latinoamérica. Aziziyeh R et al. ( estimaron que para el 2020 el aumento en fracturas de cadera en adultos entre 50 y 89 años fue de 7.3%, 17%, 19.1%, 15.3% en Argentina, Brazil, Colombia y México, respectivamente, dado por el envejecimiento poblacional.

En Colombia, la osteoporosis y las fracturas de cadera producen alta morbilidad y mortalidad. Su prevalencia aumenta dramáticamente después de los 50 años y su manejo requiere, en muchos casos, de manejo quirúrgico. Estas fracturas se relacionan con empeoramientos de la calidad de vida, de la discapacidad, aumentos en modalidad y costos . El costo anual estimado por fracturas asociadas con osteoporosis fue de USD 411, USD 360, USD 310 y USD 94 millones, respectivamente . Múltiples estudios han mostrado que entre 44% y 57% de todos los costos de hospitalización se asocian con cuidado de fracturas de cadera -.

Por lo anterior, se han desarrollado programas de manejo integral a nivel global, conocidos como programas de adulto mayor fracturado. Estos programas se caracterizan por un manejo conjunto multidisciplinario, intervenciones quirúrgicas tempranas, cuidado centrado en pacientes basado en protocolos estandarizados y planeación de una alta temprana para reducir la estancia hospitalaria ,. Sus objetivos son mejorar la calidad del cuidado de la salud y los desenlaces clínicos y reducir los costos. Estos programas han mostrado tener varios efectos positivos para los pacientes, los profesionales de salud y para el sistema de salud ,. En 2008, un programa de adulto mayor fracturado se implementó en el Hospital San José de Bogotá. Se evidenciaron reducciones en mortalidad y estancia hospitalaria en 298 pacientes atendidos en los primeros cuatro años del programa .

El objetivo de este estudio fue describir los resultados de la implementación de un programa de adulto mayor fracturado en dos instituciones de salud colombianas. El propósito final es comprar estas implementaciones con otras previamente publicadas en Colombia para evaluar reproducibilidad. Si se logran resultados positivos similares al implementar el programa en otras instituciones, se podría pensar que el modelo es reproducible.

Materiales y Métodos

Se realizó un estudio descriptivo retrospectivo usando información de pacientes mayores de 65 años quieren se fracturaron por fragilidad y fueron atendidos en dos instituciones que implementaron el programa de adulto mayor fracturado. Estas son instituciones de alta complejidad con programas de largo plazo para pacientes fracturados. La institución A se encuentra en Bogotá y tiene 230 camas de hospitalización general, 5 de cuidados intermedios y 21 de cuidados intensivos para adultos. La institución B se encuentra en Cali y tiene 168 camas de hospitalización general, 17 de cuidado intermedio y 31 de cuidado intensivo.

Descripción del programa de adulto mayor fracturado

El modelo implementado se basó en el modelo de manejo ortopédico de Rochester , que había sido previamente implementado en otra institución en Colombia . En resumen, el modelo es un sistema de manejo conjunto multidisciplinario que produce un plan de cuidado integral. Los pacientes objetivos tenían al menos 65 años y sufrieron una fractura de cadera que requirió manejo quirúrgico. El programa consideró dos componentes (Figura S1). El primero se relacionó con el cuidado intrahospitalario. Esta fase inició apenas se ingresó un paciente eligible en urgencia y es referido a los servicios de ortopedia y geriatría. Estos definieron el diagnóstico inicial, el plan terapéutico según el estado del paciente y el tipo de fractura y se diseñaron las estrategias iniciales de rehabilitación. El segundo componente consideró el cuidado ambulatorio durante el primer año posterior a la cirugía. Se realizaron controles con ortopedia a los 15 días, 1 mes, 3 meses, 6 meses y 12 meses posterior a la cirugía cuyo foco fue la rehabilitación y el manejo de la osteoporosis. Se podían considerar controles adicionales según la necesidad. Se realizaron también consultas ambulatorias con geriatría, enfocadas en el estado de salud general, manejo de comorbilidad, evaluación de funcionalidad, prevención de caídas y manejo de la osteoporosis. La cantidad y frecuencia de los controles se definió para cada caso, según la circunstancia y evolución individual.

Figura S1

El programa consideró dos componentes. Uno relacionado con la atención hospitalaria. El otro componente consideró la atención ambulatoria durante el primer año posquirúrgico.

Uno de los objetivos del modelo fue minimizar los tiempos hospitalarios antes y después del procedimiento quirúrgico, para reducir la estancia total. De esta manera, se esperaba reducir las complicaciones y mortalidad y mejorar la rehabilitación de los pacientes.

Recolección de información

Las instituciones adheridas al programa realizaron una recolección sistemática de información de indicadores clínicos y de proceso, para monitorear el desempeño del programa. Cada institución recogió la siguiente información:

Información general y demográfica: cantidad de pacientes admitidos, edad, sexo.

Tipo de procedimiento quirúrgico.

Variables de la estancia hospitalaria: tiempo entre ingreso y cirugía, estancia prequirúrgica, estancia posquirúrgica estancia total.

Variables del seguimiento clínico: mortalidad intrahospitalaria, mortalidad en el primer mes posquirúrgico, mortalidad en el primer año posquirúrgico, readmisión hospitalaria en los primeros 30 días después de la estancia

Complicaciones intrahospitalarias: delirium neumonía, infección del tracto urinario, infección del sitio quirúrgico, úlcera por presión, trombosis venosa profunda, tromboembolismo pulmonar, eventos cardiovasculares, eventos neurológicos

Las instituciones recogieron originalmente esta información a nivel individual. Posteriormente, construyeron informes de resumen de las variables continuas con promedias y desviación estándar (DE) y las variables categóricas con conteos de eventos. La información acumulada fue reportada por cada institución desde el inicio de implementación del programa hasta junio de 2018 para todos los pacientes incluidos en el programa. Dado que las dos instituciones iniciaron la implementación en momentos distintos, se definió como año base el año calendario en la que la institución inició la implementación del programa y como años de seguimiento los subsiguientes.

Análisis de información

Se realizó la descripción de las variables de interés estratificando por institución. Es importante considerar que el objetivo de esta descripción era ver la tendencia de cambio de los indicadores a lo largo de la implementación del programa y no realizar comparaciones directas entre las dos instituciones. Asimismo, considerando la naturaleza descriptiva del ejercicio y la ausencia de mecanismo para control de variables de confusión, estas tendencias se interpretaron únicamente de manera descriptiva y no en términos de causalidad. Todos los procedimientos y gráficos se realizaron usando el programa estadístico R, versión 3.5.0.

De manera inicial, se caracterizó la cantidad de pacientes atendidos en cada institución y sus características generales y demográficas, describiendo las tendencias de los diferentes tipos y tiempo de estancia hospitalaria. Estas se calcularon en horas y se resumieron con promedios y desviación estándar. Subsecuentemente, se describieron las complicaciones descritas en cada institución, discriminando por tipo de complicación y las tendencias en mortalidad y readmisión hospitalaria en el mediano y largo plazo. Considerando la variabilidad de la cantidad de pacientes de cada institución, estos resultados se expresaron en términos de porcentajes. No fue posible estimar la mortalidad anual para 2018, dado que los datos fueron recogidos a inicios de 2019

Estimación económica

Se realizó una estimación teórica del posible impacto económico del programa, enfocado en las posibles diferencias en consumo de recursos derivadas de la estancia hospitalaria y las complicaciones. No se tuvieron en cuentas los costos del procedimiento quirúrgico, dado que este no fue directamente impactado por la dinámica del programa. Todos los costos fueron calculados en pesos colombianos y convertidos a dólares estadounidenses usando la tasa de cambio promedio para 2019 (1USD = 3,301 pesos colombianos). Se consultaron los expertos clínicos de las instituciones para construir escenarios base de consumo de recursos para cada complicación. El costeo de estos se realizó usando los métodos estandarizados del Instituto de Evaluación Tecnológica en Salud (IETS). Los costos fueron estimados desde la perspectiva del tercero pagador, considerando costos médicos directos. Los precios de medicamentos se obtuvieron de la base de información de precios de medicamentos (SISMED) del último trimestre disponible y, cuando fuera necesario, usando los últimos precios máximos de regulación fijados por el Ministerio de Salud. Los precios finales de los medicamentos se estimaron realizado un promedio ponderado por la participación de mercada para cada presentación. Los costos de los procedimientos fueron obtenidos desde el manual tarifarios del Instituto del Seguro Social de 2001, con un incremento del 30% de acuerdo con la metodología propuesta por el IETS. Los valores monetarios para los insumos fueron obtenidos de los reportes de las subastas publicas o de Colombia Compra Eficiente. Para la estancia hospitalaria, se realizó un análisis de sensibilidad considerando como límite inferior el costo de cama hospitalaria de alta complejidad y como límite superior el costo de hospitalización en unidad de cuidados intensivos. Los costos de estancias hospitalaria se calcularon considerando esos costos unitarios y las estancias de cada institución. Para las complicaciones, se calculó el promedio del costo por paciente en el programa para todas las complicaciones considerando los costos de cada complicación y la frecuencia de cada una en cada institución. Al combinar estos dos costos y la tendencia sobre el tiendo, se estimó el costo de estancia, más las complicaciones para cada paciente en el programa.

Se estimó entonces el costo en cada año de implementación y se comparó el valor del año base con el del último año disponible.

Análisis exploratorios

De manera exploratoria, se realizó una comparación estadística entre los valores de duración total de estancia y cantidad de complicación del año base y el último año disponible. Estos análisis fueron generadores de hipótesis. Para el tiempo de estancia, se realizó una prueba t de student para comparar el promedio en dos muestras no pareadas, suponiendo varianzas diferentes. Para las complicaciones, se realizó una prueba Z para dos proporciones.

Aprobación por comité de ética y consideraciones éticas

Este estudio fue aprobado por el Comité de Ética de la Fudación Santa Fe de Bogotá (Acuerdo No. 20, con numero de aprobación CCEI-9941-2018). El estudio se condujo con los estándares éticos aplicables para este tipo de estudio. El estudio se realizó en ambas instituciones de acuerdo con el protocolo aprobado.

Resultados

Descripción general

Se identificaron un total de 475 pacientes en las dos instituciones. La institución A presentó información de 3 años y 190 pacientes (63.3 pacientes/año) y la B un total de 5 años y 285 pacientes (57 pacientes/año). Las características base de los pacientes se encuentran en la Tabla 1. Se observó un incremento en el número total de pacientes a lo largo de la implementación del programa (A: desde 55 a 71, + 29%; B: desde 44 a 77, + 75%) en ambas instituciones. Cerca del 78% de los pacientes eran mujeres, de manera similar en ambas instituciones y alrededor del 80% tenían más de 76 años. El procedimiento quirúrgico más frecuentemente realizado fue la osteosíntesis con clavo o con dispositivo de compresión.

Tabla 1

Características demográficas de los pacientes identificados en las dos instituciones. Los porcentajes son relativos a los totales de cada institución.

Variable	Institución
	A	B
Pacientes totales	190	285
Pacientes de acuerdo con el año de implementación
Año base	55 (28.9%)	44 (15.4%)
1	64 (33.7%)	49 (17.2%)
2	71 (37.4%)	56 (19.6%)
3	NA (NA%)	59 (20.7%)
4	NA (NA%)	77 (27%)
Pacientes por sexo
Masculino	41 (21.6%)	64 (22.5%)
Femenino	149 (78.4%)	221 (77.5%)
Pacientes por grupos de edad (años)
65-75	45 (23.7%)	51 (17.9%)
76-85	82 (43.2%)	117 (41.1%
>85	63 (33.2%)	117 (41.1%)
Pacientes por tipo de procedimiento
Osteosíntesis con clavo o con dispositivo de compresión	115 (60.5%)	164 (57.5%)
Reducción abierta con osteosíntesis con tornillo canulado	10 (5.3%)	27 (9.5%)
Reemplazo articular	65 (34.2%)	94 (33%)

Duración de estancia hospitalaria

El promedio de estancia hospitalaria total tuvo una reducción con respecto al año base (Figura 1). Al comparar el año base con el último año disponible, ambas instituciones tuvieron reducciones, aunque fueron de magnitud diferente (A: desde 152.2 a 139.4, -8.5%; B: desde 137.3 a 101.5, -26.1%). La institución B presentó un cambio entre el año base y el segundo año de implementación de -3.4%, que fue similar al de la institución A en el mismo periodo.

Figura 1

Promedio total de la estancia hospitalaria en horas, según año de implementación e institución (A y B). Las barras de error representan ± 1 DE

Al separar el tiempo de estancia por tipo (ingreso a cirugía, prequirúrgico, posquirúrgico, total), se observó una tendencia a la reducción en los tiempos totales y posquirúrugicos. Los tiempos prequirúrgicos se mantuvieron estables. Esta tendencia fue similar en ambas instituciones (Figura 2). En ambas, el tiempo prequirúrgico promedio fue menor a 48 horas.

Figura 2

Estancia hospitalaria promedio para los diferentes tipos de estancia hospitalaria en horas, según año de implementación e institución (A y B)

Complicaciones

La proporción de complicaciones totales se redujo en ambas instituciones posterior a la implementación del programa de adulto mayor fracturado (Figura 3). Para la institución A, el análisis exploratorio encontró una diferencia de -35.1% entre el año base y el último año disponible que fue estadísticamente significativo (74.5% vs. 39.4%, p= <0.001, 95% IC -52.9% a -17.3%). Para la institución B, el análisis exploratorio encontró una diferencia de -33.4% entre el año base y el último daño isponible, que fue estadísticamente significativo (56.8% vs. 23.4%, p= <0.001, 95% IC -52.7% a -14.2%). El material suplementario 1S muestra los detalles de la proporción de cada tipo de complicación en el tiempo. Al evaluar cada institución de manera individual se pueden observar algunas diferencias. Para la institución A, la reducción total en complicaciones coincidió con la reducción en úlceras por presión (de 3.6% a 1.6%), eventos cardiovasculares (de 12.7% a 1.4%), infección del sitio operatorio (de 9.1% a 2.8%), infección del tracto urinario (de 10.9 a 5.6%), neumonía (de 7.3% a 2.8%) y tromboembolismo pulmonar (de 10.9% a 1.4%). En la institución B, la reducción se relacionó principalmente con la reducción en delirium (de 38.6% a 13%), infección del sitio operatorio (de 2.3% a 1.7%), infección del tracto urinario (de 4.5% a 2.6%), neumonía (de 6.8% a 1.3%) y úlceras por presión (de 4.5% a 2.6%).

Figure 3

Proporción de pacientes con complicaciones por tipo de complicación, institución (A y B) y año de implementación

Tabla 1S

Proporción del tipo de complicación, por institución y año de implementación.

Variable	Año de implementación	Total	A	B
Número de pacientes con delirium	Base	0.273	0.182	0.386
	1	0.142	0.156	0.122
	2	0.26	0.239	0.286
	3	0.203	NR	0.203
	4	0.13	NR	0.13
Número de pacientes con eventos cardiovasculares	Base	0.071	0.127	0
	1	0.009	0.016	0
	2	0.016	0.014	0.018
	3	0.017	NR	0.017
	4	0.013	NR	0.013
Número de pacientes con eventos neurologicos	Base	0.01	0.018	0
	1	0	0	0
	2	0.008	0.014	0
	3	0	NR	0
	4	0	NR	0
Número de pacientes con infección en el sitio de intervención quirúrgica	Base	0.061	0.091	0.023
	1	0.027	0.047	0
	2	0.016	0.028	0
	3	0.017	NR	0.017
	4	0	NR	0
Número de pacientes con infección en el tracto urinario	Base	0.081	0.109	0.045
	1	0.071	0.078	0.061
	2	0.039	0.056	0.018
	3	0.034	NR	0.034
	4	0.026	NR	0.026
Número de pacientes con neumonía	Base	0.071	0.073	0.068
	1	0.018	0.031	0
	2	0.024	0.028	0.018
	3	0.034	NR	0.034
	4	0.013	NR	0.013
Número de pacientes con tromboembolismo pulmonar	Base	0.061	0.109	0
	1	0.035	0.062	0
	2	0.008	0.014	0
	3	0	NR	0
	4	0.013	NR	0.013
Número de pacientes con trombosis venosa profunda	Base	0	0	0
	1	0.009	0.016	0
	2	0	0	0
	3	0	NR	0
	4	0.013	NR	0.013
Número de pacientes con ulceras de presión	Base	0.04	0.036	0.045
	1	0.009	0.016	0
	2	0.016	0	0.036
	3	0.051	NR	0.051
	4	0.026	NR	0.026

Resultados de seguimiento

En la institución A, se evidenció una menor proporción de pacientes con cada desenlace al comparar el año base con el último disponible (readmisión desde 14.5% a 7%, mortalidad intrahospitalaria desde 3.6% a 2.8%, mortalidad en el primer mes desde 1.8 % a 1.4% y muerte en el primer año desde 10.9% a 4.7%) (Figura 4). En la institución B, se encontró una tendencia a la reducción en la readmisión (18.2% vs. 15.6%), la mortalidad intrahospitalaria (4.5% vs. 2.6%) y la mortalidad en el primer año (11.4% vs. 5.1%). Sin embargo, se encontró un aumento en la mortalidad en el primer mes (0% vs. 2.6%), aunque es importante resaltar que no hubo eventos en el año base (Figura 4). La información detallada se encuentra en la Tabla Suplementaria 2S.

Figura 4

Proporción de pacientes con cada tipo de desenlace, según la institución (A y B) y el año de implementación

Tabla 2S

Proporción de pacientes que logran cada tipo de resultado, según la institución y el año de implementación.

		Institución
Variable	Año implementación	Total	A	B
Re-admisiones 30 dias	Base	0.162	0.145	0.182
	1	0.124	0.125	0.122
	2	0.118	0.07	0.179
	3	0.085	NR	0.085
	4	0.156	NR	0.156
Mortalidad intra-hospitalaria	Base	0.04	0.036	0.045
	1	0.009	0.016	0
	2	0.024	0.028	0.018
	3	0.034	NR	0.034
	4	0.026	NR	0.026
Mortalidad primer mes	Base	0.01	0.018	0
	1	0.035	0.047	0.02
	2	0.024	0.014	0.036
	3	0	NR	0
	4	0.026	NR	0.026
Mortalidad primer año	Base	0.111	0.109	0.114
	1	0.053	0.047	0.061
	2	0.055	NR	0.071
	3	0.051	NR	0.051
	4	NR	NR	NR

Estimación de consumo de recursos en salud y costos

En la Tabla Suplementaria 3S, reportamos las estimaciones de recursos en salud construido con los expertos clínicos para cada evento de interés. Los costos detallados de día de estancia hospitalaria y de costo por evento se encuentran en la Tabla Suplementaria 4S. Las complicaciones individuales con costos por evento más altos fueron el tromboembolismo pulmonar (USD 3,891.6), los eventos cardiovasculares (USD 3,186.4) y las úlceras por presión (USD 1,560.2). Los que tuvieron costos más bajos fueron la infección del sitio operatorio (USD 205.6), el delirium (USD 276.5) y las infecciones del tracto urinario (USD 485.9). Hubo también una diferencia importante entre el costo de día de estancia hospitalaria en los escenarios de sensibilidad bajo y alto (USD 22.1 vs USD 164.5).

Tabla 3S

Recursos estimados para hospitalización y complicación para cada evento, con precios en USD.

		Unitary Price (USD)
S11303	Ward hospitalization - 3 beds - high complexity	22.1
S12103	Adult intensive care unit	164.5
CUPS	Laboratories, consultations, procedures	5.5	Number	% Patients
890702	Emergency consultation, specialized medicine	3.3	8	100
902210	Type IV hemogram	3.8	3	100
903839	Arterial blood gases	0.9	2	100
903825	Creatinine in the blood	80.4	4	100
901314	Mycobacterium, identification by PCR	6.3	2	50
871121	Chest X-ray	2.5	2	100
939400	Respiratory therapy	33.6	40	100
879301	Chest CT scan	5.5	1	100
CUPS	Medications		Daily dose	# days	% Patients
	Sultamicillin, taken orally 375 mg (# tab/day)		750	7	40
	Clarithromycin, taken orally (mg/day)		1000	7	70
	Oxygen (L/day)		4320	7	60
	Ampicillin + Sulbactam, intravenous (g/day)		12	10	60
	Clarithromycin, intravenous (mg/day)		1000	7	70
	Paracetamol, taken orally (mg/day)		3000	7	80
	Omeprazole, taken orally (mg/day)		40	7	100
	Enoxaparin subcutaneous (mg/day)		40	7	100
	Ipratropium bromide inhaler (puff/day)		8	7	80
	Cefepime, intravenous (mg/day)		3000	10	30
	Piperacillin - Tazobactam, intravenous (mg/day)		18000	10	40
	Methylprednisolone, intravenous (mg/day)		375	5	50
			Ward (%)	ICU (%)
	In what percentage of patients is hospitalization required for care regarding the event?		80	20
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		7	5
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890702	Emergency consultation, specialized medicine	5.5	9	100
902210	Type IV hemogram	3.3	2	100
903825	Creatinine in the blood	0.9	2	100
903856	BUN in the blood	1.1	2	100
903703	Vitamin B12 [Cyanocobalamin]	9.9	1	100
903706	Vitamin D25 Hydroxy Total [D2-D3] [Calciferol]	13.8	1	100
904902	TSH	7.3	1	100
903864	Sodium in the blood	1.8	1	100
903859	Potassium in the blood	2.5	1	100
871121	Chest X-ray (PA or AP and lateral, lateral decubitus, oblique or lateral with barium)	6.3	1	100
907107	Urine test	1.1	1	100
879111	Brain CT	29.4	1	70
CUPS	Medications		Daily dose	# days	% Patients
	Haloperidol, taken orally (mg/day)		3	5	70
	Quetiapine, taken orally (mg/day)		100	5	50
	Olanzapine, taken orally (mg/day)		10	5	30
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		80%	0%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		5	0
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890702	Emergency consultation, specialized medicine	5.5	6	100
902210	Type IV hemogram	3.3	2	100
903825	Creatinine in the blood	0.9	2	60
901221	Blood culture	9.2	2	100
881332	Ultrasound of urinary tract	9.1	1	100
907107	Urine test	1.1	1	100
901236	Urine culture	8.8	1	100
550401	Percutaneous nephrostomy	75.6	1	10
879420	CT urography	40.3	1	30
CUPS	Medications		Daily dose	# days	% Patients
	Ampicillin + Sulbactam, intravenous (g/day)		12	7	10
	Ceftriaxone, intravenous (mg/day)		2000	7	80
	Piperacillin - Tazobactam, intravenous (mg/day)		18000	10	4
	Ciprofloxacin, intravenous (mg/day)		800	7	1
	Ertapenem, intravenous (g/day)		1	10	2
	Meropenem, intravenous (mg/day)		3000	10	3
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		90%	10%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		5	10
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890702	Emergency consultation, specialized medicine	5.5	1	70
902210	Type IV hemogram	3.3	1	100
906913	Automated high precision C-reactive protein test	4.7	1	100
902205	Automated erythrocyte sedimentation rate (ESR)	0.4	1	100
862803	Non-excisional debridement of devitalized tissue, between 10% and 20% of body surface	0.0	1	30
S23202	Treatment - S23202	16.8
S41101	Surgical or gyneco-obstetric clinical specialists	0.4
S41201	Anesthesiology specialists	0.3
S41301	Surgical assistant	0.1
S55104	Suture material	13.7
901217	Microorganism culture in any sample other than bone marrow, urine and feces (#2)	4.3	1	100
901209	Sample of intrasurgical cultures	3.8	1	100
901107	Gram staining and reading for any sample	0.9	1	100
CUPS	Medications		Daily dose	# days	% Patients
	Cefalexin, taken orally (mg/day)		4000	7	70
	Amikacin, intravenous (mg/day)		500	7	30
	Paracetamol, taken orally (mg/day)		1500	3	70
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		100%	0%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		2	0
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890702	Emergency consultation, specialized medicine	5.5	8	70
902210	Type IV hemogram	3.3	3	100
906913	Automated high precision C-reactive protein test	4.7	2	100
902205	Automated erythrocyte sedimentation rate (ESR)	0.4	2	100
862803	Non-excisional debridement of devitalized tissue, between 10% and 20% of body surface	0.0	2	100
901217	Microorganism culture in any sample other than bone marrow, urine and feces (#2)	4.3	2	100
901209	Sample of intrasurgical cultures	3.8	2	100
901107	Gram staining and reading for any sample	0.9	2	100
862601	Debridement with placement of subatmospheric pressure device	552.1	1	100
862602	Subatmospheric pressure device replacement	318.5	7	100
965902C	Enterostomal therapy (wound care)	2.0	8	100
CUPS	Medications		Daily dose	# days	% Patients
	Ampicillin + Sulbactam, intravenous (g/day)		12	7	1
	Zinc oxide (30 g of active agent)		1	1	60
	Collagenase 120 UI (40 g)		1	1	10
	Hydrocolloid dressing	8.7	1	1	10
	Saline solution		250	1	90
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		90%	10%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		15	0
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Patients
890701	Emergency consultation, general medicine	3.8	1	100
S20201	Emergency observation unit (service for highly complex cases)	11.1	1	100
902104	D-dimer	9.0	1	100
890302	Specialized medicine consultation	3.8	3	100
871121	Chest X-ray	6.3	1	100
879301	Chest CT	33.6	1	90
920304	Gammagraphy of pulmonary ventilation and perfusion	41.1	1	10
882333	Duplex scanning of the lower extremity arteries	24.8	1	100
895101	Electrocardiogram of the rhythm or the surface	4.1	1	100
881234	M-mode and two-dimensional echocardiogram	50.1	1	100
895001	Dynamic electrocardiography (Holter)	37.6	1	40
902045	PT	2.3	2	100
902049	PTT	2.8	1	100
902210	Type IV hemogram	3.3	1	100
903839	Arterial gases	3.8	1	100
903066	Brain natriuretic peptide (BNP)	43.9	1	100
903439	Troponin T, quantitative	11.9	1	100
CUPS	Medications		Daily dose	# days	% Patients
	Enoxaparin, subcutaneous (mg/day)		120	180	85
	Warfarin, taken orally (mg/day)		5	180	80
	Apixaban, taken orally (mg/day)		10	180	10
	Rivaroxaban, taken orally (mg/day)		20	180	10
	Dabigatran, taken orally (mg/day)		300	180	10
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		95%	5%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		3	8
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Use
890701	Emergency consultation, general medicine	3.8	1	100
S20201	Emergency observation unit (service for highly complex cases)	11.1	1	100
902104	D-dimer	9.0	1	100
890302	Specialized medicine consultation	3.8	10	100
894402	6-minute walk	16.7	1	30
871121	Chest X-ray	6.3	1	100
879301	Chest CT	33.6	1	90
920304	Gammagraphy of pulmonary ventilation and perfusion	41.1	1	10
882333	Duplex scanning of the lower extremity arteries	24.8	1	100
895101	Electrocardiogram of the rhythm or the surface	4.1	5	100
881234	M-mode and two-dimensional echocardiogram	50.1	1	100
895001	Dynamic electrocardiography (Holter)	37.6	1	60
902045	PT	2.3	1	100
902049	PTT	2.8	5	100
902210	Type IV hemogram	3.3	1	100
903839	Arterial gases	3.8	1	100
903066	Brain natriuretic peptide (BNP)	43.9	1	100
903439	Troponin T, quantitative	11.9	1	100
CUPS	Medications		Daily dose	# days	% Patients
	Enoxaparin, subcutaneous (mg/day)		120	180	95
	Warfarin, taken orally (mg/day)		5	180	80
	Apixaban, taken orally (mg/day)		10	180	10
	Rivaroxaban, taken orally (mg/day)		20	180	10
	Dabigatran, taken orally (mg/day)		300	180	10
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		30%	70%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		10	15
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Use
890701	Emergency consultation, general medicine	3.8	1	100
890701	Interconsultation by specialized medicine (internal medicine, family medicine or cardiology)	5.1	10	100
903426	Glycated hemoglobin	5.9	1	100
903818	Total cholesterol	1.3	1	100
903815	HDL cholesterol	1.7	1	100
903816	LDL cholesterol	1.7	1	100
903868	Triglycerides	1.6	1	100
895101	Electrocardiogram	4.1	10	100
881232	Transthoracic echocardiogram (M-mode and two-dimensional)	24.9	1	100
372301	Cardiac catheterization of the right and left sides of the heart with electrophysiological study	227.0	1	100
C40558	Coronary angioplasty with balloon	1,378.2	1	60
	Medicated stent		1	100
871121	Chest X-ray	6.3	1	100
903841	Glycemia	0.9	10	100
902045	PT	2.3	5	100
902049	PTT	2.8	5	100
903439	Troponin T	11.9	5	100
904902	Thyroid stimulating hormone (TSH)	7.3	1	100
903825	Creatinine in the blood	0.9	4	100
903856	Blood urea nitrogen (BUN)	1.1	4	100
907107	Urinary sediment and density analysis	1.1	2	100
902210	Type IV hemogram	3.3	3	100
933600	Cardiac rehabilitation therapy	5.9	10	100
CUPS	Medications		Daily dose	# days	% Patients
	Losartan, taken orally (mg/day)		100	10	90
	Metoprolol tartrate, taken orally (mg/day)		300	10	50
	Atorvastatin, taken orally (mg/day)		80	10	100
	Aspirin, taken orally (mg/day)		100	10	100
	Clopidogrel, taken orally (mg/day)		75	10	100
	Oxygen (L/day)		4320	5	100
	Morphine, intravenous (mg/day)		10	5	70
	Metoclopramide, taken orally (mg/day)		30	5	50
	Bisacodyl, taken orally (mg/day)		10	10	100
	Nitroglycerine, intravenous (mg/day)		50	3	100
	Carvedilol, taken orally (mg/day)		25	10	20
	Bisoprolol, taken orally (mg/day)		10	10	30
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		10%	90%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		5	7
CUPS	Laboratories, consultations, procedures	ISS 2001	Number	% Use
890701	Emergency consultation, general medicine	3.8	1	100
890701	Interconsultation by specialized medicine (internal medicine, family medicine or neurology)	5.1	10	100
903426	Glycated hemoglobin	5.9	1	100
903818	Total cholesterol	1.3	1	100
903815	HDL cholesterol	1.7	1	100
903816	LDL cholesterol	1.7	1	100
903868	Triglycerides	1.6	1	100
903841	Glycemia	0.9	7	100
902045	PT	2.3	3	100
902049	PTT	2.8	3	100
903439	Troponin T	11.9	1	100
904902	Thyroid stimulating hormone (TSH)	7.3	1	100
903825	Creatinine in the blood	0.9	2	100
903856	Blood urea nitrogen (BUN)	1.1	2	100
907107	Urinary sediment and density analysis	1.1	2	90
903605	Ionogram (chlorine, sodium, potassium and bicarbonate or calcium)	6.6	3	100
902210	Type IV hemogram	3.3	2	100
902109	Glucose-6-phosphate dehydrogenase, quantitative	8.1	1	20
895101	Electrocardiogram	4.1	1	100
881232	Transthoracic echocardiogram (M-mode and two-dimensional)	24.9	1	100
881233	Echocardiogram, M-mode and two-dimensional with Doppler	39.2	1	100
881235	Transoesophageal echocardiogram	63.7	1	50
871121	Chest X-ray	6.3	1	100
879111	Brain CAT	29.4	1	100
882110	Carotid Doppler test (vertebral arteries and jugular vein)	21.1	1	100
883101	Nuclear magnetic resonance of the brain	80.6	1	100
931000	Complete physical therapy	3.9	7	100
938300	Complete occupational therapy	1.8	5	100
937000	Complete phonoaudiological therapy	1.8	5	100
S41501	Daily enteral or parenteral nutritional management of the hospitalized patient	1.2	3	100
CUPS	Medications		Daily dose	# days	% Patients
	Losartan, taken orally (mg/day)		100	8	90
	Metoprolol tartrate, taken orally (mg/day)		300	8	50
	Atorvastatin, taken orally (mg/day)		80	8	90
	Aspirin, taken orally (mg/day)		100	8	100
	Clopidogrel, taken orally (mg/day)		75	8	100
	Oxygen (L/day)		4320	5	100
	Bisoprolol, taken orally (mg/day)		10	8	30
	Carvedilol, taken orally (mg/day)		25	8	20
	Enalapril, taken orally (mg/day)		40	8	10
	Enoxaparin, subcutaneous (mg/day)		120	8	50
			Ward	ICU
	In what percentage of patients is hospitalization required for care regarding the event?		50%	50%
CUPS		ISS 2001	Ward	ICU
	Of those hospitalized, what is the average duration of their stay (days)?		5	3

Tabla 4S

Costos estimados por evento y por día para hospitalización y complicaciones en USD.

Evento	promedio
Pneumonia/evento	$ 882.0
Delirium/evento	$ 276.5
Infección del tracto urinario /evento	$ 485.9
Infección del sitio quirúrgico /evento	$ 205.6
Úlceras por presión /evento	$ 1,560.2
trombosis venosa profunda /evento	$ 1,519.9
Embolia pulmonar /evenot	$ 3,891.6
Evento cardiovascular /evento	$ 3,186.4
Evento neurológico /evento	$ 986.9
Piso de hospitalización - alta complejidad / dia	$ 22.1
Unidad de cuidados intensivos para adultos / dia	$ 164.5

Los resultados de las variaciones de costos de estancia y complicaciones se encuentran en la Tabla 2. Considerando la duración de estancia y frecuencia de las complicaciones observadas en las instituciones, se estimó una reducción general en los costos de estancia y complicaciones a lo largo de la implementación del programa. La reducción absoluta en costos totales varió entre USD 94 y USD 966. La reducción relativa varió entre -22.0% and -68.3%. Se observaron resultados similares al considerar solo costos de estancia o solo costos de complicaciones, aunque estos últimos fueron generalmente de magnitud mayor

Tabla 2

Costos estimados relacionados con la estancia hospitalaria (en los escenarios de sensibilidad mínimo y máximo), con complicaciones y con estancia más complicaciones (en los escenarios de sensibilidad mínimo y máximo) para cada institución en cada año de implementación. A partir de esta información se presentan las diferencias absolutas y relativas calculadas. NR = no reportado.

Año de implementación	Institución
	A	B
Costo de estancia - escenario de sensibilidad mínimo
Base	$182	$164
1	$173	$139
2	$167	$159
3	NR	$149
4	NR	$122
Variación absoluta	-$15	-$43
Variación relativa	-8.4%	-26.0%
Costo de estancia - escenario de sensibilidad máximo
Base	$1,356	$1,223
1	$1,289	$1,037
2	$1,242	$1,182
3	NR	$1,112
4	NR	$904
Variación absoluta	-$113	-$319
Variación relativa	-8.4%	-26.0%
Costos de complicaciones
Base	$1,089	$263
1	$460	$63
2	$237	$217
3	NR	$240
4	NR	$212
Variación absoluta	-$853	-$51
Variación relativa	-78.3%	-19.4%
Costo estancia más complicaciones - escenario de sensibilidad mínimo
Base	$1,271	$428
1	$633	$203
2	$404	$376
3	NR	$389
4	NR	$334
Variación absoluta	-$868	-$94
Variación relativa	-68.3%	-22.0%
Costo estancia más complicaciones - escenario de sensibilidad máximo
Base	$2,445	$1,487
1	$1,749	$1,100
2	$1,479	$1,400
3	NR	$1,352
4	NR	$1,117
Variación absoluta	-$966	-$370
Variación relativa	-39.5%	-24.9%

Discusión

Este estudio describe la experiencia de dos instituciones de salud colombianas que implementaron programas de adulto mayor fracturado. Este tipo de modelos busca construir programas de atención a pacientes multidisciplinarios e integrales . Una de las prioridades es lograr realizar los procedimientos quirúrgicos en las primeras 48 horas posterior a la fractura. Tiempos más largos se han asociado a mayor estancia hospitalaria, mortalidad y morbilidad . Estas experiencias, junto con otra previamente realizada en Colombia , representan entre los primeros reportes de experiencia con este tipo de modelos en Latinoamérica.

Durante la implementación del modelo, se identificaron varias tendencias al comparar variables en el año base de implementación comparado con el último año disponible. En primer lugar, hubo un incremento en la cantidad de pacientes atendidos, lo cual puede ser relevante en la medida en que significa una ampliación de la capacidad institucional para ofrecer este tipo de servicios. Esto es valioso en pacientes que tienen limitaciones en capacidad en servicios especializados.

Se observó también una reducción en el tiempo de estancia hospitalaria, particularmente posterior a la cirugía, y en la proporción de complicaciones intrahospitalarias. Estas complicaciones son deseables para los pacientes, las instituciones de salud y el sistema de salud en general. En la experiencia previa de implementación , se reportó una reducción en el tiempo de estancia al comparar los primeros dos años de implementación (5.3 días en promedio) y los dos años subsiguientes (3.42 días en promedio). En general, se observa que el tiempo de estancia hospitalaria se reduce a lo largo del programa de adulto mayor fracturado, replicando la dirección de resultados previamente obtenidos en Colombia.

Adicionalmente, se observaron reducciones en desenlaces como reingresos y mortalidad. Las estimaciones de costos construidas a partir de estas reducciones en tiempos de estancia y complicaciones mostraron también reducción de costos a lo largo del programa. En la publicación del programa previamente implementado, se reportó una reducción en mortalidad durante la implementación del programa (año 1: 22.99%, año 2: 16.22%, año 3: 9.09%, año 4: 12.68%) que fue estadísticamente significativa al comparar los primeros dos años con los últimos dos . El programa de adulto mayor fracturado ha mostrado tendencias en la reducción de la mortalidad y los reingresos, que replican resultados de implementaciones previas.

Hay algunos aspectos interesantes para resaltar. En general, ambas instituciones mostraron tendencias similares. Las dos registraron también una reducción en la variabilidad de los tiempos de estancia, indicando posible homogeneización de estos tiempos. Esto puede ser interesante en la medida en que refleje una homogeneización de las necesidades de salud de los pacientes.

Aunque tuvieran tendencias similares, las dos instituciones presentaron algunas diferencias, tanto en las variables observadas en el año base, así como en la magnitud de los cambios vistos durante la implementación. Esto es particularmente evidente en las diferencias en la frecuencia de las complicaciones en las dos instituciones. Este efecto puede deberse a diferencias sistemáticas en las instituciones o el tipo de pacientes atendidos. Una posible explicación para lo observado es que el impacto del programa del adulto mayor no es específico para algún tipo de complicación, sino que afecta las complicaciones en general, mostrando resultados diferentes según el perfil base de la institución. Esta hipótesis podría ser verificada en otro estudio.

En general estos resultados replican los observados en la mortalidad y la estancia en el otro ejemplo de implementación en Colombia, realizado hace más de 10 año en 298 pacientes . Esto sugiere que los programas del adulto mayor fracturado pueden tener resultados similares en diferentes instituciones en Colombia. Replicar la implementación y los resultados del programa podría ser factible en nuestro contexto.

Las tendencias registradas en este estudio son similares a las de otros estudios. Dos estudios muestran implementación de programas similares en Estados Unidos. Ellos encontraron que los tiempos de estancia hospitalaria (entre 4.2 y 4.6 días) y el costo total del evento (USD 15,188) fueron sustancialmente mejores en las cohortes de la implementación respecto a otras cohortes presentadas en la literatura ,. Otro programa de manejo integral implementado en tres instituciones en Estados Unidos mostró reducciones de tiempos de estancia desde 5.6 días en 826 pacientes antes de la implementación a 4.7 días en 2,069 pacientes después de la implementación . Estos resultados son consistentes con las tendencias encontradas en las tres implementaciones reportadas para Colombia.

Nuestro estudio presenta algunas limitaciones derivadas del diseño y la fuente de información. Dada la naturaleza observacional del estudio, no se puede asegurar un control completo de las variables de confusión. Por lo tanto, las variaciones encontradas en los indicadores no se pueden atribuir de manera causal al programa del adulto mayor fracturado. La naturaleza descriptiva implica que las tendencias vistas no tienen necesariamente significancia estadística y los análisis exploratorios son generadores de hipótesis. El uso retrospectivo de información obtenida de forma rutinaria para el cuidado clínico introduce potenciales sesgos de información, particularmente para los desenlaces que ocurren fuera de la institución como la mortalidad al año. Sin embargo, dado que las instituciones usan esta información para proceso de auditoría interna, existen procesos de verificación de la información que mejoran esta situación. Estos aspectos limitan la extrapolación de la información, pero no invalidan los resultados observados.

Conclusiones

El presente estudio describe la experiencia en dos instituciones que implementaron un programa de adulto mayor fracturado en 475 pacientes tratados. Durante los años de implementación, las instituciones mostraron un aumento en el número de pacientes atendidos y en las reducciones en la estancia hospitalaria, las complicaciones, los reingresos y las muertes. El impacto teórico de costos de la estancia y la complicación mostró también una reducción. Estos resultados fueron en general similares en las dos instituciones. Adicionalmente, son similares a los de otra experiencia de implementación previa en Colombia y otros internacionales. Ambos aspectos sugieren que otras instituciones podría replicar la implementación y los resultados del programa a nivel nacional.

1) Why was this study conducted?

To describe the results related to the Geriatric fracture programs implementation in two Colombian institutions to assess reproducibility.

2) What were the most relevant results of the study?

The present study presents the experience of two institutions that implemented the Geriatric fracture programs with increase in the number of patients treated and reductions in the time of hospital stay, the proportion of complications, readmissions, mortality and estimated costs.

3) What do these results contribute?

Both institutions showed positive results from program implementation. These are similar between both institutions and with other published implementations. This could hint that geriatric fracture program may be implemented with reproducible results.

1) ¿Por qué se realizó este estudio?

Describir los resultados relacionados con la implementación de un programa de adulto mayor fracturado en dos instituciones colombianas para evaluar reproducibilidad.

2) ¿Cuáles fueron los resultados más relevantes del estudio?

El estudio presenta la experiencia de dos instituciones que implementaron programas de adulto mayor fracturado con aumentos en las cantidades de pacientes atendidos y reducciones en tiempos de estancia hospitalaria, proporción de complicaciones, readmisiones, mortalidad y costos estimados.

3¿Qué aportan estos resultados?

Ambas instituciones mostraron resultados positivos con la implementación del programa. Estos resultados fueron consistentes entre las dos instituciones evaluadas y con otras implementaciones publicadas. Esto sugiere que el programa de adulto mayor fracturado se puede implementar con resultados positivos reproducibles.