Background: Hip fractures in older adults are associated with considerable morbidity and mortality. A model at a single center, where hip fracture patients are comanaged by geriatricians and orthopedic surgeons, demonstrated decreased LOS, readmission rates, and mortality when compared with national data. This study compares results to a usual-care site.
Study design: Retrospective cohort study.
Setting: Community-based teaching hospital and a tertiary-care hospital in Rochester, N.Y.
Synopsis: Researchers enrolled 314 patients with hip fractures. The 193 patients in the intervention group were comanaged by geriatricians and orthopedic surgeons. The 121 patients in the usual-care group were admitted under the care of orthopedic surgeons, and hospitalists were consulted when deemed necessary. Retrospective chart reviews were performed; complications were defined a priori.
When compared with usual care, patients in the intervention group had significantly shorter times to surgery (24.1 hours vs. 37.4 hours), shorter LOS (4.6 days vs. 8.3 days), fewer complications (30.6% vs. 46.3%), including fewer postoperative infections (2.3% vs. 19.8%), cardiac complications (1.0% vs. 7.4%), cases of thromboembolism (0.5% vs. 5.0%), episodes of bleeding (0% vs. 3.3%), and episodes of hypoxia (6.7% vs. 14.1%). There was no difference in inpatient mortality or 30-day readmission rates.
Further assessment comanagement by hospitalists and comanagement by geriatricians is needed.
Bottom line: Perioperative comanagement of hip-fracture patients by geriatricians and orthopedic surgeons significantly improves short-term outcomes.
Citation: Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a comanaged geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med. 2009;169 (18):1712-1717.
Niacin Is Superior to Ezetimibe in Causing Significant Regression of Carotid Intima-Media Thickness when Combined with a Statin
Clinical question: Is ezetimibe superior to niacin for reducing carotid intima-media thickness (CIMT) in patients with coronary artery disease (CAD) already on statin monotherapy?
Background: Statin montherapy significantly reduces the risk of cardiovascular events, and further lowering of this risk can be achieved by reducing the LDL, using statin intensification, or adding ezetimibe, or by raising the HDL levels by adding niacin therapy. This comparative-effectiveness trial compared the efficacy of these two approaches.
Study design: Prospective, randomized, parallel-group, open-label study.
Setting: Tertiary-care military medical center, and private tertiary-care hospital in Washington, D.C.
Synopsis: Three hundred sixty-three patients with known CAD or CAD equivalent were enrolled, and all of the patients were maintained on statin therapy with LDL <100 and HDL <50. Patients were randomized to ezetimibe 10 mg/day or niacin, starting at 500 mg at bedtime and titrated to 2 g/day. Primary endpoint was a mean change in CIMT after 14 months. Secondary endpoints were change in lipid levels, composite of major cardiovascular events, drug discontinuation, and quality of life.
The trial was terminated early after 208 patients had completed the trial. Although ezetimibe showed greater reduction of LDL, niacin showed significantly greater reduction in the progression of CIMT. Patients receiving niacin experienced fewer cardiovascular events (1% vs. 5%) but had higher rates of withdrawal (15% vs. 9%) due to flushing.
Limitations of the study are small sample size, short follow-up period, and use of CIMT as a surrogate marker for clinical endpoint.