Postoperative length of stay and 30-day readmission after geriatric hip fracture: an analysis of 8434 patients

[Translated article] Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early

INTRODUCTION

Pre-operative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge.

MATERIAL AND METHODS

A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA≤II were included for analysis and divided according to their post-operative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year post-operative mortality rates; 30-day post-operative hospital readmission rate; and medical or surgical cause were recorded.

RESULTS

In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% versus 4.1%, p=.16) and 1-year post-operative (4.3% versus 16.3%, p=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% versus 16.3%, p=.037).

CONCLUSIONS

In the present study, the early discharge group obtained better results 30-day and 1-year post-operative mortality indicators, as well as readmission for medical reasons.

Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early

INTRODUCTION

Preoperative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge.

MATERIAL AND METHODS

A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA ≤II were included for analysis and divided according to their postoperative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year postoperative mortality rates; 30-day postoperative hospital readmission rate; and medical or surgical cause were recorded.

RESULTS

In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% vs 4.1%, P=.16) and 1-year postoperative (4.3% vs 16.3%, P=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% vs 16.3%, P=.037).

CONCLUSIONS

In the present study, the early discharge group obtained better results 30-day and 1-year postoperative mortality indicators, as well as readmission for medical reasons.

Complications of Hip Hemiarthroplasty

Hip hemiarthroplasty is a commonly performed orthopedic surgery, used to treat proximal femur fractures in the elderly population. Although hip hemiarthroplasty is frequently successful in addressing these injuries, complications can occur. Commonly seen complications include dislocation, periprosthetic fracture, acetabular erosion, and leg-length inequality. Less frequently seen complications include neurovascular injury and capsular interposition. This article presents a comprehensive review of the complications associated with the management of hip hemiarthroplasty. [Orthopedics. 2023;46(4):e199-e209.].

Spinal anesthesia with better outcome in geriatric hip fracture surgery - An analysis of the Registry for Geriatric Trauma (ATR-DGU)

BACKGROUND

Literature shows conflicting results regarding spinal (SA) or general anesthesia (GA) and their influence on the outcome of elderly patients with hip fractures. We, therefore, conducted an analysis from the Registry for Geriatric Trauma (ATR-DGU).

METHODS

A retrospective, multicenter registry study including patients aged 70 years or above with hip fractures requiring surgery from 131 Centers for Geriatric Trauma (AltersTraumaZentrum DGU®) from 2016 to 2021. Patients with SA or GA were compared using matched-pair analysis and linear and logistic regression models.

RESULTS

A total of 43,714 patients were included, of whom 3,242 received SA. The median age was 85 (SA) and 84 years (GA). Adjustments for the American Society of Anesthesiologists (ASA) grade, sex, age, additional injuries, and anticoagulation resulted in a higher in-hospital (odds ratio (OR) 1.31; 95% confidence interval [CI], 1.07 - 1.61, p = 0.009) and 120 days mortality (OR 1.47; 95% CI, 1.1 - 1.95, p = 0.009) in the GA group. GA had a significant negative influence on walking ability seven days after surgery and on the quality of life (QoL). The length of hospital stay (LoS) was significantly shorter in the SA group.

CONCLUSIONS

SA is associated with a higher survival rate, a better walking ability seven days after surgery, a higher QoL, and a shorter LoS.

Association of Brain Natriuretic Peptide Levels at Time of Injury with Morbidity and Mortality in Patients with Surgically Treated Hip Fractures

An elevated brain natriuretic peptide (BNP) level has been shown to be associated with mortality and cardiac events in cardiac surgery, but its utility in the prediction of morbidity and mortality in hip fracture surgery is unknown. The primary aim of this study was to determine if there is a difference in BNP level at the time of injury between patients who do and do not develop complications after hip fracture surgery. The secondary aim was to determine if there is a predictive relationship between complications associated with the initial BNP level and mortality.

Factors Associated with Readmission within 30 Days after Discharge and In-Hospital Mortality after Proximal Femoral Fracture Surgery in the Elderly: Retrospective Cohort

Objective  To evaluate the factors associated with readmission within 30 days after discharge (R30) and in-hospital mortality (IHM) in elderly patients undergoing proximal femur fracture surgery (PFF). Methods  Retrospective cohort with data from 896 medical records of elderly (≥ 60 years) patients submitted to PFF surgery in a Brazilian hospital between November 2014 and December, 2019. The patients included were followed-up from the date of hospitalization for surgery up to 30 days after discharge. As independent variables, we evaluated gender, age, marital status, pre- and postoperative hemoglobin (Hb), international normalized ratio, time of hospitalization related to the surgery, door-surgery time, comorbidities, previous surgeries, use of medications, and the American Society of Anesthesiologists (ASA) score. Results The incidence of R30 was 10.2% (95% confidence interval [CI]: 8.3-12.3%), and the incidence of IHM was 5.7% (95%CI: 4.3-7.4%). Regarding R30, hypertension (odds ratio [OR]: 1.71; 95%CI: 1.03-2.96), and regular use of psychotropic drugs (OR: 1.74; 95%CI: 1.12-2.72) were associated in the adjusted model. In the case of IHM, higher chances were associated with chronic kidney disease (CKD) (OR: 5.80; 95%CI: 2.64-12.31), longer hospitalization time (OR: 1.06; 95%CI: 1.01-1.10), and R30 (OR: 3.60; 95%CI: 1.54-7.96). Higher preoperative Hb values were associated with a lower chance of mortality (OR: 0.73; 95%CI: 0.61-0.87). Conclusion Findings suggest that the occurrence of these outcomes is associated with comorbidities, medications, and Hb.

Predictive model for prolonged length of hospital stay in patients with osteoporotic femoral neck fracture: A 5-year retrospective study

Prolonged length of stay (LOS) in osteoporotic femoral neck fracture patients increased the hospital care cost and demonstrated in-hospital complications. This study aimed to develop an ease-of use predictive model of prolonged LOS in osteoporotic femoral neck fracture patients. In this 5-year retrospective study, the medical charts of 255 patients admitted to hospital with an osteoporotic femoral neck fracture resulting from a simple fall from January 2014 to December 2018 were reviewed. Multivariable fractional polynomials (MFP) algorithms was applied to develop the predictive model from candidate predictors of prolonged LOS. The discrimination performance of predictive model was evaluated using the receiver operating characteristic curve (ROC). Internal validity was assessed using bootstrapping. From 289 patients who were hospitalized with an osteoporotic fracture of femoral neck throughout this study, 255 (88%) fulfilled the inclusion criteria. There was 54.90% (140 of 255 patients) of patients who had prolonged LOS. The predictors of the predictive model were age, BMI, ASA score class 3 or 4, arthroplasty and time from injury to surgery. The area under ROC curve of the model was 0.83 (95% confidence interval 0.77-0.88). Internal validation with bootstrap re-sampling revealed an optimism of -0.002 (range -0.300-0.296) with an estimated shrinkage factor of 0.907 for the predictive model. The current predictive model developed from preoperative predictors which had a good discriminative ability to differentiate between length of hospitalization less than 14 days and prolonged LOS in osteoporotic femoral neck patients. This model can be applied as ease-of use calculator application to help patients, their families and clinicians make appropriate decisions in terms of treatment planning, postoperative care program, and cost-effectiveness before patients receiving the definitive treatments.

Risk Factors and Outcomes of Extended Length of Stay in Older Adults with Intertrochanteric Fracture Surgery: A Retrospective Cohort Study of 2132 Patients

We aimed to identify the risk factors associated with an extended length of hospital stay (eLOS) in older hip-fracture patients and to explore the relationships between eLOS and mortality and functional outcomes. In this retrospective analysis of surgically treated intertrochanteric fracture (IF) patients, all variables were obtained and compared between the eLOS group and the normal LOS group. All participants were followed-up for a minimum of two years and the relation between the eLOS and all-cause mortality and functional outcomes were compared. After adjustment for potential confounders, we identified that patients with high modified Elixhauser's Comorbidity Measure (mECM) had the highest likelihood of eLOS, followed by obesity, admission in winter, living in urban, pulmonary complications, admission in autumn, and time from injury to surgery. In addition, our results showed no significant difference in the mortality and functional outcomes between the two groups during follow-up. By identifying these risk factors in the Chinese geriatric population, it may be possible to risk-stratify IF patients and subsequently streamline inpatient resource utilization. However, the differences between health care systems must be taken into consideration. Future studies are needed to preemptively target the modifiable risk factors to demonstrate benefits in diminishing eLOS.

The influence of the patient's health-state compared with time to surgery on the outcomes following hip fracture surgery: a longitudinal study of 4,791 patients

INTRODUCTION

This study investigated whether the health-state of hip fracture patients or the time to surgery had a greater effect on outcomes.

METHODS

Of the 5,120 patients admitted with a fragility hip fracture, 4,791 (93.6%) were included in the analysis. Patients operated after 36 hours were initially group by length of delay (36-48 hours and >48 hours) and then regrouped by delay cause (medical and administrative). Patients operated within 36 hours were the comparative group. Data were collected at admission, discharge, 120 days and 365 days post discharge.

RESULTS

Multivariate logistic regression analysis revealed that the patients who were delayed over 36 hours, owing to medical causes, had a higher mortality at all studied time points, but the patients who were delayed owing to administrative causes had no increase in mortality. Analysis by time to surgery revealed that patients operated after 36 and 48 hours had a higher mortality at discharge only. Medically delayed patients were less likely to return to their premorbid level of residence at discharge. Older, male patients had a higher risk of inferior outcomes. Postoperative length of stay was significantly greater in the >48-hour delay group and the medical delay group. All delay groups had a significantly higher rate of reoperation within 30 days compared with the no-delay group.

CONCLUSIONS

The health-state of the hip fracture patient had a greater impact on the outcome in contrast to time to surgery. This study concurs that hip fracture patients should receive surgery within the timeframe of current guidelines, but medically unwell patients have relatively worse outcomes and should receive enhanced clinical attention.

Predictors of hospital readmission after fractures: One-year follow-up study

OBJECTIVE

Identify the incidence and predictive factors for readmissions of elderly hospitalized with fractures.

METHOD

Prospective cohort study on 376 elderly people from a trauma referral large hospital in central Brazil. Data were collected from medical records of elderly people with radiological diagnosis of fractures. Readmission that occurs up to one year after the first discharge was defined the outcome variable. Pre- and post-admission characteristics were analyzed as predictive factors. Multiple analysis was performed using robust Poisson regression.

RESULTS

The main cause of hospitalization was fracture of the femur (53.2%) and the most frequent trauma mechanism was fall from standing height (72.9%). The incidence of readmission was 20.7%, of which 30.5% were related to the fracture itself, with emphasis on Surgical Site Infection. The predictors of readmissions were: age range 60 to 69 years, COPD, delirium and fracture of the femur.

CONCLUSIONS

The incidence of readmissions was high, with various causes and associated conditions pre-admission (age range 60-69, presenting COPD) and post-admission (delirium). The monitoring of these factors in the hospital environment is essential for prevention of readmissions.

[What risk factors are associated with mortality and readmissions in osteoporotic hip fracture?]

INTRODUCTION AND OBJECTIVE

Hip fracture in the elderly leads to long hospital stays, readmissions and mortality.

OBJECTIVE

To identify risk factors associated with mortality and readmissions in elderly with hip fracture.

PATIENTS AND METHODS

Prospective observational study in people over 65years with hip fracture between October-2017 and November-2018, followed for 12months (128 patients).

STATISTICAL ANALYSIS

SPSS vs27.0.

RESULTS

6 (4.7%) patients were readmitted at 1 month; at year 24 (19.4%); 55 (44.4%) consulted for emergencies; 4 (3.1%) died during admission, and 26 (20.3%) in 12months; hospital stay 6.5 (SD: 4.80) days. Those with a previous Barthel less than 85 (6 [8.5%] vs 0 [0%]; P=.037) and less EuroQol5D (6 [10.0] vs 0 [0%]; P=.011) were readmitted more at one month. Those taking anticoagulants (OR: 3.33 (1.13-9.81); P=.003) and those with high surgical risk (18 [23.4%] vs 1 [5.6%]) were readmitted more after one year; P=.038). There was higher intra-episode mortality with renal failure (OR: 34.2 [3.25-359.93]; P=.003) and decompensated heart failure (OR: 23.8 [2.76-205.25]; P=.015). Higher mortality at one year in those older than 85years (OR: 4.3 [1.48-12.49]; P=.007); in those taking benzodiazepines (OR: 2.86 [1.06-7.73]; P=.038); if Barthel was less than 85 (OR: 2.96 [1.1-7.99]; P=.027) and if EuroQol5D was low (0.249 vs 0.547; P=.025). Those operated after 72h (24 [57.1%] vs. 29 [38.2%]; P=.047) consulted more for the emergency department.

CONCLUSIONS

Renal failure and cardiac decompensation increased intra-episode mortality. Older age, benzodiazepines, and previous low functionality and low EuroQol5D increased mortality at one year. They were readmitted more if higher surgical risk, previously anticoagulated and worse quality of life and functionality.

Derivation and validation of a 90-day unplanned hospital readmission score in older patients discharged form a geriatric ward

PURPOSE

To derive and validate a 90-day unplanned hospital readmission (UHR) score based on information available to non-hospital based care providers.

METHODS

Retrospective longitudinal study with cross-validation method. Participants were older adults (≥ 65 years) admitted to a geriatric short-stay department in a general hospital in France. Patients were split into a derivation cohort and a validation cohort. We recorded demographic information, medical history, and concurrent clinical characteristics. The main outcome was 90-day UHR. Data obtained from hospital discharge letters were used in a logistic regression model to construct a predictive score, and to identify risk groups for 90-day UHR.

RESULTS

In total, 750 and 250 aged adults were included in both the derivation and the validation cohorts. Mean age was 87.2 ± 5.2 years, most were women (68.1%). Independent risk factors for 90-day UHR were: use of mobility aids (p = .02), presence of dementia syndrome (p = .02), history of recent hospitalisation (p = .03), and discharge to domiciliary home (p = .005). From these four risk factors, three groups were determined: low-risk group (score < 4), medium-risk group (score between 4 and 6), and high-risk group (score ≥ 6). In the derivation cohort the 90-day UHR rates increased significantly across risk groups (14%, 22%, and 30%, respectively). The 90-day UHR score had the same discriminant power in the derivation cohort (c-statistic = 0.63) as in the validation cohort (c-statistic = 0.63).

CONCLUSIONS

This score makes it possible to identify aged adults at risk of 90-day UHR and to target multidisciplinary interventions to limit UHR for patients discharged from a Geriatric Short-Stay Unit.

Safety of Elderly Fallers: Identifying Associated Risk Factors for 30-Day Unplanned Readmissions Using a Clinical Data Warehouse

BACKGROUND

Hospital readmissions are a major problem in the older people as they are frequent, costly, and life-threatening. Falls among older adults are the leading cause of injury, deaths, and emergency department visits for trauma.

OBJECTIVE

The main objective was to determine risk factors associated with a 30-day readmission after index hospital admission for fall-related injuries.

METHODS

A retrospective nested case-control study was conducted. Data from elderly patients initially hospitalized for fall-related injuries in 2019, in 11 of the Greater Paris University Hospitals and discharged home, were retrieved from the clinical data warehouse. Cases were admission of elderly patients who subsequently experienced a readmission within 30 days after discharge from the index admission. Controls were admission of elderly patients who were not readmitted to hospital.

RESULTS

Among 670 eligible index admissions, 127 (18.9%) were followed by readmission within 30 days after discharge. After multivariate analysis, men sex (odds ratio [OR] = 2.29, 95% confidence interval [CI] = 1.45-3.61), abnormal concentration of C-reactive protein, and anemia (OR = 2.22, 95% CI = 1.28-3.85; OR = 1.85, 95% CI = 1.11-3.11, respectively) were associated with a higher risk of readmission. Oppositely, having a traumatic injury at index admission decreased this risk (OR = 0.47, 95% CI = 0.28-0.81).

CONCLUSIONS

Reducing early unplanned readmission is crucial, especially in elderly patients susceptible to falls. Our results indicate that the probability of unplanned readmission is higher for patients with specific characteristics that should be taken into consideration in interventions designed to reduce this burden.

The Analysis of Hospital Readmission Rates After the Implementation of Hospital Readmissions Reduction Program

OBJECTIVES

This study aims to analyze the impact of Hospital Readmissions Reduction Program (HRRP) on the nationwide optimization efforts of length of stay (LOS) and readmissions in the United States.

METHODS

We use the Nationwide Readmission Database between 2010 and 2016 provided in the Healthcare Cost and Utilization Project by the Agency for Healthcare Research and Quality. The study focuses on acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure (CHF), pneumonia monitored by the HRRP and 2 conditions, septicemia, and mood disorders that were not monitored by the HRRP but had among the highest readmissions. Patient demographics and readmissions were analyzed based on insurance type, LOS, and Charlson Comorbidity Index.

RESULTS

The readmissions vary by conditions, LOS, and insurance types. Congestive heart failure has the highest readmissions among the 6 analyzed conditions at approximately 25%. The readmission rate of CHF rises to 30% for the Medicaid patients and varies between 30% and 35% by LOS. Patients with CHF with higher Charlson Comorbidity Index demonstrates the highest readmissions among 6 conditions. The patients with longer LOSs had higher readmissions, and Medicare patients have a higher reduction in readmissions in acute myocardial infarction and mood disorders compared with the other forms of payments.

CONCLUSIONS

Our figures show that targeted programs, such as HRRP, may have a positive impact on readmission rates. We, however, observe some graphical evidence that nontargeted conditions could exhibit similar trends. Because of heterogeneity in hospital and patient characteristics, it is pivotal for researcher to consider them in formal analyses.

Association of length of hospital stay with delay to surgical fixation of hip fracture

Background:

Previous research has shown increases in length of stay (LOS), morbidity and mortality when the standard for surgical fixation of hip fracture of 48 hours is not met. However, few investigators have analyzed LOS as a primary outcome, and most used time of diagnosis as opposed to time of fracture as the reference point. We examined the effect of time to surgical fixation of hip fracture, measured from time of fracture, on length of hospital stay; the secondary outcome was average 1-year mortality.

Methods:

We conducted a retrospective cohort study of patients presenting to 1 of 2 tertiary care centres in St. John’s, Newfoundland and Labrador, Canada, with a hip fracture from Jan. 1, 2014, to Dec. 31, 2018. We analyzed 3 groups based on timing of surgical fixation after fracture: less than 24 hours (group 1), 24–48 hours (group 2) and more than 48 hours (group 3). We assessed statistical significance using 1-way analysis of variance.

Results:

Of the 692 patients included in the study, 212 (30.6%) were in group 1, 360 (52.0%) in group 2 and 120 (17.3%) in group 3. A delay to surgical fixation exceeding 48 hours was associated with a significantly longer LOS, by an average of 2.9 and 2.8 days compared to groups 1 and 2, respectively (p = 0.04); there was no significant difference in LOS between groups 1 and 2. A significant difference in average 1-year mortality was observed between groups 1 (11%) and 3 (26%) (p = 0.004), and groups 2 (13%) and 3 (p = 0.009).

Conclusion:

Surgical fixation beyond 48 hours after hip fracture resulted in significantly increased LOS and 1-year mortality. Further research should be conducted to evaluate reasons for delays to surgery and the effects of these delays on time to surgical fixation as measured from time of fracture.

Enhanced recovery after surgery for hip fractures: a systematic review and meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) programs have achieved promising results in many surgical specialties. However, uncertainty still remains regarding the effect of ERAS on hip fractures. The objective of this review was to investigate the clinical prognosis of ERAS programs in terms of (1) hospital-related endpoints (time to surgery [TTS], length of stay [LOS]), (2) readmission rate, (3) complications, and (4) mortality.

METHODS

Published literature was searched in the PubMed, EMBASE, and Cochrane Library databases. All of the included studies met the inclusion criteria. The primary outcomes were TTS and LOS. The secondary outcomes included the 30-day readmission rate, overall complication rate, specific complication rate (delirium and urinary tract infection), and 30-day and 1-year mortality. Language was restricted to English. The data analysis was carried out by Review Manager 5.3.

RESULTS

A total of 7 published studies (9869 patients) were finally included, and these were all cohort studies. The meta-analysis showed that the TTS, LOS, and overall complication rate were significantly reduced in the ERAS group compared with the control group (p < 0.01). Moreover, no significant change was found in the 30-day readmission rate or 30-day and 1-year mortality.

CONCLUSIONS

ERAS significantly decreases the TTS, LOS, and complication rate without increasing readmission rate and mortality, which adds to the evidence that the implementation of ERAS is beneficial to patients undergoing hip fracture repair surgeries.

Examining trajectories of hospital readmission in older adults hospitalised with hip fracture from residential aged care and the community

Hip fracture trajectories have not been examined for older adults in aged care or living in the community. Trajectories of health care use were defined by distinct predictive factors. These results can inform the development of targeted strategies to reduce health service use following hip fracture.

OBJECTIVE

To examine hospital service use trajectories of older adults who were hospitalised for hip fracture and living in a residential aged care facility (RACF) or the community, and to identify factors predictive of trajectory group membership. These findings may inform future programmes aimed at reducing unexpected hospitalisations and subsequently reduce health care costs.

METHODS

A group-based trajectory analysis of hospitalisations was conducted for adults aged ≥ 65 years hospitalised for hip fracture during 2008-2009 in New South Wales, Australia. Linked hospitalisation and RACF data were examined for a 5-year period. Group-based trajectory models were derived for RACF and community-dwelling older adults based on the number of subsequent hospital admissions following the index hip fracture. Multinomial logistic regression examined predictors of trajectory group membership for subsequent hospital admissions.

RESULTS

There were 5752 hip fracture hospitalisations, with two-thirds of hip fractures occurring in community-dwellers. Key predictors of trajectory group membership for both RACF residents and community-dwellers were age group, sex, hospital length of stay and cognitive impairment. Assistance with activities of daily living and complex health care needs were also predictive of group membership in RACF residents. Location of residence and time to move to a RACF were additional predictors of group membership for community-dwellers.

CONCLUSION

Health service use trajectories differed for RACF residents and community-dwellers; however, there were similar patient characteristics that defined trajectory group membership. Low users of hospital services living in RACFs or the community included older adults with generally unfavourable health conditions, potentially indicating that palliative care or advanced care directives and community-care initiatives, respectively, have played a part in the lowered frequency of rehospitalisation.

Impact of multiple nerves blocks anaesthesia on intraoperative hypotension and mortality in hip fracture surgery intermediate-risk elderly patients: A propensity score-matched comparison with spinal and general anaesthesia

BACKGROUND

A Hip fracture in the intermediate-risk elderly patient is common and associated with a high rate of postoperative morbidity and mortality. There is a lack of consensus on the optimal anaesthetic technique but there is a clear association between intraoperative hypotension and postoperative morbidity and mortality. We aimed to compare the haemodynamic stability of three anaesthesia techniques: general anaesthesia (GA), continuous spinal anaesthesia (CSA), and multiple nerve blocks (MNB).

METHODS

The primary outcome was the occurrence of intraoperative hypotension defined by a 30% decrease in mean arterial pressure (MAP) from baseline. Secondary outcomes included incidence of hypotension under 50 mmHg of MAP, time spent below MAP 50 mmHg, use of vasopressors, in-hospital and 30-day mortality. A propensity score-matched analysis was performed.

RESULTS

After screening and application of the exclusion criteria, 593 patients undergoing hip fracture surgery between the 1^st of January 2015 and the 31^st of December 2016 were included. The propensity score match analysis selected 43 patients in each group. The incidence of hypotension was significantly higher in the GA group than in the MNB and CSA groups: 39 (90%), 22 (51%), and 23 (53.5%), respectively; p < 0.0001. The incidence of MAP < 50 mmHg (59.5%, 23.3%, and 16.3%; p < 0.0001) and the use of vasopressors (93%, 39.5%, and 25.6%; p < 0.0001) were increased significantly in the GA group. With the GA group as a reference, odds ratios were reported in the MNB group at 0.08 [0.022-0.30] (p = 0.0002) for hypotension episodes; 0.17 [0.04-0.66] (p = 0.01) for hypotension < 50 mmHg for more than 3 min and 0.049 [0.013-0.018] (p < 0.0001) for use of vasopressors. The duration of hospital stay, postoperative complications, in-hospital and 30-day mortality rates did not differ significantly between the groups.

CONCLUSION

CSA and MNB provide better haemodynamic stability than GA. However, whatever the anaesthesia technique used, the mortality rates do not change even if MNB leads to less hypotension. IRB contact information: CERAR IRB 00010254-2016-118. Clinical Trial Number: ClinicalTrials.gov. ID: NCT03356704.

Incidence of COVID-19 After Nonelective Hip and Knee Surgery During the Peak of the Pandemic: The New Jersey Experience

In an attempt to preserve essential equipment and health care system capacity and slow the spread of coronavirus disease 2019 (COVID-19) infection, Governor Murphy suspended all elective surgeries performed in New Jersey from March 27, 2020, through May 25, 2020. The objective of this study was to determine the incidence of postoperative COVID-19 infection following nonelective hip and knee surgery during the peak of the COVID-19 pandemic in New Jersey during this time. A retrospective cohort of 149 patients who underwent nonelective hip and knee surgery from March 27, 2020, through May 25, 2020, at 2 institutions was identified. The cohort was divided into hip fracture and non-fracture patients to compare the postoperative experience of these patient populations. The primary outcome was the incidence of postoperative COVID-19 infection diagnosed via severe acute respiratory syndrome coronavirus 2 nasopharyngeal real-time reverse transcription polymerase chain reaction. Secondary outcomes included length of stay, discharge disposition, postoperative complications, and mortality rate. A total of 149 patients underwent nonelective hip and knee surgeries, including 76 hip fracture cases and 73 nonelective hip and knee arthroplasty cases. A postoperative diagnosis of COVID-19 was made for 5 (6.6%) of 76 hip fracture patients, and 2 of the 5 died secondary to COVID-19. There were no infections in the arthroplasty cohort. This study describes a low incidence of COVID-19 infection after nonelective hip and knee surgery during the surge of the COVID-19 pandemic in New Jersey. Patients who underwent hip fracture surgery had an increased incidence of postoperative COVID-19 infection. [Orthopedics. 2021;44(3):180-186.].

Social deprivation predicts adverse health outcomes after hospital admission with hip fracture in England

We found social deprivation to be associated with higher mortality in the year following hip fracture among men and women aged 60 years and older in England. In those who did survive, deprivation was associated with longer hospital stays and greater risk of subsequent emergency readmission particularly for patients with dementia.

INTRODUCTION

Social deprivation predicts a range of adverse health outcomes; however, its impact on outcomes following hip fracture is not established. We examined the effect of area-level social deprivation on outcomes following hospital admission for hip fracture in England.

METHODS

We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011-March 2015) and Office for National Statistics mortality database, to identify patients aged 60+ years admitted with hip fracture. Deprivation was measured using Index of Multiple Deprivation quintiles; Q1-least deprived; Q5-most deprived, and outcomes by mortality over 1-year, length-of-stay in NHS acute and rehabilitation hospitals ('superspell'), and emergency 30-day readmission.

RESULTS

We identified 218,907 admissions with an index hip fracture (mean age 82.8 [standard deviation, SD 8.4] years; 72.6% female). Each quintile of deprivation was associated with greater mortality; age-adjusted 30-day mortality odds ratio, OR 1.30 [95% confidence interval, CI: 1.24, 1.37], p < 0.001, equating to on average 1038 fewer deaths/year among those who are least deprived (Q1 versus 2-5). Similarly, at 365 days, those most deprived had 24% higher mortality (age-sex-comorbidity-adjusted OR:1.24 [1.20, 1.28], p < 0.001; Q5 versus Q1). Among survivors, mean superspell was longer in the most versus least deprived (Q5:24.4 [SD 21.7] days, Q1:23.3 [SD 22.1], p < 0.001). Readmission was more common in those most versus least deprived (age-sex-comorbidity-adjusted OR 1.27 [1.22, 1.32], p < 0.001).

CONCLUSION

Greater deprivation is associated with reduced survival at all timepoints in the year following hip fracture. Among survivors, hospital stay is increased as is readmission risk. The extent to which configuration of English hospital services, rather than patient case-mix, explains these apparent health inequalities remains to be determined.

When does hip fracture surgery delay affects the length of hospital stay?

PURPOSE

To define factors influencing length of hospital stay (LOS) besides surgery delay.

METHODS

We retrospectively analyzed 634 patients operated for hip fractures in 1-year period. Investigated characteristics were age, gender, American Society of Anesthesiologists score (ASA), time to surgery (first 48 h was considered early), type of surgery, anticoagulant therapy and non-routine pre-operative tests. Univariate and multivariable analysis were performed. p values < 0.05 were considered statistically significant.

RESULTS

Median LOS was 12 days. Patients operated within 48 h had a LOS of 10 days, while patients operated after 48 h had 4 days longer LOS (p < 0.01). In multiple regression analyses, it was predicted that patients operated after 48 h with every 10 h delay to surgery had 7.3 h longer hospitalizations. All other factors did not influence the LOS. In early operation group, patients with hip arthroplasty had 3.3 days longer hospitalization compared to patients with osteosynthesis, every higher ASA score was associated with 1.4 days longer hospitalization, patients on anticoagulant therapy had 2.6 days longer LOS but surgery delay had no influence on LOS. Preinjury residence at a nursing home was associated with 4.4 days shorter hospitalizations compared to preinjury residence at home in both time frames.

CONCLUSIONS

In patients operated in first 48 h longer LOS is associated with ASA, anticoagulant therapy and operation type but not with delay to surgery. If patients are operated after 48 h, surgery delay is the only factor increasing LOS.

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BACKGROUND

With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.

METHODS

Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.

RESULTS

This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).

CONCLUSION

Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

Predictive models for identifying risk of readmission after index hospitalization for hip arthroplasty: A systematic review

BACKGROUND

An aging United States population profoundly impacts healthcare from both a medical and financial standpoint, especially with an increase in related procedures such as Total Hip Arthroplasty (THA). The Hospital Readmission Reduction Program and Comprehensive Care for Joint Replacement Program incentivize hospitals to decrease post-operative readmissions by correlating reimbursements with smoother care transitions, thereby decreasing hospital burden and improving quantifiable patient outcomes. Many studies have proposed predictive models built upon risk factors for predicting 30-day THA readmissions.

QUESTIONS

(1) Are there validated statistical models that predict 30-day readmissions for THA patients when appraised with a standards-based, reliable assessment tool?. (2) Which evidence-based factors are significant and have support across models for predicting risk of 30-day readmissions post-THA?

METHODS

Five major electronic databases were searched to identify studies that examined correlations between post-THA readmission and risk factors using multivariate models. We rigorously applied the PRISMA methodology and TRIPOD criteria for assessment of the prognostic studies.

RESULTS

We found 26 studies that offered predictive models, of which two presented models tested with validation cohorts. In addition to the many factors grouped into demographic, administrative, and clinical categories, bleeding disorder, higher ASA status, discharge disposition, and functional status appeared to have broad and significant support across the studies.

CONCLUSIONS

Reporting of recent predictive models establishing risk factors for 30-day THA readmissions against the current standard could be improved. Aside from building better performing models, more work is needed to follow the thorough process of undergoing calibration, external validation, and integration with existing EHR systems for pursuing their use in clinical settings. There are several risk factors that are significant in multiple models; these factors should be closely examined clinically and leveraged in future risk modeling efforts.

Association between increased neutrophil-to-lymphocyte ratio and postoperative delirium in elderly patients with total hip arthroplasty for hip fracture

BACKGROUND

Delirium is a common complication in elderly patients with total hip arthroplasty (THA) for hip fracture. The mechanism of postoperative delirium (POD) is associated with the neuroinflammatory process. The aim of this study was to the incidence and perioperative risk factors of POD and investigate whether NLR could serve as a potential marker for POD in elderly patients with THA for hip fracture.

METHODS

This was a multicenter prospective study, we included elderly patients with THA for hip fracture under general anesthesia. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut point of NLR for POD. The relationship between NLR and POD was analyzed by multivariable analysis.

RESULTS

Seven hundred eighty patients (mean age 73.33 ± 7.66) were eligible for inclusion in the study. 23.33% (182/780) of patients had POD. ROC curve analysis showed that the optimal cut point of NLR for POD was NLR ≥ 3.5. Compared with no POD, higher NLR, older age, diabetes, and higher neutrophil count were more likely in patients with POD(P < 0.05). Multivariate logistic regression analysis showed that NLR ≥ 3.50 [adjusted odds ratio(aOR), 3.93; confidence interval (CI), 2.47-6.25; P < 0.001)], older age (aOR, 1.04; 95%CI, 1.02-1.07; P = 0.001), diabetes (aOR, 1.58; 95% CI, 1.06-2.36; P = 0.025),higher neutrophil count (aOR, 1.25; 95%CI, 1.15-1.35; P < 0.001) were associated with increased risk of POD.

CONCLUSIONS

Older age, diabetes, higher neutrophil count, and NLR ≥ 3.5 were independent risk factors for POD, and NLR can be used as a potential marker for prediction of delirium in elderly patients with THA for hip fracture.

Factors Contributing to Extended Hospital Length of Stay in Emergency General Surgery†

BACKGROUND

Emergency general surgery (EGS) is a field characterized by disproportionately high costs, post-operative mortality, and complications. We attempted to identify independent factors predictive of an increased postoperative length of stay (LOS), a key contributor to economic burden and worse outcomes.

METHODS

The ACS-NSQIP database was queried for data from2005 to 2017. Current procedural terminology (CPT) codes were used to identify the most commonly performed EGS procedures: appendectomy, bowel resection, colectomy, and cholecystectomy. Cohorts above and below 75^th percentile LOS were determined, compared by preoperative variables, and evaluated with univariate and multivariate logistic regression to quantify risk.

RESULTS

Of 267,495 cases, 70,703 cases were above the 75^th percentile for LOS. A larger proportion of patients in the extended LOS group were 41 years or older (88.6% vs 45.7%). More Blacks (10.3% vs 6.7%) were observed in the extended LOS group. Age, race, cardiopulmonary, hepatic, and renal disease, diabetes, recent weight loss, steroid use, and sepsis history were significant factors on multivariate analysis but varied in terms of risk proportion by procedure. Age (61+), Black race, hypertension, sepsis, and cancer were significant for all 4 procedures.

CONCLUSIONS

Several factors are independently associated with extended LOS for those undergoing the most common EGS procedures. Five of these were associated with an increased LOS for all four procedures. These included, age (61+), hypertension, sepsis, cancer, and Black race.

The Association between High Body Mass Index and Early Clinical Outcomes in Patients with Proximal Femur Fractures

Background: Fractures of the proximal femur constitute daily work in orthopedic trauma surgery. With the continuous increase of obesity in the general population, surgeons face several known technical challenges. The aim of this study was to investigate the association of high body mass index (BMI) in patients with proximal femur fractures with intra- and postoperative adverse events, as well as with functional outcomes after successful surgery. Methods: In this retrospective, single-center cohort study, 950 patients who sustained a fracture of the proximal femur (femoral neck fracture or trochanteric fracture) and underwent surgical treatment at our level I trauma center between 2003 and 2015 were included. Patient-specific data were obtained in regard to demographics, comorbidities, and fracture morphology. In-hospital postoperative complications (i.e., need for revision surgery, wound site infection, pneumonia, urinary tract infection, necessary transfusion, and deep-vein thrombosis) were analyzed, along with the length of hospitalization and overall mortality rate. Functional outcome was assessed using the Barthel index and the patient’s ability to walk on crutches. Mortality rate and need for revision surgery were assessed over a two-year time period. Any adverse event was correlated to one of the four WHO’s BMI groups. Results: The cohort included 80 (8.4%) underweight patients, 570 (60.0%) normal weight patients, 241 (25.4%) overweight patients, and 59 (6.2%) obese patients. We found more femoral neck fractures (506, or 53%) than trochanteric fractures (444, or 47%). In bivariate analysis, no significant difference was found in regard to overall mortality or postoperative complications. Hospitalization time (LOS) differed between the underweight (12.3 ± 4.8 days), normal (13.6 ± 7.8 days), overweight (14.2 ± 11.7 days), and obese patients (16.0 ± 9.7 days) (p = 0.040). Operation time increased stepwise with increasing BMI: underweight = 85.3 ± 42.9 min; normal weight = 90.2 ± 38.2 min; overweight = 99.9 ± 39.9 min; obese = 117.2 ± 61.5 min (p < 0.001). No significant difference was found by analyzing functional outcomes. However, patients with intermediate BMI levels (18.5–30 kg/m²) tended to achieve the best results, as represented by a higher Barthel index score and the patient’s ability to walk on crutches. Conclusion: Increased BMI in patients with proximal femur fractures is associated with both longer operation time and length of hospitalization (LOS). Postoperative mobilization and functional outcomes appear to follow a reversed J-curve distribution (with overweight patients showing the best functional results), whereas both obese and underweight patients have associated poorer function.

A Reimbursement System Based on a 48-Hour Target Time for Surgery Shortens the Waiting Time for Hip Fracture Fixation in Elderly Patients

OBJECTIVES

To evaluate whether a pay-for-performance reimbursement system, aimed at expediting surgical fixation of hip fractures in elderly patients, has, in fact, succeeded in shortening the waiting time for surgery.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Academic Level II trauma center.

PATIENTS/PARTICIPANTS

One hundred fifty patients older than 70 years with femoral neck fractures (OTA/AO 31 A1-A3).

INTERVENTION

Implementation of a reimbursement system which incentivizes meeting a 48-hour target time for surgical fixation of hip fractures in elderly patients.

METHODS

Medical records of 75 consecutive patients operated on 1 year before the implementation of the reimbursement system were compared with records of 75 consecutive patients operated on 1 year after the implementation of the reimbursement system. The collected data included age, sex, American Society of Anesthesiologist score, time from injury to hospital admission, time from admission to surgery, reason for surgical delay beyond 48 hours, perioperative complication rate, and length of postoperative hospitalization.

RESULTS

Patients' mean age, sex distribution, American Society of Anesthesiologist score, and time from injury to hospital admission were similar in both groups. The average waiting time for surgery shortened from a mean of 77 hours before implementing the reimbursement system to 28 hours after the implementation (P < 0.001). Before the reimbursement system implementation, 41% of the surgeries were delayed beyond 48 hours due to medical causes, compared with 20% only after the implementation (P < 0.001). Fewer patients developed perioperative complications in the postimplementation group in comparison with the preimplementation group (9% vs. 13%, respectively); however, because the study was not powered to examine differences in complication rate, the significance of this difference remains unclear.

CONCLUSIONS

A reimbursement system which incentivizes meeting a 48-hour target time for surgery has led to a substantial shortening in the waiting time for surgical fixation of hip fractures in elderly patients in our institution.

Process-related predictors of readmissions and mortality following hip fracture surgery: a population-based analysis

Aim

To study the readmission rates and predictors of readmission following hip fracture surgery in a tertiary care centre with the very short postoperative length of stay.

Findings

Postoperative length of stay of only 1–2 days did not increase the risk of readmissions. Delay to surgery, prolonged length of stay, not receiving orthogeriatric contribution and discharge to primary rather than secondary care were associated higher readmission rate and/or mortality.

Message

Although a very short stay in the operating hospital appears safe, hip fracture patients should not be discharged to primary care wards with insufficient resources for managing the acute postoperative phase.

Purpose

Readmissions are common and complicate recovery after hip fracture. The objective of this study was to study readmission rates, factors associated with readmissions and effects of orthogeriatric liaison service in a setting where patients are discharged typically on the first postoperative day from the operating tertiary care hospital to lower-level health care units.

Methods

A regionally representative cohort of 763 surgically treated hip fracture patients aged ≥ 50 years was included in this retrospective study, based on hospital discharge records. Primary outcome was a 30-day readmission, while the secondary outcome was a composite outcome, defined as readmission or death with a follow-up of 1 year at maximum.

Results

The 30-day readmission rate was 8.3% and 1-year mortality was 22.1%. Short length of stay did not lead to poorer outcomes. Delay from admission to surgery of ≥ 4 days and discharge to primary health care wards were associated with an increased 30-day readmission rate. Age ≥ 90 years, delay to surgery, postoperative length of stay of ≥ 2 days and discharge on a Saturday were associated with higher risk for the composite outcome. Use of orthogeriatric liaison service at the operating hospital was associated with a lower risk of 30-day readmissions (11.8% vs. 6.2%, P = 0.012) whereas in longer follow-up readmissions seemed to cumulate similarly independent of orthogeriatric contribution. Patients living in the largest community in the area were discharged to a secondary care orthogeriatric ward and had a lower risk of 30-day readmissions than other patients (4.8% vs. 10.2%, P = 0.009).

Conclusion

Use of orthogeriatric liaison service and later care at secondary care orthogeriatric ward seem to be beneficial for hip fracture patients in terms of reducing readmissions and mortality. Of the other care-related factors, short delay from admission to surgery and short total length of stay in the operating hospital was also associated with these outcomes, which, however, may relate to the effects of patient characteristics rather than the care process.

Association of Geriatric-Specific Variables with 30-Day Hospital Readmission Risk of Elderly Surgical Patients: A NSQIP Analysis

BACKGROUND

Elderly patients (65 years of age and older) undergo an increasing number of operations performed annually in the US and they present with unique healthcare needs. Preventing postoperative readmission remains an important challenge to improving surgical care. This study examined whether geriatric-specific variables were independently associated with postoperative readmissions of elderly patients.

METHODS

The American College of Surgeons (ACS) Geriatric Surgery Research File (GSRF) was joined with the ACS NSQIP Participant Use Data Files for 2014 to 2016. This data set included 13 GSRF variables and 26 ACS NSQIP variables. Associations between clinically relevant variables and readmission were tested with multivariable logistic regression.

RESULTS

The data represented 6,039 general surgery patients age 65 years and older. Fifty-eight percent of patients had colorectal operations, 19% pancreatic or hepatobiliary, 15% hernia, 4% thyroid or esophageal, and 3% had appendix operations. Twenty-four percent of patients experienced an NSQIP-defined 30-day postoperative complication and 3% died within 30 days after operation. Eleven percent of patients had unplanned 30-day readmission. Standard NSQIP variables, including 30-day composite morbidity (odds ratio [OR] 5.11; 95% CI, 4.24 to 6.16; p < 0.001), reoperation (OR 2.8; 95% CI, 2.07 to 3.79; p < 0.001), and steroid use (1.42; 95% CI, 1.03 to 1.96; p = 0.03) were associated with readmission. In addition, GSRF variables, including incompetent on admission (OR 1.63; 95% CI, 1.11 to 2.38; p = 0.01), fall risk at discharge (OR 1.42; 95% CI, 1.11 to 1.82; p = 0.005), use of mobility aid (OR 1.26; 95% CI, 1.02 to 1.56; p = 0.03), and discharged home with skilled care (OR, 1.22; 95% CI, 1.0 to 1.49; p = 0.04) were associated with readmission.

CONCLUSIONS

Four GSRF and 3 current standard ACS NSQIP variables were important in the evaluation of postoperative readmission of elderly patients. Geriatric-specific variables contributed to the explanation of the relationship between clinical variables and readmissions in elderly surgical patients.

Effectiveness of regional clinical pathways on postoperative length of stay for hip fracture patients: A retrospective observational study using the Japanese Diagnosis Procedure Combination database

BACKGROUND

Regional clinical pathways, a new type of clinical pathway, are practiced with the aim of standardizing and optimizing medical care by cooperation among multiple medical institutions in a region. However, current evaluation of the effectiveness of regional clinical pathways for hip fracture, a major health problem requiring hospitalization for orthopedic surgery, is insufficient. This study aimed to determine the association between regional clinical pathways and postoperative hospital length of stay (LOS) among hip fracture patients. In particular, we focused on the variation in postoperative LOS of hip fracture patients among hospitals and the contribution of regional clinical pathways to this variation.

METHODS

Using data from the Diagnosis Procedure Combination (DPC) database in Japan from April 2011 to March 2013, patients who were diagnosed with "fracture of head and neck of femur" (ICD10 code S72.0) or "pertrochanteric fracture" (S72.1) and received "bipolar hip arthroplasty" or "open reduction and internal fixation" were extracted. A total of 110,133 patients were included. Associations between regional clinical pathways and postoperative LOS were analyzed using cross-sectional analysis with multilevel regression models.

RESULTS

Hospitals that implemented a regional clinical pathway showed a significant reduction (13 days) in the postoperative LOS of hip fracture patients. We found a 16% inter-hospital variation in postoperative LOS, which might be explained by hospital-level implementation of regional clinical pathways. Application of regional clinical pathways at the patient level resulted in a 4-day decrease in postoperative LOS.

CONCLUSIONS

Implementation of regional clinical pathways for hip fracture patients at the hospital level was associated with reduced postoperative LOS, regardless of whether or not pathways were implemented at the patient level. This suggests that regional clinical pathways are effective for patient care management in hospitals.

[Perioperative complications and mortality in elderly patients following surgery for femoral fracture: prospective observational study]

BACKGROUND AND OBJECTIVES

Perioperative management of femoral fractures in elderly patients has been studied to determine modifiable causes of complications and death. The aim of this study was to evaluate the mortality rate and its causes in the elderly population with FF. We also evaluated perioperative complications and their association with postoperative mortality.

METHOD

In this prospective and observational study, we evaluated 182 patients, by questionnaire and electronic medical record, from the moment of hospitalization to one year after surgery. Statistical analyzes using the multivariate Cox proportional hazards model and Kaplan-Meier curves were performed to detect independent mortality factors.

RESULTS

Fifty-six patients (30.8%) died within one year after surgery, and the main cause of death was infection followed by septic shock. The main complication, both preoperatively and postoperatively, was hydroelectrolytic disorder. For every one-unit (one-year) increase in age, the odds ratio for death increased by 4%. With each new preoperative complication, the odds ratio for death increased by 28%. Patients ASA III or IV had a 95% higher odds ratio for death than patiets ASA I or II.

CONCLUSIONS

Increasing age and number of preoperative complications, in addition to ASA classification III or IV, were independent factors of increased risk of death in the population studied. The mortality rate was 30.8%, and infection followed by septic shock was the leading cause of death.

A predictive model for increased hospital length of stay following geriatric hip fracture

BACKGROUND

The purpose of this study was to identify the risk factors that are significantly associated with hospital length of stay (LOS) following geriatric hip fracture and to use these significant variables to develop a LOS calculator.

MATERIALS AND METHODS

This was a retrospective study examining 614 patients treated for geriatric hip fracture between January 2000 and December 2009 at an urban, Level 1 trauma center. A negative binomial regression analysis was used to identify perioperative variables associated with hospital LOS.

RESULTS

614 patients met the inclusion criteria, presenting with a mean age of 78 (±10) years. The most common pre-operative comorbidity was hypertension, followed by diabetes and COPD. After controlling for all collected comorbidities as well as demographics and operative variables, hypertension (IRR: 1.10, p = 0.029) and disseminated cancer (IRR: 1.24, p = 0.007) were found to be significantly associated with LOS. In addition, two demographic/presenting variables, admission to the medicine service (IRR: 1.48, p < 0.001) and male sex (IRR: 1.09, p = 0.034), were shown to be independent risk factors for prolonged LOS. These variables were synthesized into a LOS formula, which estimated LOS to within 3 days of the true length of stay for 0.758 of the series (95% confidence interval: 0.661 to 0.855).

CONCLUSIONS

This study identified several comorbidity and perioperative variables that were significantly associated with LOS following geriatric hip fracture surgery. The resulting LOS model may have utility in the risk stratification of orthopaedic trauma patients presenting with hip fracture.

Cost-Effectiveness of Osteoporosis Interventions to Improve Quality of Care After Upper Extremity Fracture: Results From a Randomized Trial (C-STOP Trial)

We assessed the cost-effectiveness of two models of osteoporosis care after upper extremity fragility fracture using a high-intensity Fracture Liaison Service (FLS) Case-Manager intervention versus a low-intensity FLS (ie, Active Control), and both relative to usual care. This analysis used data from a pragmatic patient-level parallel-arm comparative effectiveness trial of 361 community-dwelling participants 50 years or older with upper extremity fractures undertaken at a Canadian academic hospital. We used a decision-analytic Markov model to evaluate the cost-effectiveness of the three treatment alternatives. The perspective was health service payer; the analytical horizon was lifetime; costs and health outcomes were discounted by 3%. Costs were expressed in 2016 Canadian dollars (CAD) and the health effect was measured by quality adjusted life years (QALYs). The average age of enrolled patients was 63 years and 89% were female. Per patient cost of the Case Manager and Active Control interventions were $66CAD and $18CAD, respectively. Compared to the Active Control, the Case Manager saved $333,000, gained seven QALYs, and averted nine additional fractures per 1000 patients. Compared to usual care, the Case Manager saved $564,000, gained 14 QALYs, and incurred 18 fewer fractures per 1000 patients, whereas the Active Control saved $231,000, gained seven QALYs, and incurred nine fewer fractures per 1000 patients. Although both interventions dominated usual care, the Case Manager intervention also dominated the Active Control. In 5000 probabilistic simulations, the probability that the Case Manager intervention was cost-effective was greater than 75% whereas the Active Control intervention was cost-effective in less than 20% of simulations. In summary, although the adoption of either of these approaches into clinical settings should lead to cost savings, reduced fractures, and increased quality-adjusted life for older adults following upper extremity fracture, the Case Manager intervention would be the most likely to be cost-effective. © 2019 American Society for Bone and Mineral Research.

Comprehensive Hip Fracture Care Program: Successive Implementation in 3 Hospitals

Introduction:

Hip fractures are common and costly in the elderly population, often contributing to loss of function and independence. Prompt, coordinated surgical care may improve clinical and economic outcomes for this population.

Materials and Methods:

We created an interdisciplinary care program focused on minimizing time spent immobilized awaiting surgery and streamlining the care pathway for hip fracture. Patients older than 65 years with any hip fracture type including hip fracture repair Diagnosis-Related Group codes (MS-DRG 480, 481, or 482) and MS-DRG 469 and 470 with a hip fracture diagnosis were included in the study. The Hip Fracture Care program (HFCP) was implemented on a staggered basis in 3 hospitals in the HonorHealth system. Time to surgery, length of stay, and discharge location (home/skilled nursing facility) were compared pre- and post-intervention, utilizing an interrupted time series analysis to account for background trends.

Results:

More than 2000 patients across the 3 facilities received HFCP care; demographics were similar for the 826 patients serving as the pre-implementation comparison group. Mean (standard deviation [SD]) length of stay decreased from 5.6 (4.0) to 4.7 (2.9) days (mean difference 0.9 days; P < .05). Mean (SD) time from admission to the operating room decreased from 30.8 (21.1) to 25.6 (20.5) hours (mean difference 5.2 hours; P < .05). There was no change in the proportion of patients discharged to home versus skilled nursing facility.

Discussion:

Optimal care of this vulnerable population can significantly reduce the time to surgery and length of stay.

Conclusions:

Length of stay was reduced by nearly 1 day with implementation of a multifactorial program for hip fracture care.

Clinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture

STUDY OBJECTIVE

To identify modifiable preoperative factors that might influence the morbidity and mortality associated with non-elective, inpatient hip fracture surgeries in the geriatric surgical population.

DESIGN

Retrospective database analysis from the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project.

SETTING

Inpatient, perioperative.

PATIENTS

Geriatric patients undergoing surgery.

INTERVENTIONS

Non-elective hip repair surgery.

MEASUREMENTS

Preoperative demographic, medical, surgical, and anesthetic variables; post-operative rates of delirium, decline in functional status, and 30-day mortality.

MAIN RESULTS

The 1261 patients in this study were predominantly female (74%), white (89%), and non-Hispanic (92%). Ages were distributed across groups from 65 to over 90 years. Most patients were categorized as American Society of Anesthesiologists Physical Status class 3 (64%). General anesthesia (57%) was the most common anesthetic, followed by spinal (38%). Preoperative functional status was recorded in 79% as independent in activities of daily living (ADLs). About one third of patients had baseline dementia. Post-operatively, 42% experienced delirium, and most patients required partial or total assistance with ADLs (72% and 12%, respectively). Reoperation was required in 2.8% of cases. Mortality at 30 days was 5.0%. In the multivariable analysis, risk factors associated with post-operative delirium included dementia and lack of competency to sign consent. In the analysis for postoperative decline in functional status, the major risk factor was a history of falls, while emergently performed surgery was protective. The analysis for mortality at thirty days was under-powered.

CONCLUSIONS

Hip fractures remain a major source of morbidity in geriatric patients. Baseline dementia and inability to sign surgical consent are significant risk factors for adverse outcomes after hip fractures and should be considered in the informed consent process. Data from this study and currently ongoing randomized trials will help guide reductions in morbidity and mortality in this population.

Geriatric fracture centers-improved patient care and economic benefits : English Version

The world's population is aging resulting in changes in the way we manage geriatric care. Furthermore, this population has a considerable risk of fragility fractures, most notably hip fractures. Hip fractures are associated with significant morbidity and mortality and have large economic consequences. It is due to these factors that the concept of an elderly trauma center was developed. These trauma centers utilize the expertise in orthopedic and geriatric disciplines to provide coordinated care to the elderly hip fracture patient. As a result, studies have demonstrated improvements in clinical outcomes within the hospital stay, a reduction in iatrogenic complications, and improvements in 1-year mortality rates compared to the usual care given at a similar facility. Furthermore, economic models have demonstrated that there is a role for regionalized hip fracture centers that can be both profitable and provide more efficient care to these patients.

Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay

BACKGROUND

Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway.

METHODS

A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016.

RESULTS

LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications.

DISCUSSION

Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program.

LEVEL OF EVIDENCE

III.

Is There an Influence of Surgeon's Experience on the Clinical Course in Patients With a Proximal Femoral Fracture?

OBJECTIVES

Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome.

DESIGN AND SETTING

Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders.

PARTICIPANTS

In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures.

RESULTS

There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders.

CONCLUSIONS

There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.

Patient and Caregiver Understanding of Prognosis After Hip Fracture

Background

Hip fracture (HF) is common and requires communication between patient, family, surgeons, and hospitalists. Patient and family understanding of the seriousness of HF is unclear.

Methods

We interviewed older patients (age > 65 years) hospitalized with HF at two Canadian academic hospitals, or their surrogate decision-makers (SDMs). We used qualitative methods to explore understanding of HF treatment options and prognosis. Participants estimated probability of mortality and living independently 30 days after surgery. Results were compared with estimates from the National Surgery Quality Improvement Program (NSQIP) surgical risk calculator.

Results

9 patients and 3 SDMs were interviewed. Mean age of 12 patients was 82.5 years (75% female). Participants were uncertain about recovery timeline and degree of functional recovery, as well as content and duration of rehabilitation. Participants’ mean estimated 30-day mortality of 6.7% did not differ significantly from estimated mortality predicted by NSQIP (7.5%; p = .88). Participants’ mean estimated probability of living independently 30 days after surgery was 90.8% (range 65–100%).

Conclusions

Older patients and SDMs lack understanding about prognosis and functional recovery even after providing informed consent for HF surgery. Clinical teams should improve communication of prognosis and recovery information to patients and surrogates.

Systematic Changes in the National Surgical Quality Improvement Program Database Over the Years Can Affect Comorbidity Indices Such as the Modified Frailty Index and Modified Charlson Comorbidity Index for Lumbar Fusion Studies

STUDY DESIGN

Retrospective cohort study of prospectively collected data.

OBJECTIVE

The aim of this study was to investigate the influence of changes in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database over the years on the calculation of the modified Frailty Index (mFI) and the modified Charlson Comorbidity Index (mCCI) for posterior lumbar fusion studies.

SUMMARY OF BACKGROUND DATA

Multiple studies have utilized the mFI and/or mCCI and showed them to be predictors of adverse postoperative outcomes. However, changes in the NSQIP database have resulted in definition changes and/or missing data for many of the variables included in these indices. No studies have assessed the influence of different methods of treating missing values when calculating these indices on such studies.

METHODS

Elective posterior lumbar fusions were identified in NSQIP from 2005 to 2014. The mFI was calculated for each patient using three methods: treating conditions for which data was missing as not present, dropping patients with missing values, and normalizing by dividing the raw score by the number of variables collected. The mCCI was calculated by the first two of these methods. Mean American Society of Anesthesiologists (ASA) scores used for comparison.

RESULTS

In total, 19,755 patients were identified. Mean ASA score increased between 2005 and 2014 from 2.27 to 2.50 (+10.1%). For each of the methods of data handling noted above, mean mFI over the years studied increased by 33.3%, could not be calculated, and increased by 183.3%, respectively. Mean mCCI increased by 31.2% and could not be calculated respectively.

CONCLUSION

Systematic changes in the NSQIP database have resulted in missing data for many of the variables included in the mFI and the mCCI and may affect studies utilizing these indices. These changes can be understood in the context of ASA trends, and raise questions regarding the use of these indices with data available in later NSQIP years.

LEVEL OF EVIDENCE

3.

The Rothman Index Is Associated With Postdischarge Adverse Events After Hip Fracture Surgery in Geriatric Patients

BACKGROUND

The Rothman Index is a comprehensive measure of overall patient status in the inpatient setting already in use at many medical centers. It ranges from 100 (best score) to -91 (worst score) and is calculated based on 26 variables encompassing vital signs, routine laboratory values, and organ system assessments from nursing rounds from the electronic medical record. Past research has shown an association of Rothman Index with complications, readmission, and death in certain populations, but it has not been evaluated in geriatric patients with hip fractures, a potentially vulnerable patient population.

QUESTIONS/PURPOSES

(1) Is there an association between Rothman Index scores and postdischarge adverse events in a population aged 65 years and older with hip fractures? (2) What is the discriminative ability of Rothman Index scores in determining which patients will or will not experience these adverse events? (3) Are there Rothman Index thresholds associated with increased incidence of postdischarge adverse outcomes?

METHODS

One thousand two hundred fourteen patients aged 65 years and older who underwent hip fracture surgery at an academic medical center between 2013 and 2016 were identified. Demographic and comorbidity characteristics were characterized, and 30-day postdischarge adverse events were calculated. The associations between a 10-unit change in Rothman Index scores and postdischarge adverse events, mortality, and readmission were determined. American Society of Anesthesiologists (ASA) class was used as a measure of comorbidity because prior research has shown its performance to be equivalent or superior to that of calculated comorbidity measures in this data set. We assessed the ability of Rothman Index scores to determine which patients experienced adverse events. Finally, Rothman Index thresholds were assessed for an association with increased incidence of postdischarge adverse outcomes.

RESULTS

We found a strong association between Rothman Index scores and postdischarge adverse events (lowest score: odds ratio [OR] = 1.29 [1.18-1.41], p < 0.001; latest score: OR = 1.37 [1.24-1.52], p < 0.001) after controlling for age, sex, body mass index, ASA class, and surgical procedure performed. The discriminative ability of lowest and latest Rothman Index scores was better than those of age, sex, and ASA class for any adverse event (lowest value: area under the curve [AUC] = 0.641; 95% confidence interval [CI], 0.601-0.681; latest value: AUC = 0.640; 95% CI, 0.600-0.680); age (0.534; 95% CI, 0.493-0.575, p < 0.001 for both), male sex (0.552; 95% CI, 0.518-0.585, p = 0.001 for both), and ASA class (0.578; 95% CI, 0.542-0.614; p = 0.004 for lowest Rothman Index, p = 0.006 for latest Rothman Index). There was never a difference when comparing lowest Rothman Index value and latest Rothman Index value for any of the outcomes (Table 5). Patients experienced increased rates of postdischarge adverse events and mortality with a lowest Rothman Index of ≤ 35 (p < 0.05) or latest Rothman Index of ≤ 55 (p < 0.05).

CONCLUSIONS

The Rothman Index provides an objective method of assessing perioperative risk in the setting of hip fracture surgery in patients older than age 65 years and is more accurate than demographic measures or ASA class. Furthermore, there are Rothman Index thresholds that can be used to identify patients at increased risk of complications. Physicians can use this tool to monitor the condition of patients with hip fracture, recognize patients at high risk of adverse events to consider changing their plan of care, and counsel patients and families. Further investigation is needed to determine whether interventions based on Rothman Index values contribute to improved outcomes or value of hip fracture care.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Incidence, Risk Factors, and Clinical Implications of Pneumonia After Surgery for Geriatric Hip Fracture

BACKGROUND

Little is known regarding the occurrence of pneumonia after hip fracture surgery. The purpose of this study is to determine the incidence, risk factors, and clinical implications of pneumonia after surgery for geriatric hip fracture.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to retrospectively study geriatric patients undergoing surgery for hip fracture during 2006-2014. Independent risk factors for developing pneumonia within 30 days of surgery were identified using multivariate regression.

RESULTS

Of the 29,377 patients meeting inclusion criteria, 13,736 (46.8%) underwent hemiarthroplasty, 9468 (32.2%) intramedullary fixation, 4294 (14.6%) plate and/or screw fixation, 1299 (4.4%) total joint arthroplasty, and 580 (2.0%) percutaneous fixation. In total 1191 patients developed pneumonia, an incidence of 4.1%. The strongest risk factors for pneumonia were male sex, older age (especially ≥90 years), low body mass index, and chronic obstructive pulmonary disease. Patients who developed pneumonia had a higher readmission rate (79.1% vs 8.2%, P < .001), a higher rate of sepsis (16.6% vs 1.7%, P < .001), and a higher mortality rate (29.2% vs 5.7%, P < .001). Among 1602 total mortalities, 348 (17.9%) occurred in patients with pneumonia.

CONCLUSION

Pneumonia is a serious complication after geriatric hip fracture surgery, which increases the readmission and mortality risks. Evidence-based pneumonia prevention programs should be implemented among high-risk patients-males, patients ≥90 years, body mass index <18.5 kg/m², and/or patients with chronic obstructive pulmonary disease-to decrease morbidity and mortality.

How Common-and How Serious- Is Clostridium difficile Colitis After Geriatric Hip Fracture? Findings from the NSQIP Dataset

BACKGROUND

Patients with geriatric hip fractures may be at increased risk for postoperative Clostridium difficile colitis, which can cause severe morbidity and can influence hospital quality metrics. However, to our knowledge, no large database study has calculated the incidence of, factors associated with, and effect of C. difficile colitis on geriatric patients undergoing hip fracture surgery.

QUESTIONS/PURPOSES

To use a large national database with in-hospital and postdischarge data (National Surgical Quality Improvement Program [NSQIP®]) to (1) determine the incidence and timing of C. difficile colitis in geriatric patients who underwent surgery for hip fracture, (2) identify preoperative and postoperative factors associated with the development of C. difficile colitis in these patients, and (3) test for an association between C. difficile colitis and postoperative length of stay, 30-day readmission, and 30-day mortality.

PATIENTS AND METHODS

This is a retrospective study. Patients who were 65 years or older who underwent hip fracture surgery were identified in the 2015 NSQIP database. The primary outcome was a diagnosis of C. difficile colitis during the 30-day postoperative period. Preoperative and procedural factors were tested for association with the development of C. difficile colitis through a backward stepwise multivariate model. Perioperative antibiotic type and duration were not included in the model, as this information was not recorded in the NSQIP. The association between C. difficile colitis and postoperative length of stay, 30-day readmission, and 30-day mortality were tested through multivariate regressions, which adjusted for preoperative and procedural characteristics such as age, comorbidities, and surgical procedure. A total of 6928 patients who were 65 years or older and underwent hip fracture surgery were identified.

RESULTS

The incidence of postoperative C. difficile colitis was 1.05% (95% CI, 0.81%-1.29%; 73 of 6928 patients). Of patients who had C. difficile colitis develop, 64% (47 of 73 patients) were diagnosed postdischarge and 79% (58 of 73 patients) did not have a preceding infectious diagnosis. Preoperative factors identifiable before surgery that were associated with the development of C. difficile colitis included admission from any type of chronic care facility (versus admitted from home; relative risk [RR] = 1.98; 95% CI, 1.11-3.55; p = 0.027), current smoker within 1 year (RR = 1.95; 95% CI, 1.03-3.69; p = 0.041), and preoperative anemia (RR = 1.76; 95% CI, 1.07-2.92; p = 0.027). Patients who had pneumonia (RR = 2.58; 95% CI, 1.20-5.53; p = 0.015), sepsis (RR = 4.20; 95% CI, 1.27-13.82; p = 0.018), or "any infection" (RR = 2.26; 95% CI, 1.26-4.03; p = 0.006) develop after hip fracture were more likely to have C. difficile colitis develop. Development of C. difficile colitis was associated with greater postoperative length of stay (22 versus 5 days; p < 0.001), 30-day readmission (RR = 3.41; 95% CI, 2.17-5.36; p < 0.001), and 30-day mortality (15% [11 of 73 patients] versus 6% [439 of 6855 patients]; RR = 2.16; 95% CI, 1.22-3.80; p = 0.008).

CONCLUSIONS

C. difficile colitis is a serious infection after hip fracture surgery in geriatric patients that is associated with 15% mortality. Patients at high risk, such as those admitted from any type of chronic care facility, those who had preoperative anemia, and current smokers within 1 year, should be targeted with preventative measures. From previous studies, these measures include enforcing strict hand hygiene with soap and water (not alcohol sanitizers) if a provider is caring for patients at high risk and those who are C. difficile-positive. Further, other studies have shown that certain antibiotics, such as fluoroquinolones and cephalosporins, can predispose patients to C. difficile colitis. These medications perhaps should be avoided when prescribing prophylactic antibiotics or managing infections in patients at high risk. Future prospective studies should aim to determine the best prophylactic antibiotic regimens, probiotic formula, and discharge timing that minimize postoperative C. difficile colitis in patients with hip fractures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Missing data may lead to changes in hip fracture database studies: a study of the American College of Surgeons National Surgical Quality Improvement Program

AIMS

The aims of this study were to characterize the frequency of missing data in the National Surgical Quality Improvement Program (NSQIP) database and to determine how missing data can influence the results of studies dealing with elderly patients with a fracture of the hip.

PATIENTS AND METHODS

Patients who underwent surgery for a fracture of the hip between 2005 and 2013 were identified from the NSQIP database and the percentage of missing data was noted for demographics, comorbidities and laboratory values. These variables were tested for association with 'any adverse event' using multivariate regressions based on common ways of handling missing data.

RESULTS

A total of 26 066 patients were identified. The rate of missing data was up to 77.9% for many variables. Multivariate regressions comparing three methods of handling missing data found different risk factors for postoperative adverse events. Only seven of 35 identified risk factors (20%) were common to all three analyses.

CONCLUSION

Missing data is an important issue in national database studies that researchers must consider when evaluating such investigations. Cite this article: Bone Joint J 2018;100-B:226-32.

Serum Albumin Predicts Survival and Postoperative Course Following Surgery for Geriatric Hip Fracture

BACKGROUND

Serum albumin level is the most well-established serum marker of malnutrition, with a serum albumin concentration <3.5 g/dL considered to be suggestive of malnutrition. The purpose of this study was to test if serum albumin level is associated with death, specific postoperative complications (e.g., pneumonia), length of hospital stay, and readmission following a surgical procedure for geriatric hip fracture.

METHODS

A retrospective cohort study of geriatric patients (≥65 years of age) undergoing a hip fracture surgical procedure as part of the American College of Surgeons National Surgical Quality Improvement Program was conducted. Outcomes were compared between patients with and without hypoalbuminemia. All comparisons were adjusted for baseline and procedural differences between populations, and patients with missing serum albumin concentration were included in analyses using a missing data indicator.

RESULTS

There were 29,377 geriatric patients undergoing a hip fracture surgical procedure who met inclusion criteria; of these patients, 17,651 (60.1%) had serum albumin available for analysis. The prevalence of hypoalbuminemia was 45.9%. Following adjustment for baseline and procedural characteristics, the risk of death was inversely associated with serum albumin concentration as a continuous variable (adjusted relative risk, 0.59 [95% confidence interval (CI), 0.53 to 0.65]; p < 0.001). In comparison with patients with normal albumin concentration, patients with hypoalbuminemia had higher rates of death (9.94% compared with 5.53% [adjusted relative risk, 1.52 (95% CI, 1.37 to 1.70); p < 0.001]), sepsis (1.19% compared with 0.53% [adjusted relative risk, 1.92 (95% CI, 1.36 to 2.72); p < 0.001]), and unplanned intubation (2.64% compared with 1.47% [adjusted relative risk, 1.51 (95% CI, 1.21 to 1.88); p < 0.001]). The mean length of stay (and standard deviation) was longer among patients with hypoalbuminemia at 5.67 ± 4.68 days compared with those without hypoalbuminemia at 4.99 ± 3.95 days; the adjusted difference was 0.50 day (95% CI, 0.38 to 0.63 day; p < 0.001). However, the rate of readmission did not differ (p = 0.054) between patients with hypoalbuminemia (10.91%) and those without hypoalbuminemia (9.03%); the adjusted relative risk was 1.10 (95% CI, 1.00 to 1.21).

CONCLUSIONS

Hypoalbuminemia is a powerful independent risk factor for mortality following a surgical procedure for geriatric hip fracture. These data suggest that further investigation into postoperative nutritional supplementation is warranted to decrease the risk of complications.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Results of Database Studies in Spine Surgery Can Be Influenced by Missing Data

BACKGROUND

National databases are increasingly being used for research in spine surgery; however, one limitation of such databases that has received sparse mention is the frequency of missing data. Studies using these databases often do not emphasize the percentage of missing data for each variable used and do not specify how patients with missing data are incorporated into analyses. This study uses the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to examine whether different treatments of missing data can influence the results of spine studies.

QUESTIONS/PURPOSES

(1) What is the frequency of missing data fields for demographics, medical comorbidities, preoperative laboratory values, operating room times, and length of stay recorded in ACS-NSQIP? (2) Using three common approaches to handling missing data, how frequently do those approaches agree in terms of finding particular variables to be associated with adverse events? (3) Do different approaches to handling missing data influence the outcomes and effect sizes of an analysis testing for an association with these variables with occurrence of adverse events?

METHODS

Patients who underwent spine surgery between 2005 and 2013 were identified from the ACS-NSQIP database. A total of 88,471 patients undergoing spine surgery were identified. The most common procedures were anterior cervical discectomy and fusion, lumbar decompression, and lumbar fusion. Demographics, comorbidities, and perioperative laboratory values were tabulated for each patient, and the percent of missing data was noted for each variable. These variables were tested for an association with "any adverse event" using three separate multivariate regressions that used the most common treatments for missing data. In the first regression, patients with any missing data were excluded. In the second regression, missing data were treated as a negative or "reference" value; for continuous variables, the mean of each variable's reference range was computed and imputed. In the third regression, any variables with > 10% rate of missing data were removed from the regression; among variables with ≤ 10% missing data, individual cases with missing values were excluded. The results of these regressions were compared to determine how the different treatments of missing data could affect the results of spine studies using the ACS-NSQIP database.

RESULTS

Of the 88,471 patients, as many as 4441 (5%) had missing elements among demographic data, 69,184 (72%) among comorbidities, 70,892 (80%) among preoperative laboratory values, and 56,551 (64%) among operating room times. Considering the three different treatments of missing data, we found different risk factors for adverse events. Of 44 risk factors found to be associated with adverse events in any analysis, only 15 (34%) of these risk factors were common among the three regressions. The second treatment of missing data (assuming "normal" value) found the most risk factors (40) to be associated with any adverse event, whereas the first treatment (deleting patients with missing data) found the fewest associations at 20. Among the risk factors associated with any adverse event, the 10 with the greatest effect size (odds ratio) by each regression were ranked. Of the 15 variables in the top 10 for any regression, six of these were common among all three lists.

CONCLUSIONS

Differing treatments of missing data can influence the results of spine studies using the ACS-NSQIP. The current study highlights the importance of considering how such missing data are handled.

CLINICAL RELEVANCE

Until there are better guidelines on the best approaches to handle missing data, investigators should report how missing data were handled to increase the quality and transparency of orthopaedic database research. Readers of large database studies should note whether handling of missing data was addressed and consider potential bias with high rates or unspecified or weak methods for handling missing data.

Nutritional markers may identify patients with greater risk of re-admission after geriatric hip fractures

PURPOSE

Osteoporotic hip fractures are increasing in prevalence with the growing elderly population. Morbidity and mortality remain high following osteoporotic hip fractures despite advances in medical and surgical treatments. The associated costs and medical burdens are increased with a re-admission following hip fracture treatment. This study sought to identify demographic and clinical values that may be a predictive model for 30-day re-admission risk following operative management of an isolated hip fracture.

METHODS

Between January 1, 2013 and April 30, 2015 all patients admitted to a single academic medical centre for treatment of a hip fracture were reviewed. Candidate variables included standard demographics, common laboratory values, and markers of comorbid conditions and nutrition status. A 30-day, all-cause re-admission model was created utilizing multivariate logistic regression.

RESULTS

A total of 607 patients with hip fractures were identified and met the inclusion criteria; of those patients, 67 were re-admitted within 30 days. Univariate analysis indicates that the re-admission group had more comorbidities (p < 0.001) and lower albumin (p = 0.038) and prealbumin (p < 0.001). The final, reduced model contained 12 variables and incorporated four out of five nutritional makers with an internally, cross-validated C-statistic of 0.811 (95% CI: 0.754, 0.867).

CONCLUSION

Our results indicate that specific nutritional laboratory markers at the index admission may identify patients that have a greater risk of re-admission after hip fracture. This model identifies potentially modifiable risk factors and may allow orthogeriatricians to better educate patients and better treat post-operative nutritional status and care.