Medical and economic consequences of perioperative complications in older hip fracture patients

Association between operative duration and adverse outcomes after hip fracture surgery: A NSQIP matched cohort study

BACKGROUND

Prolonged operative duration is an independent risk factor for surgical complications in numerous subspecialties. However, associations between adverse events and operative duration of hip fracture fixation in older adults have not been well-quantified. This study aims to determine if prolonged operative duration of hip fracture surgery is related to adverse outcomes. We hypothesized that patients with high operative durations experience greater rates of 30-day complications.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify older adults (55 years and above) who underwent hip fracture fixation between 2015-2019. Prolonged operative duration was defined as >75th percentile, and cases were matched using propensity scores based on demographic, surgical, and comorbidity factors. Univariate differences in adverse events (including readmission, reoperation, mortality, and organ-system complications) were analyzed. Multivariable mixed-effects logistic regression analyses were completed for statistically significant events.

RESULTS

A total of 8827 case-control pairs were identified for comparison. Rates of superficial surgical site infection (SSI) (p= 0.022), any SSI (p= 0.032), and any complication (p < 0.001) were elevated in those with prolonged surgical duration in univariate analyses. In multivariable models, prolonged operative time was associated with superficial SSI (OR 1.50, p= 0.019), any SSI (OR 1.35; p= 0.029) and any complication (OR 1.58; p < 0.001). In subgroup analyses, all findings persisted for IMN with operative time associated with superficial SSI (OR 1.98, p= 0.012), any SSI (OR 1.71; p= 0.019), and any complication (OR 1.84; p < 0.001). Operative time was associated only with any complication for hemiarthroplasty/internal fixation and sliding hip screw (OR 1.27 and 1.89, respectively; p < 0.001).

CONCLUSION

Our study demonstrates that duration of surgery is an independent risk factor for superficial SSI, any SSI, and any complication. Notably, our findings suggest that high operative durations may be most concerning for SSIs in IMN fixation, which is currently the most common choice for hip fracture fixation in the US. However, the rate of any complication is significantly elevated when surgical duration is prolonged, regardless of surgery type.

Glucose-albumin ratio (GAR) as a novel biomarker of postoperative urinary tract infection in elderly hip fracture patients

Purpose

Postoperative urinary tract infections (UTIs) worsen the prognosis of elderly patients with hip fractures. This study aimed to assess the predictive ability of blood-based biomarkers, specifically the glucose-albumin ratio (GAR), in predicting postoperative UTIs.

Methods

A retrospective observational study of 1,231 patients from a Level I trauma center was conducted. We evaluated the prognostic and predictive value of 15 biomarkers, including the glucose-albumin ratio, in elderly patients with hip fractures. The primary outcome measure was the incidence of postoperative UTIs.

Results

The glucose to albumin ratio transformed into GAR was superior to any other biomarker in predicting postoperative UTIs in elderly hip fracture patients (AUC = 0.756, p < 0.001). Elevated GAR (using the best cut-off value of 0.18) was independently associated with postoperative UTIs (OR 3.20, 95% CI 2.23-4.58). Further analysis dividing GAR levels into four groups according to quartiles showed that compared to patients with GAR levels of Q1 (< 0.14), GAR levels of Q2 (0.14-0.17; OR 2.11, 95% CI 1.07-4.15), Q3 (0.17-0.21; OR 3.36, 95% CI 1.74-6.52) and Q4 (> 0.21; OR 7.55, 95% CI 3.84-14.83) patients had significantly higher odds of UTIs.

Conclusion

GAR holds potential as a novel biomarker for predicting postoperative UTIs in elderly patients with hip fractures.

Postfracture survival in a population-based study of adults aged ≥66 yr: a call to action at hospital discharge

Postfracture survival rates provide prognostic information but are rarely reported along with other mortality outcomes in adults aged ≥50 yr. The timing of survival change following a fracture also needs to be further elucidated. This population-based, matched-cohort, retrospective database study examined 98 474 patients (73% women) aged ≥66 yr with an index fracture occurring at an osteoporotic site (hip, clinical vertebral, proximal non-hip non-vertebral [pNHNV], and distal non-hip non-vertebral [dNHNV]) from 2011 to 2015, who were matched (1:1) to nonfracture individuals based on sex, age, and comorbidities. All-cause 1- and 5-yr overall survival and relative survival ratios (RSRs) were assessed, and time trends in survival changes were characterized starting immediately after a fracture. In both sexes, overall survival was markedly decreased over 6 yr of follow-up after hip, vertebral, and pNHNV fractures, and as expected, worse survival rates were observed in older patients and males. The lowest 5-yr RSRs were observed after hip fractures in males (66-85 yr, 51.9%-63.9%; ≥86 yr, 34.5%), followed by vertebral fractures in males (66-85 yr, 53.2%-69.4%; ≥86 yr, 35.5%), and hip fractures in females (66-85 yr, 69.8%-79.0%; ≥86 yr, 52.8%). Although RSRs did not decrease as markedly after dNHNV fractures in younger patients, relatively low 5-yr RSRs were observed in females (75.9%) and males (69.5%) aged ≥86 yr. The greatest reduction in survival occurred within the initial month after hip, vertebral, and pNHNV fractures, indicating a high relative impact of short-term factors, with survival-reduction effects persisting over time. Therefore, the most critical period for implementing interventions aimed at improving post-fracture prognosis appears to be immediately after a fracture; however, considering the immediate need for introducing such interventions, primary fracture prevention is also crucial to prevent the occurrence of the initial fracture in high-risk patients.

Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) to predict postoperative pneumonia in elderly hip fracture patients

PURPOSE

Investigate the association between the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) about the presence of postoperative pneumonia (POP) in geriatric patients with hip fractures. Compare the predictive value of these biomarkers for POP and assess their potential for early detection of POP.

METHODS

We retrospectively included elderly patients with hip fractures who underwent surgical treatment at our institution. POP was diagnosed according to the guidelines provided by the American Thoracic Society. We collected neutrophil, lymphocyte, and platelet counts upon admission to calculate the NLR, PLR, and SII. Receiver operating characteristic curves were utilized to establish the optimal cutoff values for each index. Multivariate logistic regression analysis and propensity score matching analysis were utilized to assess the independent association between each index and POP after adjusting for demographic, comorbidity, and surgery-related variables.

RESULTS

The study included a total of 1199 patients, among whom 111 cases (9.26%) developed POP. NLR exhibited the highest predictive value for POP in elderly patients with hip fractures compared to PLR and SII (AUC = 0.648, 95% CI 0.594-0.701). A high NLR, using the optimal cutoff value of 5.84, was significantly associated with an increased incidence of POP (OR = 2.24, 95% CI 1.43-3.51). This finding remained statistically significant even after propensity score matching (OR = 2.04, 95% CI 1.31-3.20).

CONCLUSIONS

Among the three inflammatory/immune markers considered, the NLR demonstrates the highest reliability as a predictor for POP in elderly patients with hip fractures. Therefore, it serves as a valuable tool for early identification.

D-dimer-albumin ratio (DAR) as a new biomarker for predicting preoperative deep vein thrombosis after geriatric hip fracture patients

PURPOSE

Hip fractures in the elderly are complicated by preoperative deep vein thrombosis (DVT). The objective of this study is to determine the usefulness of blood-based biomarkers, particularly the D-dimer-albumin ratio (DAR), in predicting preoperative DVT.

METHODS

A retrospective observational study was carried out on 1149 patients from a single hospital, and subsequently validated on an additional 626 patients from a separate hospital. The aim was to evaluate the prognostic and predictive value of 10 biomarkers, with a specific emphasis on DAR, in both cohorts. The primary measure of interest was the occurrence of preoperative DVT.

RESULTS

The ratio of D-dimer to albumin demonstrated superior predictive capability for preoperative DVT in older patients with hip fractures compared to other biomarkers (AUC = 0.677). Using the optimal cutoff point of 0.24, high DAR was significantly associated with preoperative DVT (OR 3.45, 95% CI 2.00-5.95). Notably, all the DAR definitions detailed above were successfully validated in an external, independent cohort.

CONCLUSIONS

DAR may be a valuable biomarker for predicting preoperative DVT in elderly patients with hip fractures.

Adaptive Risk Modeling: Improving Risk Assessment of Geriatric Hip Fracture Patients Throughout their Hospitalization

INTRODUCTION

The purpose of this study was twofold: 1. To assess how adaptive modeling, accounting for development of inpatient complications, affects the predictive capacity of the risk tool to predict inpatient mortality for a cohort of geriatric hip fracture patients. 2. To compare how risk triaging of secondary outcomes is affected by adaptive modeling. We hypothesize that adaptive modeling will improve the predictive capacity of the model and improve the ability to risk triage secondary outcomes.

METHODS

Between October 2014-August 2021, 2421 patients >55 years old treated for hip fracture obtained through low-energy mechanisms were analyzed for demographics, injury details and hospital quality measures. The baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for hip fractures (STTGMA_HIP) was calculated in the emergency department setting. A new mortality risk score (STTGMA_{HIP_ADPTV}) was created including inpatient complications. Each models' predictive ability was compared using DeLong's test. Patients were grouped into quartiles based on their respective STTGMA_{HIP_ADPTV} and comparative analyses were conducted.

RESULTS

AUROC comparison demonstrated STTGMA_{HIP_ADPTV} significantly improved the predictive capacity for inpatient mortality compared to STTGMA_HIP (p < 0.01). STTGMA_{HIP_ADPTV} correctly triaged 80% and 64% of high-risk patients with inpatient and 30-day mortality compared to 64% and 57% for STTGMA_HIP. STTGMA_{HIP_ADPTV} quartile stratification demonstrated that the highest risk cohort had the worst mortality outcomes and hospital quality measures. Patients whose risk classification changed from minimal risk using STTGMA_HIP to high risk using STTGMA_{HIP_ADPTV} experienced the highest rate of mortality, readmission, ICU admission, with longer lengths of stay and higher hospital costs.

DISCUSSION

Adaptive modeling accounting for inpatient complications improves the predictive capacity and risk triaging of the STTGMA_HIP tool. Real-time modulation of a patient's mortality risk profile can inform their requisite level of medical management to improve the quality and value of care as patients progress through their index hospitalization. STTGMA_{HIP_ADPTV} can better identify patients at risk for developing complications whose mortality and readmission risk profile increase significantly, allowing their new risk classification to inform higher levels of care. While this may increase length of stay and total costs, it may improve outcomes in both the short and long-term.

LEVEL OF EVIDENCE

III.

Data-driven development of the nationwide hip fracture registry in the Netherlands

Additional variables for a nationwide hip fracture registry must be carefully chosen to prevent unnecessary registry load. A registry pilot in seven hospitals resulted in recommending polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for development of quality indicators.

PURPOSE

Clinical registries help improve the quality of care but come at the cost of registration load. Datasets should therefore be as compact as possible; however, variables are usually chosen empirically. This study aims to evaluate potential variables with additional value to improve the nationwide Dutch Hip Fracture Audit (DHFA).

METHODS

An expert panel selected eleven new variables for the DHFA, which were tested in a prospective cohort of all hip fracture patients treated in 2018 and 2019 in seven pilot hospitals participating in the DHFA. The association of these eleven variables with complications, mortality, and functional outcomes at 3 months was analyzed using multivariable logistic regression analysis. Based on the results, a proposal for variables to add to the dataset of the DHFA was made.

RESULTS

In 4.904 analyzed patients, three tested variables had significant associations (p < 0.01) with outcomes: polypharmacy with complications (aOR 1.34), serum hemoglobin at admittance with complications (aOR 0.63) and mortality (aOR for 30-day mortality 0.78), and a set of questions screening for risk of delirium with complications in general (aOR 1.55), e.g., delirium (aOR 2.98), and decreased functional scores at three months (aOR 1.98).

CONCLUSION

This study assesses potential new variables for a hip fracture registry. Based on the results of this study, we recommend polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for the development of quality indicators. Incorporating these variables in the DHFA dataset may contribute to better and clinically relevant quality indicators.

The Financial Burden of Delayed Hip Fracture Surgery: A Single-Center Experience

Fragility hip fractures have become a worldwide epidemic with serious socioeconomic implications. The projected number of hip fractures by 2050 is estimated to reach 4.5 million cases. The aim of this study was to calculate the in-hospital financial burden on public health insurance funds related to the delayed treatment of hip fractures. This research took place in a tertiary university hospital that is a major trauma center in Thessaloniki, which is second largest city in Greece . A retrospective search was conducted in the electronic hospital database for patients older than 65 years, with low energy hip fractures that were surgically treated between November 18, 2018, and October 20, 2019. Age, length of stay (LOS), days to surgery, postoperative LOS, anticoagulation medication, major and minor complications, and the reimbursement that the hospital received from public health insurance funds were recorded. Cost deviation from the standard tariff for the treatment of these fractures was also calculated. Of a total of 145 patients, 32.4% had early surgery as opposed to 67.6% who were operated after 48 hours from admission. The excess financial burden from the baseline reimbursement for those operated within 48 hours from admission was 4,074.64€, while for the group that received delayed surgery it was 45,654.14€. Patients under any form of anticoagulation therapy were seven times more probable to have delayed surgery [OR=6.8; 95% confidence interval (CI): 2.97-18.18; p<0.01] and were 3.5 times more probable to have minor complications (OR: 3.6; 95% CI: 1.19-11.23; p<0.017). Early surgery is beneficial to the patient and reduces the economic burden on healthcare public funds. Every effort should be made to manage these patients in a timely manner.