Comorbidity and the association with 1-year mortality in hip fracture patients: can the ASA score and the Charlson Comorbidity Index be used interchangeably?

Risk factors associated with 1-year mortality after osteoporotic hip fracture in Hawai'i: higher mortality risk among Native Hawaiians and other Pacific Islanders

We studied factors affecting osteoporotic hip fracture mortality in Hawai'i, a region with unique geography and racial composition. Men, older adults, higher ASA score, lower BMI, and NHPI race were associated with higher mortality. This is the first study demonstrating increased mortality risk after hip fracture in NHPI patients.

PURPOSE

To estimate mortality rates and identify specific risk factors associated with 1-year mortality after osteoporotic hip fracture in Hawai'i.

METHODS

A retrospective review of adults (≥ 50 years) hospitalized with an osteoporotic hip fracture at a large multicenter healthcare system in Hawai'i from 2011 to 2019. The Kaplan-Meier curves and log-rank tests examined survival probability by sex, age group, race/ethnicity, primary insurance, body mass index (BMI), and American Society of Anesthesiologists (ASA) physical status classification. After accounting for potential confounders, adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were obtained from Cox proportional hazards regression models.

RESULTS

We identified 1755 cases of osteoporotic hip fracture. The cumulative mortality rate 1 year after fracture was 14.4%. Older age (aHR 3.50; 95% CI 2.13-5.76 for ≥ 90 vs 50-69), higher ASA score (aHR 5.21; 95% CI 3.09-8.77 for ASA 4-5 vs 1-2), and Native Hawaiian/Pacific Islander (NHPI) race (aHR 1.84; 95% CI 1.10-3.07 vs. White) were independently associated with higher mortality risk. Female sex (aHR 0.64; 95% CI 0.49-0.84 vs male sex) and higher BMI (aHR 0.35; 95% CI 0.18-0.68 for obese vs underweight) were associated with lower mortality risk.

CONCLUSION

In our study, men, older adults, higher ASA score, lower BMI, and NHPI race were associated with significantly higher mortality risk after osteoporotic hip fracture. NHPIs are an especially vulnerable group and comprise a significant portion of Hawai'i's population. Further research is needed to address the causes of higher mortality and interventions to reduce hip fractures and associated mortality.

Hip Fracture Patterns, Hospital Course, and Mortality Differ Between Males and Females

Introduction

The purpose of this study was to describe how hip fractures differentially affect male and female patients regarding fracture pattern, hospital course, and postoperative course.

Materials and Methods

This retrospective case series was performed in a metropolitan healthcare system involving 2996 hip fracture patients >59 years old who underwent surgical management (eg, intramedullary nail, hemiarthroplasty, percutaneous pinning, etc.). Male patients were matched to female patients using 1:2 nearest neighbor matching on the basis of age and Charlson Comorbidity Index. Outcomes of interest included AO/OTA fracture classification, 30- and 90-day readmission, and 30-day and 1-year mortality rates.

Results

The cohort was predominantly female (64.5%). Female patients were more likely to sustain a type 31A fracture compared to males (P = .016). The average CCI was higher for males vs females (3.0 ± 2.5 vs 2.6 ± 2.3, P < .001). Males were more likely to be readmitted at 30 (P < .001) and 90 (P = .015) days after discharge. The 30-day mortality was higher for males vs females (6.6% vs 4.5%, P = .015). Approximately 19.9% of male patients vs 15.1% of females died within a year of surgery (P < .001). The average time to surgery was longer for males vs females (23.8 ± 18.8 vs 22.5 ± 21.9 h, P = .048). Males were more likely to die within a year if they underwent surgery >24 h after admission (P = .029).

Discussion

Hip fractures have different implications for male and female patients. With age, the incidence of IT fractures increased in females, while it decreased in males. On average, males with hip fractures are sicker than females, which likely contributes to the longer time to surgery as well as increased readmission and mortality rates seen in males.

Conclusions

Male and female hip fracture patients are not similar in baseline health status, fracture pattern, or postoperative morbidity and mortality. Orthogeriatricians and other providers that care for this patient population should be aware of these differences when implementing treatment strategies to optimize the recovery of their patients, and while educating patients and their families about postoperative expectations.

Evaluating the accuracy of ChatGPT-4 in predicting ASA scores: A prospective multicentric study ChatGPT-4 in ASA score prediction

BACKGROUND

This study investigates the potential of ChatGPT-4, developed by OpenAI, in enhancing medical decision-making processes, particularly in preoperative assessments using the American Society of Anesthesiologists (ASA) scoring system. The ASA score, a critical tool in evaluating patients' health status and anesthesia risks before surgery, categorizes patients from I to VI based on their overall health and risk factors. Despite its widespread use, determining accurate ASA scores remains a subjective process that may benefit from AI-supported assessments. This research aims to evaluate ChatGPT-4's capability to predict ASA scores accurately compared to expert anesthesiologists' assessments.

METHODS

In this prospective multicentric study, ethical board approval was obtained, and the study was registered with clinicaltrials.gov (NCT06321445). We included 2851 patients from anesthesiology outpatient clinics, spanning neonates to all age groups and genders, with ASA scores between I-IV. Exclusion criteria were set for ASA V and VI scores, emergency operations, and insufficient information for ASA score determination. Data on patients' demographics, health conditions, and ASA scores by anesthesiologists were collected and anonymized. ChatGPT-4 was then tasked with assigning ASA scores based on the standardized patient data.

RESULTS

Our results indicate a high level of concordance between ChatGPT-4 predictions and anesthesiologists' evaluations, with Cohen's kappa analysis showing a kappa value of 0.858 (p = 0.000). While the model demonstrated over 90% accuracy in predicting ASA scores I to III, it showed a notable variance in ASA IV scores, suggesting a potential limitation in assessing patients with more complex health conditions.

DISCUSSION

The findings suggest that ChatGPT-4 can significantly contribute to the medical field by supporting anesthesiologists in preoperative assessments. This study not only demonstrates ChatGPT-4's efficacy in medical data analysis and decision-making but also opens new avenues for AI applications in healthcare, particularly in enhancing patient safety and optimizing surgical outcomes. Further research is needed to refine AI models for complex case assessments and integrate them seamlessly into clinical workflows.

Effects of body mass index on mortality in elderly patients with hip fractures

Hip fractures remain a substantial health concern, particularly among elderly individuals with osteoporosis, leading to high global mortality rates. This study aimed to analyze the association between body mass index (BMI) and postoperative mortality in patients who underwent surgery for hip fractures. A total of 680 patients treated at a single institution between January 2018 and December 2022 were included. Factors such as age, BMI, sex, Charlson Comorbidity Index (CCI), preoperative hemoglobin levels, American Society of Anesthesiologists score, anesthesia method, duration of surgery, and time from injury to surgery were assessed. Underweight status, male sex, higher CCI, and general anesthesia were significantly associated with 1-year and in-hospital mortality. Notably, underweight individuals exhibited a higher risk of mortality than normal-weight individuals, and female patients had lower mortality rates. This study underscores the importance of considering BMI, along with other demographic and clinical factors, in predicting postoperative mortality among patients with hip fractures, aiding the development of tailored management strategies to improve outcomes and reduce complications in this vulnerable patient population.

Associated factors of stress, urgency, and mixed urinary incontinence in a geriatric outpatient assessment of older women with hip fracture

PURPOSE

Urinary incontinence (UI) is known to be common among older female hip fracture patients. Little is known about different subtypes of UI among these patients. Our aim was to identify factors associated with subtypes of UI in a cross-sectional design.

METHODS

1,675 female patients aged ≥ 65 and treated for their first hip fracture in Seinäjoki Central Hospital, Finland, during 2007-2019, were included in a prospective cohort study. Of these, 1,106 underwent comprehensive geriatric assessment (CGA), including questions on continence, at our geriatric outpatient clinic 6 month post-fracture. A multivariable-adjusted multinomial logistic regression model was used to examine factors associated with UI subtypes.

RESULTS

Of the 779 patients included, 360 (46%) were continent and 419 (54%) had UI 6-month post-fracture. Of the women with UI, 117 (28%) had stress UI, 183 (44%) had urgency UI and 119 (28%) had mixed UI, respectively. Mean age of the patients was 82 ± 6,91. In multivariable analysis, depressive mood and poor mobility and functional ability were independently associated with stress UI. Fecal incontinence (FI) and Body Mass Index (BMI) over 28 were independently associated with urgency UI. Mixed UI shared the aforementioned factors with stress and urgency UI and was independently associated with constipation.

CONCLUSIONS

Mixed UI was associated with most factors, of which depressive mood and impaired mobility and poor functional ability were shared with stress UI, and FI and higher BMI with urgency UI. CGA is key in assessing UI in older hip fracture patients, regardless of subtype.

Can we predict 1-year functional outcomes and mortality following hip fracture in middle-aged and geriatric patients at time of admission?

This study's purpose is to determine if patients treated for hip fracture at highest risk for poor functional outcomes, shorter time to death, and death within 1-year can be predicted at the time of admission. We hypothesized that the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool can be used to predict risk of these variables. Between February 2019-July 2020, 544 patients ≥ 55-years-old were treated for hip fracture [AO/OTA 31A/B, 32A/C]. Each patient's demographics, functional status, and injury details were used to calculate their respective risk (STTGMA) score at time of admission. Patients were divided into risk quartiles by STTGMA score. Patients were contacted by phone to complete EuroQol-5 Dimension (EQ5D-3L) questionnaires on functional status. Comparative analyses were conducted on outcomes and EQ5D-3L questionnaire results. 439 patients (80.7%) had at least 1-year follow-up. 82 patients (18.7%) died within 1-year after hospitalization. Mean STTGMA score was 1.67% ± 4.49%. The highest-risk cohort experienced a 42x (p < 0.01) and 2.5x (p = 0.01) increased rate of 1-year mortality compared to the minimal- and low-risk groups respectively. The highest-risk cohort had the shortest time to death (p = 0.015). The highest-risk cohort had the lowest EQ5D index (p < 0.01) and VAS scores (p < 0.01) along with the highest rate of 30 day readmission (p < 0.01) and the longest length of stay (p < 0.01). The STTGMA tool provides important prognostic information for middle-aged and geriatric hip fracture patients that can help modulate care levels. This information is useful when counseling patients, their families, and caregivers on expected outcomes.

Improved outcomes for spinal versus general anesthesia for hip fracture surgery: a retrospective cohort study of the National Surgical Quality Improvement Program

BACKGROUND

There is a lack of consensus in the literature as to whether anesthetic modality influences perioperative complications in hip fracture surgery. The aim of the present study was to assess the effect of spinal anesthesia compared with general anesthesia on postoperative morbidity and mortality in patients who underwent hip fracture surgery using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

METHODS

We used the ACS NSQIP to identify patients aged 50 and older who received either spinal or general anesthesia for hip fracture surgery from 2016 to 2019. Propensity-score matching was performed to control for clinically relevant covariates. The primary outcome of interest was the combined incidence of stroke, myocardial infarction (MI) or death within 30 days. Secondary outcomes included 30-day mortality, hospital length of stay and operative time.

RESULTS

Among the 40 527 patients aged 50 and over who received either spinal or general anesthesia for hip fracture surgery from 2016 to 2019, 7358 spinal anesthesia cases were matched to general anesthesia cases. General anesthesia was associated with a higher incidence of combined 30-day stroke, MI or death compared with spinal anesthesia (OR 1.219 (95% CI 1.076 to 1.381); p=0.002). General anesthesia was also associated with a higher frequency of 30-day mortality (OR 1.276 (95% CI 1.099 to 1.481); p=0.001) and longer operative time (64.73 vs 60.28 min; p<0.001). Spinal anesthesia had a longer average hospital length of stay (6.29 vs 5.73 days; p=0.001).

CONCLUSION

Our propensity-matched analysis suggests that spinal anesthesia as compared with general anesthesia is associated with lower postoperative morbidity and mortality in patients undergoing hip fracture surgery.

Stray energy injury during robotic versus laparoscopic inguinal hernia repair: a randomized controlled trial

BACKGROUND

Stray energy transfer from monopolar instruments during laparoscopic surgery is a recognized cause of potentially catastrophic complications. There are limited data on stray energy injuries in robotic surgery. We sought to characterize stray energy injury in the form of superficial burns to the skin surrounding laparoscopic and robotic trocar sites. Our hypothesis was that stray energy burns will occur at all laparoscopic and robotic port sites.

METHODS

We conducted a prospective, randomized controlled trial of patients undergoing elective unilateral inguinal hernia repair at a VAMC over a 4-year period. Surgery was performed via transabdominal preperitoneal approach either laparoscopic-assisted (TAPP) or robotic-assisted (rTAPP). A monopolar scissor was used to deliver energy at 30W coagulation for all cases. At completion of the procedure, skin biopsies were taken from all the port sites. A picro-Sirius red stain was utilized to identify thermal injury by a blinded pathologist.

RESULTS

Over half (54%, 59/108) of all samples demonstrated thermal injury to the skin. In the laparoscopic group, 49% (25/51) samples showed thermal injury vs. 60% (34/57) in the robotic group (p = 0.548). The camera port was the most frequently involved with 68% (13/19) rTAPP samples showing injury vs. 47% (8/17) in the TAPP group (p = 0.503). There was no difference in the rate of injury at the working port site (rTAPP 53%, 10/19 vs. TAPP 47%, 8/17; p = 0.991) or the assistant port site (rTAPP 58%, 11/19 vs. TAPP 53%, 9/17; p = 0.873).

CONCLUSIONS

Stray energy causes thermal injury to the skin at port sites in the majority robotic laparoscopic TAPP inguinal hernia repairs. There is no difference in stray energy transfer between the laparoscopic and robotic platform. This is the first study to confirm in-vivo transfer of stray energy during robotic surgical procedures. More study is needed to determine the clinical significance of these thermal injuries.

Clinical data or scoring system for predicting mortality in elderly patients with hip fracture: A prospective study

INTRODUCTION

Hip fracture in elderly individuals is frequent and is related to a high rate of mortality. Finding the best predictor of death will help to develop better patient care. Aim - To analyze the reliability of the clinical data and assessment scores to predict mortality in acute hip fracture in elderly patients.

PATIENT AND METHODS

Prospective data were collected from all patients > 65 years with acute hip fracture from May to October 2020. The clinical data collected were age, sex, comorbidities, medication, type of fracture and presence of delirium. The assessment scores were ASA, Lee, ACP and Charlson.

RESULTS

The statistically significant results were age > 80 years (OR 1.121 IC95% [1.028-1.221] p = 0.0101) and number of medications (OR5.991 95% CI [2.422-14.823] p <0.001). Three scores showed a correlation with mortality: ASA score (p = 0.017), Lee score (p = 0.024) and ACP score (p = 0.013). The Charlson Comorbidity Index did not correlate with mortality (p = 0.172).

CONCLUSION

To stratify the risk of death, both clinical data and scores should be used. The best clinical indicators are age and number of medications, and the scores are ASA, Lee and ACP.

Comorbidity and risk of infection among patients with hip fracture: a Danish population-based cohort study

Impact of comorbidity on infection risk among hip fracture patients is unclear. We found high incidence of infection. Comorbidity was an important risk factor for infection up to 1 year after surgery. Results indicates a need for additional investment in pre- and postoperative programs that assist patients with high comorbidity.

PURPOSE

Comorbidity level and incidence of infection have increased among older patients with hip fracture. The impact of comorbidity on infection risk is unclear. We conducted a cohort study examining the absolute and relative risks of infection in relation to comorbidity level among hip fracture patients.

METHODS

Utilizing Danish population-based medical registries, we identified 92,600 patients aged ≥ 65 years undergoing hip fracture surgery between 2004 and 2018. Comorbidity was categorized by Charlson comorbidity index scores (CCI): none (CCI = 0), moderate (CCI = 1-2), or severe (CCI ≥ 3). Primary outcome was any hospital-treated infection. Secondary outcomes were hospital-treated pneumonia, urinary tract infection, sepsis, reoperation due to surgical-site infection (SSI), and a composite of any hospital- or community-treated infection. We calculated cumulative incidence and hazard ratios (aHRs) adjusted for age, sex, and surgery year, including 95% confidence intervals (CIs).

RESULTS

Prevalence of moderate and severe comorbidity was 40% and 19%, respectively. Incidence of any hospital-treated infection increased with comorbidity level within 0-30 days (none 13% vs. severe 20%) and 0-365 days (none 22% vs. 37% severe). Patients with moderate and severe comorbidity, compared to no comorbidity, had aHRs of 1.3 (CI: 1.3-1.4) and 1.6 (CI: 1.5-1.7) within 0-30 days, and 1.4 (CI: 1.4-1.5) and 1.9 (CI: 1.9-2.0) within 0-365, respectively. Highest incidence was observed for any hospital- or community-treated infection (severe 72%) within 0-365 days. Highest aHR was observed for sepsis within 0-365 days (severe vs. none: 2.7 (CI: 2.4-2.9)).

CONCLUSION

Comorbidity is an important risk factor for infection up to 1 year after hip fracture surgery.

Comparison of different prognostic scores in estimating short- and long-term mortality in COVID-19 patients above 60 years old in a university hospital in Belgium

BACKGROUND AND OBJECTIVES

Multiple scoring systems were used for risk stratification in COVID-19 patients. The objective was to determine among 6 scores which performed the best in predicting short-and long-term mortality in hospitalized COVID-19 patients ≥ 60 years.

METHODS

An observational, retrospective cohort study conducted between 21/10/2020 and 20/01/2021. 6 scores were calculated (Clinical Frailty Scale (CFS), Charlson Comorbidity Index (CCI), 4C Mortality Score (4CMS), NEWS score (NEWS), quick-SOFA score (qSOFA), and Quick COVID-19 Severity Index (qCSI)). We included unvaccinated hospitalized patients with COVID-19 ≥ 60 years old in Brugmann hospital, detected by PCR and/or suggestive CT thorax images. Old and nosocomial infections, and patients admitted immediately at the intensive care unit were excluded.

RESULTS

199 patients were included, mean age was 76.2 years (60-99). 47.2% were female. 56 patients (28%) died within 1 year after the first day of hospitalization. The 4CMS predicted the best intrahospital, 30 days and 6 months mortality, with area under the ROC curve (AUROC) 0.695 (0.58-0.81), 0.76 (0.65-0.86) and 0.72 (0.63-0.82) respectively. The CCI came right after with respectively AUROC of 0.69 (0.59-0.79), 0.74 (0.65-0.83) and 0.71 (0.64-0.8). To predict mortality at 12 months after hospitalization, the CCI had the highest AUROC with 0.77 (0.69-0.85), before the 4CMS with 0.69 (0.60-0.79).

DISCUSSION

Among 6 scores, the 4CMS was the best to predict intrahospital, 30-day and 6-month mortality. To predict mortality at 12 months, CCI had the best performance before 4CMS. This reflects the importance of considering comorbidities for short- and long-term mortality after COVID 19.

REGISTRATION

This study was approved by the ethical committee of Brugmann University Hospital (reference CE 2020/228).

Predictors of one-year mortality following hip fracture surgery in elderly

Background

Understanding mortality risk factors is critical to reducing mortality among elderly hip fracture patients. To investigate the effects of admission and post-operative levels of distribution width of red blood cells (RDW), albumin, and RDW/albumin (RA) ratio on predicting 1-year mortality following hip fracture surgery.

Methods

A retrospective study was conducted on 275 elderly patients who underwent hip fracture surgery in a tertiary hospital between January 2018 and January 2022. Deaths within one year of hip fracture were defined as the deceased group. The survivors were defined as those who survived for at least one year. The relationship between admission and post-operative levels of RDW, albumin, RA, and mortality within one year after hip surgery was assessed statistically, including binary logistic regression analysis. The study also assessed other factors related to mortality.

Results

One-year mortality was 34.7%. There was a 3.03-year (95% CI [1.32-4.75]) difference between the deceased (79.55 ± 8.36 years) and survivors (82.58 ± 7.41 years) (p < 0.001). In the deceased group, the mean hemoglobin (HGB) values at admission (p = 0.022) and post-operative (p = 0.04) were significantly lower. RDW values at admission (p = 0.001) and post-op (p = 0.001) were significantly lower in the survivor group. The mean albumin values at admission (p < 0.001) and post-operative (p < 0.001) in the survivor group were significantly higher than in the deceased group. A significant difference was found between the survivor group and the deceased group in terms of mean RA ratio at admission and post-operative (p < 0.001). Based on binary logistic regression analysis, presence of chronic obstructive pulmonary disease (COPD) (OR 3.73, 95% CI [1.8-7.76]), RDW (OR 1.78, 95% CI [1.48-2.14]), and albumin (OR 0.81, 95% CI [0.75-0.87]), values at admission were found to be independent predictors of 1-year mortality in elderly patients with hip fracture.

Conclusion

Based on this study, presence of COPD, higher RDW, and lower albumin levels at admission were independent predictors of 1-year mortality following hip fracture surgery in the elderly.

Recent COVID-19 infection is associated with increased mortality in the ambulatory surgery population

BACKGROUND

The effect of COVID-19 infection on post-operative mortality and the optimal timing to perform ambulatory surgery from diagnosis date remains unclear in this population. Our study was to determine whether a history of COVID-19 diagnosis leads to a higher risk of all-cause mortality following ambulatory surgery.

METHODS

This cohort constitutes retrospective data obtained from the Optum dataset containing 44,976 US adults who were tested for COVID-19 up to 6 months before surgery and underwent ambulatory surgery between March 2020 to March 2021. The primary outcome was the risk of all-cause mortality between the COVID-19 positive and negative patients grouped according to the time interval from COVID-19 testing to ambulatory surgery, called the Testing to Surgery Interval Mortality (TSIM) of up to 6 months. Secondary outcome included determining all-cause mortality (TSIM) in time intervals of 0-15 days, 16-30 days, 31-45 days, and 46-180 days in COVID-19 positive and negative patients.

RESULTS

44,934 patients (4297 COVID-19 positive, 40,637 COVID-19 negative) were included in our analysis. COVID-19 positive patients undergoing ambulatory surgery had higher risk of all-cause mortality compared to COVID-19 negative patients (OR = 2.51, p < 0.001). The increased risk of mortality in COVID-19 positive patients remained high amongst patients who had surgery 0-45 days from date of COVID-19 testing. In addition, COVID-19 positive patients who underwent colonoscopy (OR = 0.21, p = 0.01) and plastic and orthopedic surgery (OR = 0.27, p = 0.01) had lower mortality than those underwent other surgeries.

CONCLUSIONS

A COVID-19 positive diagnosis is associated with significantly higher risk of all-cause mortality following ambulatory surgery. This mortality risk is greatest in patients that undergo ambulatory surgery within 45 days of testing positive for COVID-19. Postponing elective ambulatory surgeries in patients that test positive for COVID-19 infection within 45 days of surgery date should be considered, although prospective studies are needed to assess this.

Coronal shear fractures of the femoral neck: a comparison with basicervical fractures

PURPOSE

We propose coronal shear fracture of the femoral neck (CSFF) as a new type of fracture that differs from a basicervical fracture. This study aimed to present the incidence of CSFF and compare its clinical characteristics and outcomes with those of basicervical fractures.

METHODS

In this multicenter retrospective cohort study, 2207 patients with hip fractures were identified using computed tomography (CT), 17 and 27 patients were diagnosed with CSFF (CSFF group) and basicervical fractures (basicervical fracture group), respectively. The primary outcome was reoperation, while the secondary outcomes were postoperative radiographic findings, ambulatory ability, and 1-year mortality rate. These outcomes were compared between the two groups. We also conducted diagnostic reliability tests for these fractures using the Cohen's kappa coefficient.

RESULTS

The incidence of CSFF and basicervical fractures in the 2207 patients were 0.77% and 1.22%, respectively. The inter-and intra-observer agreements for the diagnosis were almost perfect. The comorbidity score was significantly higher in the CSFF group than in the basicervical fracture group. No reoperations occurred in both groups. There were no significant intergroup differences in the postoperative radiographic findings. The 1-year mortality rate was higher in the CSFF group than in the basicervical fracture group (38.5% vs. 5.3%; odds ratio: 11.9, 95% CI: 1.2-118.5; p = 0.025).

CONCLUSION

This study presents the definition and incidence of CSFF with a high diagnostic reliability. Patients with CSFF had similar reoperation rate postoperative radiographic outcomes to basicervical fractures, while 1-year mortality rate was high.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record

BACKGROUND

Advanced care planning documents provide a patient's healthcare team and loved ones with guidance on patients' treatment preferences when they are unable to advocate for themselves. A substantial proportion of patients will die within a few months of experiencing a hip fracture, but despite the importance of such documents, patients undergoing surgery for hip fracture seldom have discussions documented in the medical records regarding end-of-life care during their surgical admission. To the best of our knowledge, the proportion of patients older than 65 years treated with surgery for hip fractures who have advanced care planning documents in their electronic medical record (EMR) has not been explored, neither has the association between socioeconomic status and the presence of those documents in the EMR. Determining this information can help to identify opportunities to promote advanced care planning.

QUESTIONS/PURPOSES

(1) What percentage of patients older than 65 years who undergo hip fracture surgery have completed advanced care planning documents uploaded in the EMR before or during their surgical hospitalization, or at any timepoint (before admission, during admission, and after admission)? (2) Are patients from distressed communities less likely to have advanced care planning documents in the EMR than patients from wealthier communities, after controlling for economic well-being as measured by the Distressed Communities Index? (3) What percentage of patients older than 65 years with hip fractures who died during their hospitalization for hip fracture surgery had advanced care planning documents uploaded in the EMR?

METHODS

This was a retrospective, comparative study conducted at two geographically distinct hospitals: one urban Level I trauma center and one suburban Level II trauma center. Between 2017 and 2021, these two centers treated 850 patients for hip fractures. Among those patients, we included patients older than 65 years who were treated with open reduction and internal fixation, intramedullary nailing, hemiarthroplasty, or THA for a fragility fracture of the proximal femur. Based on that, 83% (709 of 850) of patients were eligible; a further 6% (52 of 850) were excluded because they had codes other than ICD-9 820 or ICD-10 S72.0, and another 2% (17 of 850) had incomplete datasets, leaving 75% (640 of 850) for analysis here. Most patients with incomplete datasets were in the prosperous Distressed Communities Index category. Among patients included in this study, the average age was 82 years, 70% (448 of 640) were women, and regarding the Distressed Communities Index, 32% (203 of 640) were in the prosperous category, 25% (159 of 640) were in the comfortable category, 15% (99 of 640) were in the mid-tier category, 5% (31 of 640) were in the at-risk category, and 23% (145 of 640) were in the distressed category. The primary outcome included the presence of advanced care planning documents (advanced directives, healthcare power of attorney, or physician orders for life-sustaining treatment) in the EMR before surgery, during the surgical admission, or at any time. The Distressed Communities Index was used to indicate economic well-being, and patients were identified as being in one of five Distressed Communities Index categories (prosperous, comfortable, mid-tier, at-risk, and distressed) based on ZIP Code. An exploratory analysis was conducted to determine variables associated with the presence of advanced care planning documents in the EMR. A multivariate regression was then performed for patients who did or did not have advanced care planning documents in their medical record at any time. The results are presented as ORs with the associated 95% confidence interval (CI).

RESULTS

Nine percent (55 of 640) of patients had advanced care planning documents in the EMR preoperatively or during their surgical admission, and 22% (142 of 640) of patients had them in the EMR at any time. After controlling for potential confounding variables such as age, laterality (left or right hip), hospital type, and American Society of Anesthesiologists (ASA) classification, we found that patients in Distressed Communities Index categories other than prosperous had ORs lower than 0.7, with patients in the distressed category (OR 0.4 [95% CI 0.2 to 0.7]; p < 0.01) and comfortable category (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.01) having a substantially lower odds of having advanced care planning documents in their EMR. Patients aged 86 to 95 years (OR 1.9 [95% CI 1.1 to 3.4]), those 96 years and older (OR 4.0 [95% CI 1.7 to 9.5]), and those with a higher ASA classification (OR 1.6 [95% CI 1.1 to 2.3]) had a higher odds of having advanced care planning documents in the EMR at any time. Among 14 patients who experienced in-hospital mortality, two had advanced care planning documents uploaded into their EMR, whereas 12 of 14 who died in the hospital did not have advanced care planning documents uploaded into their EMR.

CONCLUSION

Orthopaedic surgeons should counsel patients regarding the risk for postoperative complications after fragility hip fracture surgery and engage in shared decision-making regarding advanced care planning documents with patients or, if the patients are unable, with their families. Additionally, implementing virtual education about advanced care planning documents and using easy-to-read forms may facilitate the completion of advanced care planning documents by patients older than 65 years, especially patients with low economic well-being. Limitations of this study include having a restricted number of patients in the at-risk and mid-tier Distressed Communities Index categories and a restricted number of patients identifying as non-White races/ethnicities. Future research should evaluate the effect of advanced care document presence in the EMR on end-of-life care intensity in patients treated for fragility hip fractures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A New Nomogram Model for Predicting 1-Year All-Cause Mortality After Hip Arthroplasty in Nonagenarians With Hip Fractures: A 20-Year Period Retrospective Cohort Study

Background

China has become an ageing society and as it continues to age, it will face an increasing number of hip fractures in nonagenarians. However, few preoperative assessment tools to determine the postoperative mortality risk in nonagenarians with hip fracture were available. The aim of this study was to identify all-cause mortality risk factors after hip arthroplasty in nonagenarians with hip fractures and to establish a new nomogram model to optimize the individualized hip arthroplasty in nonagenarians with hip fractures.

Methods

We retrospectively studied 246 consecutive nonagenarians diagnosed with hip fracture from August 2002 to February 2021 at our center. During the follow-up, 203 nonagenarians with a median age of 91.9 years treated with hip arthroplasty were included, of which 136 were females and 67 were males, and 43 nonagenarians were excluded (40 underwent internal fixation and 3 were lost to follow-up). The full cohort was randomly divided into training (50%) and validation (50%) sets. The potential predictive factors for 1-year all-cause mortality after hip arthroplasty were assessed by univariate and multivariate COX proportional hazards regression on the training set, and then, a new nomogram model was established and evaluated by concordance index (C-index) and calibration curves.

Results

After analyzing 44 perioperative variables including demographic characteristics, vital signs, surgical data, laboratory tests, we identified that age-adjusted Charlson Comorbidity Index (aCCI) (p = 0.042), American Society of Anesthesiologists (ASA) classification (p = 0.007), Urea (p = 0.028), serum Ca2+ (p = 0.011), postoperative hemoglobin (p = 0.024) were significant predictors for 1-year all-cause mortality after hip arthroplasty in the training set. The nomogram showed a robust discrimination, with a C-index of 0.71 (95%CIs, 0.68–0.78). The calibration curves for 1-year all-cause mortality showed optimal agreement between the probability as predicted by the nomogram and the actual probability in training and validation sets.

Conclusion

A novel nomogram model integrating 5 independent predictive variables were established and validated. It can effectively predict 1-year all-cause mortality after hip arthroplasty in nonagenarians with hip fracture and lead to a more optimized and rational therapeutic choice.

Prognostic nomogram for risk of mortality after hip fracture surgery in geriatrics

PURPOSE

Hip fracture is a significant public health problem, with associated high morbidity and mortality. Orthopedic surgeons are concerned to improve prognosis and stratify mortality risk after hip fracture surgery. This study established a nomogram that combines the Charlson Comorbidity Index (CCI) with specific laboratory parameters to predict mortality risk after hip fracture surgery in geriatrics.

METHODS

The records of consecutive patients who underwent hip fracture surgery from January 2015 through May 2020 at one medical center were reviewed for perioperative factors and mortality. Patients with age ≥ 70 years who were diagnosed with intertrochanteric or femoral neck fractures were included. Patients who were diagnosed with pathological fracture, received only conservative treatment or lost to follow-up were excluded. A multivariate Cox proportional hazards regression model was used to identify risk factors. A nomogram was established with R software and evaluated using concordance (C)-index, area under receiver operating characteristic (AUC), calibration curves, and decision curve analysis (DCA).

RESULTS

In total, 454 patients were included with a mean age of 81.6 years. The mean follow-up and one-year mortality rate were 37.2 months and 10.4%, respectively. Five identified risk variables for mortality after hip fracture surgery in geriatrics comprised age (HR 1.05, 95% CI 1.01-1.08; P = 0.003), CCI (HR 1.38, 95% CI 1.24-1.54; P = 0.000), albumin (HR 1.78, 95% CI 1.31-2.43; P = 0.000), sodium (HR 1.59, 95% CI 1.18-2.15; P = 0.002) and hemoglobin (HR 1.46, 95% CI 1.07-2.00; P = 0.02). A nomogram was proposed and evaluated, showing a C-index of 0.76 ± 0.02. The AUCs for 6-month, 1-year, and 3-year mortality predictions were 0.83, 0.79, and 0.77, respectively. The calibration curve and DCA showed good discrimination and clinical usefulness.

CONCLUSION

This novel nomogram for stratifying the mortality risk after hip fracture surgery in geriatrics incorporated age, CCI, serum albumin, sodium, and hemoglobin. Internal validation indicated that the model has good accuracy and usefulness. This nomogram had improved convenience and precision compared with other models. External validation is warranted to confirm its performance.