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INTERDISCIPLINARY CARE IN ORTHOGERIATRICS: A GOOD COST‐BENEFIT MODEL OF CARE

2003; Wiley; Volume: 51; Issue: 1 Linguagem: Inglês

10.1034/j.1601-5215.2002.51026.x

1532-5415

Marco Martins Amatuzzi, Clara De Rosa Carelli, Luiz Eugênio Garcez Leme, Fags, Itiro Suzuki,

Esophageal and GI Pathology

To the Editor: De Jonge et al.'s study was interesting and important.1 The literature on hip fracture model of health service is lacking, as De Jonge et al. pointed out. Despite this, the results shown in other articles2–5 and our own experience in Brazil suggest a positive cost-benefit relationship in the interdisciplinary team approach of hip and other fractures in older people.6,7 As with other developing countries, Brazil has had explosive growth in the older population, resulting in public health problems. Data from the past 20 years show that the population aged 60 and older grew from 7.5 million people in 1981 to 13.1 million in 2001, with a projection for more than 35 million people in 2025. Considering only the public health system responsible for 70% of the Brazilian population, the register of 46,930 hospital admissions for hip and femur fractures in 20018 indicates the urgency of developing efficient health structures to assist this population.9 The orthogeriatric group (OG) of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), which has many similarities to the Washington Hospital Center and Johns Hopkins hip fracture unit services, began its activities in 1997 in response to the large number of common geriatric and orthopedic problems in patients admitted to this hospital with high health costs. Since its beginning, the group promoted a strong interdisciplinary and education orientation by working with a multidisciplinary team that includes geriatric, orthopedic, anesthesia, nursing, physiotherapy, social work, nutrition, psychology, occupational therapy, and phonoaudiology professionals. The Orthopedics Institute of HCFMUSP is responsible for the geriatric and orthopedic care for all patients aged 60 and older in the emergency unit, the infirmary, and the pre- and postsurgical care units. It also provides home visits to patients 10 to 14 days after discharge and the training of family caregivers. The education activities of the OG include a discipline of orthogeriatrics (second- and third-year medical student courses) and participation in the teaching of geriatrics and orthopedics (fourth- and sixth-year medical student courses) at the University of São Paulo. During the postgraduate years, the group provides training for residents in geriatrics and orthopedics and focuses research on aging and mobility and other areas. Figure 1 summarizes the flow of OG. Geriatricians and orthopedists see all patients aged 60 and older admitted to the emergency room or for ambulatory care. A practical model of clinical evaluation of orthopedic surgery in older people is used, with a clinical assessment including cardiac risk, mental evaluation for dementia and delirium, electrocardiogram, chest x-ray, biochemical and coagulation tests, and urinalysis and culture. Unstable or old-old patients frequently have a period of semi–intensive unit care, going to the orthogeriatric floor when stable. Geriatricians and orthopedists visited all older patients daily and all other health professionals evaluate them as needed. Flow of patient in orthogeriatric group of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. ICU = intensive care unit. Meetings are held at least once a week to discuss inpatients and home visits and assure an interprofessional assessment of all patients. The team makes every effort to schedule surgery as early as possible to reduce the risks and complications of delay. Physiotherapy begins at once. Preventive intervention for thrombosis begins in admission and is provided for 15 to 30 days postsurgery. The mean time for discharge is 3 to 4 days after surgery. Patients go home or, if necessary, to an intermediary hospital for 10 days of intensive physiotherapeutic care. During hospitalization or after discharge, family caregivers receive training in basic home care of older people. The OG team makes a home visit to the patient 10 to 14 days after discharge, which improves adherence to therapeutic measures and reduces immobilization, falls, fear of falling, and other common problems in the older population. During the 4 years that this program and service have existed, 850 patients have received interdisciplinary care from the OG in the units of the Orthopedic Institute of HCFMUSP, with remarkable results. The hospital mortality rate for hip fractures in older patients in the entire city of São Paulo is approximately 5%; at HCFMUSP, 1 year after initiating the OG team activities (1997–1998), this rate was 3.61%, decreasing to 1.68% in 1998–1999 and 1.40% in 1999–2000. The decrease in the mortality rate itself justifies this model of care, but, in addition to these important results, an increase in patient satisfaction and that of health professionals was observed. Furthermore, this model proved to be an important academic tool for training all health professionals, mainly residents in geriatrics and in orthopedics, and a new and promising field for scientific research for evaluating cost-benefit models of care.