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Adeyemi OJ, Gibbons K, Schwartz LB, Meltzer-Bruhn AT, Esper GW, Grudzen C, DiMaggio C, Chodosh J, Egol KA, Konda SR. Diagnostic Accuracy of a Trauma Risk Assessment Tool Among Geriatric Patients With Crash Injuries. J Healthc Qual 2023; 45:340-351. [PMID: 37919956 DOI: 10.1097/jhq.0000000000000402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
ABSTRACT The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a risk stratification tool. We evaluated the STTGMA's accuracy in predicting 30-day mortality and the odds of unfavorable clinical trajectories among crash-related trauma patients. This retrospective cohort study (n = 912) pooled adults aged 55 years and older from a single institutional trauma database. The data were split into training and test data sets (70:30 ratio) for the receiver operating curve analysis and internal validation, respectively. The outcome variables were 30-day mortality and measures of clinical trajectory. The predictor variable was the high-energy STTGMA score (STTGMAHE). We adjusted for the American Society of Anesthesiologists Physical Status. Using the training and test data sets, STTGMAHE exhibited 82% (95% CI: 65.5-98.3) and 96% (90.7-100.0) accuracies in predicting 30-day mortality, respectively. The STTGMA risk categories significantly stratified the proportions of orthopedic trauma patients who required intensive care unit (ICU) admissions, major and minor complications, and the length of stay (LOS). The odds of ICU admissions, major and minor complications, and the median difference in the LOS increased across the risk categories in a dose-response pattern. STTGMAHE exhibited an excellent level of accuracy in identifying middle-aged and geriatric trauma patients at risk of 30-day mortality and unfavorable clinical trajectories.
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Parola R, Ganta A, Egol KA, Konda SR. Trauma Risk Score Matching for Observational Studies in Orthopedic Trauma. Injury 2022; 53:440-444. [PMID: 34916032 DOI: 10.1016/j.injury.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/27/2021] [Accepted: 12/01/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if matching by trauma risk score is non-inferior to matching by chronic comorbidities and/or a combination of demographic and patient characteristics in observational studies of acute trauma in a hip fracture model. DESIGN Retrospective cohort study SETTING: Level-1 Trauma Center PATIENTS: 1,590 hip fracture [AO/OTA 31A and 31B] patients age 55 and over treated between October 2014 and February 2020 at 4 hospitals within a single academic medical center. INTERVENTION Repeatedly matching randomized subsets of patients by (1) Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA), (2) Charlson Comorbidity Index (CCI), or (3) a combination of sex, age, CCI and body mass index (BMI). MAIN OUTCOME MEASUREMENTS "Matching failures" where rate of significant differences in variables of matched cohorts exceeds the 5% expected by chance. RESULTS STTGMA and combination matching resulted in no "matching failures". Matching by CCI alone resulted in "matching failures" of BMI, ASA class, STTGMA, major complications, sepsis, pneumonia, acute respiratory failure, and 90-day readmission. CONCLUSIONS STTGMA matching in observational cohort studies is less likely to yield significant differences of demographics and outcomes than CCI matching. STTGMA matching is noninferior to matching a combination of demographic variables optimized for each treatment cohort. STTGMA matching is apt to reflect equipoise of health at admission and outcome likelihood in observational cohort studies of orthopedic trauma, while maintaining consistent weighting of demographic and injury characteristic variables that may expand the generalizability of these studies. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rown Parola
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY.
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Risk Stratification of Operatively Treated Intertrochanteric Hip Fractures Reveals Differences in Short-Term Outcomes and Procedure Costs Between Sliding Hip Screw Versus Short Cephalomedullary Nail. J Am Acad Orthop Surg Glob Res Rev 2021. [PMCID: PMC8654425 DOI: 10.5435/jaaosglobal-d-21-00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study sought to retrospectively compare short-term outcomes between sliding hip screw (SHS) fixation versus short cephalomedullary nailing (CMN) in a risk-stratified cohort of geriatric intertrochanteric hip fracture patients. Data of 458 patients, aged 55 years and older, who sustained intertrochanteric fractures (OTA 31A1-3) and were treated with either SHS or short CMN from October 2014 to March 2019 were collected. Patient demographics, injury severity, and functional status were used to calculate a score using the Score for Trauma Triage in the Geriatric and Middle-Aged system. Based on the Score for Trauma Triage in the Geriatric and Middle-Aged tool, 229 patients (50%) were placed into a low-risk cohort, whereas 229 patients (50%) were placed into a high-risk cohort.
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Konda SR, Perskin CR, Parola R, Littlefield CP, Egol KA. Established Trauma Triage Score Predicts Risk of Falling After Femoral Neck Fracture Arthroplasty Surgery. J Healthc Qual 2021; 43:e91-e97. [PMID: 34108405 DOI: 10.1097/jhq.0000000000000311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The purpose of this study is to determine whether the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) patients is able to predict fall, fracture, periprosthetic fracture, or dislocation risk after femoral neck fracture arthroplasty surgery. METHODS Four hundred one patients who underwent hip arthroplasty surgery after a femoral neck fracture at one urban academic medical center were stratified into groups based on their risk scores assigned at femoral neck fracture presentation. The cohort was reviewed for the occurrence of postdischarge falls, secondary fractures, and prosthetic dislocations that resulted in a presentation to the emergency department (ED) after discharge from their hip fracture surgery. The incidence and timing of these complications after discharge were compared between the low-risk and high-risk groups. RESULTS The low-risk group included 201 patients, and the high-risk group included 200 patients. The high-risk group had significantly more postdischarge falls resulting in ED presentation (49 vs. 32, p = .035) that occurred significantly sooner (12.6 vs. 18.3 months, p = .034) after discharge. CONCLUSIONS The STTGMA model was able to successfully stratify patients who are at a higher risk of sustaining a fall after an arthroplasty procedure for a femoral neck fracture.
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Ganta A, Parola R, Perskin CR, Konda SR, Egol KA. Risk factors and associated outcomes of acute kidney injury in hip fracture patients. J Orthop 2021; 26:115-118. [PMID: 34385809 DOI: 10.1016/j.jor.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/23/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose To assess risk factors and associated outcomes of acute kidney injury (AKI) in hip fracture patients. Methods Risk factors for AKI were identified by multivariate logistic regression. AKI patients were matched to patients who did not experience AKI using a validated trauma triage score. Comparative analyses between matched groups were performed. Results Risk factors of AKI included increasing Charlson Comorbidity Index and use of anticoagulation medications. AKI was associated with increased likelihood of medical complications and longer, more costly hospital stays. Discussion Patients with identified risk factors for AKI may benefit from consultation with nephrology and closer lab monitoring.
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Affiliation(s)
- Abhishek Ganta
- NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10010, United States.,Jamaica Hospital Medical Center, 8900 Van Wyck Expy, Richmond Hill, NY, 11418, United States
| | - Rown Parola
- NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10010, United States
| | - Cody R Perskin
- NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10010, United States
| | - Sanjit R Konda
- NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10010, United States.,Jamaica Hospital Medical Center, 8900 Van Wyck Expy, Richmond Hill, NY, 11418, United States
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY, 10010, United States.,Jamaica Hospital Medical Center, 8900 Van Wyck Expy, Richmond Hill, NY, 11418, United States
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Konda SR, Perskin CR, Parola R, Robitsek RJ, Ganta A, Egol KA. Trauma Risk Score Also Predicts Blood Transfusion Requirements in Hip Fracture Patients. Geriatr Orthop Surg Rehabil 2021; 12:21514593211038387. [PMID: 34395049 PMCID: PMC8361552 DOI: 10.1177/21514593211038387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/27/2021] [Accepted: 07/21/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction The purpose of this study is to determine if the risk of receiving a blood transfusion during hip fracture hospitalization can be predicted by a validated risk profiling score (Score for Trauma Triage in Geriatric and Middle Aged (STTGMA)). Materials and Methods A consecutive series of 1449 patients 55 years and older admitted for a hip fracture at one academic medical center were identified from a trauma database. The STTGMA risk score was calculated for each patient. Patients were stratified into risk groups based on their STTGMA score quantile: minimal risk (0–50%), low risk (50–80%), moderate risk (80–95%), and high risk (95–100%). Incidence and volume of blood transfusions were compared between risk groups. Results There were 562 (38.8%) patients who received a transfusion during their admission. 58.3% of patients in the high risk group received a transfusion during admission compared to 31.2% of minimal risk group patients, 42.6% of low risk group patients, and 50.0% of moderate risk group patients (p < 0.001). STTGMA was predictive of first transfusion incidence in both the preoperative and postoperative periods. There was no difference in mean total transfusion volume between the four risk groups. Conclusion The STTGMA model is capable of risk stratifying hip fracture patients more likely to receive blood transfusions during hospitalization. Surgeons can use this tool to anticipate transfusion requirements.
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Affiliation(s)
- Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Cody R Perskin
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Rown Parola
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - R Jonathan Robitsek
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
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Ong CB, Krueger CA, Star AM. The Hospital Frailty Risk Score is Not an Accurate Predictor of Treatment Costs for Total Joint Replacement Patients in a Medicare Bundled Payment Population. J Arthroplasty 2021; 36:2658-2664.e2. [PMID: 33893001 DOI: 10.1016/j.arth.2021.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Medically complex patients require more resources and experience higher costs within total joint arthroplasty (TJA) bundled payment models. While risk adjustment would be beneficial for such patients, no tool currently exists which can reliably identify these patients preoperatively. The purpose of this study is to determine if the Hospital Frailty Risk Score (HFRS) is a valid predictor of high-TJA treatment costs. METHODS Retrospective analysis was performed on patients who underwent primary TJA between 2015 and 2020 from a single large orthopedic practice. ICD-10 codes from an institutional database were used to calculate HFRS. Cost data including inpatient, postacute, and episode of care (EOC) costs were collected. Charlson comorbidity index, demographics, readmissions, and complications were analyzed. RESULTS 4936 patients had a calculable HFRS and those with intermediate and high scores experienced more frequent readmissions/complications after TJA, as well as higher EOC costs. However, HFRS did not reliably predict EOC costs, yielding a sensitivity of 49% and specificity of 66%. Multivariate analysis revealed that both patient age and sex are superior individual cost predictors when compared with HFRS. Secondary analyses indicated that HFRS more effectively predicts TJA complications and readmissions but is still nonideal for clinical applications. CONCLUSION HFRS has poor sensitivity as a predictor of high-EOC costs for TJA patients but has adequate specificity for predicting postoperative readmissions and complications. Further research is needed to develop a scale that can appropriately predict orthopedic cost outcomes.
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Affiliation(s)
- Christian B Ong
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Andrew M Star
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Konda SR, Dedhia N, Ranson RA, Tong Y, Ganta A, Egol KA. Loss of Ambulatory Level and Activities of Daily Living at 1 Year Following Hip Fracture: Can We Identify Patients at Risk? Geriatr Orthop Surg Rehabil 2021; 12:21514593211002158. [PMID: 33868763 PMCID: PMC8020397 DOI: 10.1177/21514593211002158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Operative hip fractures are known to cause a loss in functional status in the elderly. While several studies exist demonstrating the association between age, pre-injury functioning, and comorbidities related to this loss of function, no studies have predicted this using a validated risk stratification tool. We attempt to use the Score for Trauma Triage for Geriatric and Middle-Aged (STTGMA) tool to predict loss of ambulatory function and need for assistive device use. Materials and Methods Five hundred and fifty-six patients ≥55 years of age who underwent operative hip fracture fixation were enrolled in a trauma registry. Demographics, functional status, injury severity, and hospital course were used to determine a STTGMA score and patients were stratified into risk quartiles. At least 1 year after hospitalization, patients completed the EQ-5D questionnaire for functional outcomes. Results Two hundred and sixty-eight (48.2%) patients or their family members responded to the questionnaire. Of the 184 patients alive, 65 (35.3%) reported a return to baseline function. Eighty-nine (48.4%) patients reported a loss in ambulatory status. Patients with higher STTGMA scores were older, had more comorbidities, reported greater need for help with daily activities, increased difficulty with self-care, and a reduction in return to activities of daily living (all p ≤ 0.001). Patients with lower STTGMA scores were more likely to never require an assistive device while those with higher scores were more likely to continue needing one (p = 0.004 and p < 0.001). Patients in the highest STTGMA risk groups were 1.5x more likely to have an impairment in ambulatory status (need for ambulatory assistive device or decreased ambulatory capacity) (p = 0.004). Discussion Patients in higher STTGMA risk quartiles were more likely to experience impairment after hip fracture surgery. The STTGMA tool can predict loss of ambulatory independence following hip fracture. At-risk populations can be targeted for enhanced physiotherapy and rehabilitation services for optimal return to prior functioning.
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Affiliation(s)
- Sanjit R Konda
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Nicket Dedhia
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Rachel A Ranson
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Yixuan Tong
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Abhishek Ganta
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
| | - Kenneth A Egol
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA.,Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY, USA
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Adenikinju A, Ranson R, Rettig SA, Egol KA, Konda SR. Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Distal Radius Fractures. Geriatr Orthop Surg Rehabil 2021; 12:2151459321999634. [PMID: 33786205 PMCID: PMC7961699 DOI: 10.1177/2151459321999634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/17/2021] [Accepted: 02/09/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Distal radius fractures are the second most common fracture in the elderly population. The incidence of these fractures has increased over time, and is projected to continue to do so. The aim of this study is to utilize a validated trauma risk prediction tool to stratify middle-aged and geriatric patients with operative distal radius fractures as well as compare hospital quality metrics and inpatient hospitalization costs among the risk groups. Materials and Methods: Patients were prospectively enrolled in an orthopedic trauma registry. The Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) was calculated using patient demographics, injury severity, and functional status. Patients were then stratified into minimal-risk, moderate-risk, and high-risk cohorts based on their scores. Length of stay, need for escalation of care, complications, mortality, discharge location, 1-year patient reported outcomes, and index admission costs were evaluated. Results: Ninety-two patients met inclusion criteria. Sixty-three (68.5%) patients were managed with outpatient surgery. The mean inpatient length of stay for the high-risk cohort was 2.9x and 2.2x higher than the minimal and moderate-risk cohorts, respectively (2.0 + 2.9 days vs. 0.7 + 0.9 and 0.9 + 1.1 days, P = .019). There were no complications or mortality in any of the risk groups. No patients required intensive care and all patients were discharged home. There was no difference in readmission rates, inpatient cost, or 1-year patient reported outcomes among the risk cohorts. Discussion/Conclusions: The Score for Trauma Triage in Geriatric and Middle-Aged is able to risk-stratify patients that undergo operative intervention of distal radius fractures. Middle aged and elderly patients with isolated closed distal radius fractures can be safely managed on an outpatient basis regardless of risk. Standardized pathways can be created in the management of these injuries, thereby optimizing value-based care. Level of evidence: Prognostic Level III
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Affiliation(s)
- Abidemi Adenikinju
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Rachel Ranson
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Samantha A Rettig
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Kenneth A Egol
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA.,Department of Orthopedics, Jamaica Hospital Medical Center, Medisys Health Network, Queens, NY, USA
| | - Sanjit R Konda
- Department of Orthopedics, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA.,Department of Orthopedics, Jamaica Hospital Medical Center, Medisys Health Network, Queens, NY, USA
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Konda SR, Johnson JR, Dedhia N, Kelly EA, Egol KA. Can We Stratify Quality and Cost for Older Patients With Proximal and Midshaft Humerus Fractures? Geriatr Orthop Surg Rehabil 2021; 12:2151459321992742. [PMID: 33680532 PMCID: PMC7900848 DOI: 10.1177/2151459321992742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/03/2021] [Accepted: 01/16/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction: This study sought to investigate whether a validated trauma triage tool can
stratify hospital quality measures and inpatient cost for middle-aged and
geriatric trauma patients with isolated proximal and midshaft humerus
fractures. Materials and Methods: Patients aged 55 and older who sustained a proximal or midshaft humerus
fracture and required inpatient treatment were included. Patient
demographic, comorbidity, and injury severity information was used to
calculate each patient’s Score for Trauma Triage in the Geriatric and
Middle-Aged (STTGMA). Based on scores, patients were stratified to create
minimal, low, moderate, and high risk groups. Outcomes included length of
stay, complications, operative management, ICU/SDU-level care, discharge
disposition, unplanned readmission, and index admission costs. Results: Seventy-four patients with 74 humerus fractures met final inclusion criteria.
Fifty-eight (78.4%) patients presented with proximal humerus and 16 (21.6%)
with midshaft humerus fractures. Mean length of stay was 5.5 ± 3.4 days with
a significant difference among risk groups (P = 0.029). Lower risk patients
were more likely to undergo surgical management (P = 0.015) while higher
risk patients required more ICU/SDU-level care (P < 0.001). Twenty-six
(70.3%) minimal risk patients were discharged home compared to zero high
risk patients (P = 0.001). Higher risk patients experienced higher total
inpatient costs across operative and nonoperative treatment groups. Conclusion: The STTGMA tool is able to reliably predict hospital quality measures and
cost outcomes that may allow hospitals and providers to improve value-based
care and clinical decision-making for patients presenting with proximal and
midshaft humerus fractures. Level of Evidence: Prognostic Level III.
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Affiliation(s)
- Sanjit R Konda
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA.,Jamaica Hospital Medical Center, Queens, NY, USA
| | - Joseph R Johnson
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA
| | - Nicket Dedhia
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA
| | - Erin A Kelly
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, New York, NY, USA.,Jamaica Hospital Medical Center, Queens, NY, USA
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Konda SR, Parola R, Perskin C, Egol KA. ASA Physical Status Classification Improves Predictive Ability of a Validated Trauma Risk Score. Geriatr Orthop Surg Rehabil 2021; 12:2151459321989534. [PMID: 33552668 PMCID: PMC7844441 DOI: 10.1177/2151459321989534] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction: The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated mortality risk score that evaluates 4 major physiologic criteria: age, comorbidities, vital signs, and anatomic injuries. The aim of this study was to investigate whether the addition of ASA physical status classification system to the STTGMA tool would improve risk stratification of a middle-aged and elderly trauma population. Methods: A total of 1332 patients aged 55 years and older who sustained a hip fracture through a low-energy mechanism between October 2014 and February 2020 were included. The STTGMA and STTGMAASA mortality risk scores were calculated. The ability of the models to predict inpatient mortality was compared using area under the receiver operating characteristic curves (AUROCs) by DeLong’s test. Patients were stratified into minimal, low, moderate, and high risk cohorts based on their risk scores. Comparative analyses between risk score stratification distribution of mortality, complications, length of stay, ICU admission, and readmission were performed using Fisher’s exact test. Total cost of admission was fitted by univariate linear regression with STTGMA and STTGMAASA. Results: There were 27 inpatient mortalities (2.0%). When STTGMA was used, the AUROC was 0.742. When STTGMAASA was used, the AUROC was 0.823. DeLong’s test resulted in significant difference in predictive capacity for inpatient mortality between STTGMA and STTGMAASA (p = 0.04). Risk score stratification yielded significantly different distribution of all outcomes between risk cohorts (p < 0.01). STTGMAASA stratification produced a larger percentage of all negative outcomes with increasing risk cohort. Total hospital cost was statistically correlated with both STTGMAASA (p < 0.01) and STTGMA (p = 0.02). Conclusion: Including ASA physical status as a variable in STTGMA improves the model’s ability to predict inpatient mortality and risk stratify middle-aged and geriatric hip fracture patients.
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Affiliation(s)
- Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Rown Parola
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Cody Perskin
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, USA
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Konda SR, Ranson RA, Solasz SJ, Dedhia N, Lott A, Bird ML, Landes EK, Aggarwal VK, Bosco JA, Furgiuele DL, Gould J, Lyon TR, McLaurin TM, Tejwani NC, Zuckerman JD, Leucht P, Ganta A, Egol KA. Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World. J Orthop Trauma 2020; 34:e317-e324. [PMID: 32815845 PMCID: PMC7446996 DOI: 10.1097/bot.0000000000001895] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS Inpatient and 30-day mortality, major, and minor complications. RESULTS Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
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Affiliation(s)
- Sanjit R. Konda
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Rachel A. Ranson
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Sara J. Solasz
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Nicket Dedhia
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Ariana Lott
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Mackenzie L. Bird
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Emma K. Landes
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Vinay K. Aggarwal
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Bellevue Hospital, New York, NY
| | - Joseph A. Bosco
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - David L. Furgiuele
- Department of Orthopaedic Surgery, NYU Winthrop Hospital, Mineola, NY; and
| | - Jason Gould
- Department of Orthopaedic Surgery, NYU Winthrop Hospital, Mineola, NY; and
| | - Thomas R. Lyon
- Department of Orthopaedic Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY
| | - Toni M. McLaurin
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Bellevue Hospital, New York, NY
| | - Nirmal C. Tejwani
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Bellevue Hospital, New York, NY
| | - Joseph D. Zuckerman
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Philipp Leucht
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Bellevue Hospital, New York, NY
| | - Abhishek Ganta
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Kenneth A. Egol
- Division of Orthopaedic Trauma Surgery, Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
- Department of Orthopaedic Surgery, Jamaica Hospital Medical Center, Queens, NY
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Konda SR, Johnson JR, Kelly EA, Chan J, Lyon T, Egol KA. Can We Accurately Predict Which Geriatric and Middle-Aged Hip Fracture Patients Will Experience a Delay to Surgery? Geriatr Orthop Surg Rehabil 2020; 11:2151459320946021. [PMID: 32821470 PMCID: PMC7412893 DOI: 10.1177/2151459320946021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/04/2020] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery. Materials and Methods Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk. Results Six hundred eleven patients met inclusion criteria with mean age 81.1 ± 10.5 years. Injuries occurred mainly secondary to low-energy mechanisms (97.9%). Median time to surgery (31.9 hours overall) was significantly associated with STTGMA stratification (P = .002). Moderate-risk patients had 33% longer (P = .019) and high-risk patients had 28% longer time to surgery (P = .041) compared to minimal risk patients. Delay to surgery (26.4% overall) was significantly associated with STTGMA stratification (P = .015). Low-risk patients had 2.14× higher odds (P = .009), moderate-risk patients had 2.70× higher odds (P = .001), and high-risk patients had 2.18× higher odds of delay to surgery (P = .009) compared to minimal risk patients. High-risk patients experienced higher 30-day mortality compared to minimal (P < .001), low (P = .046), and moderate-risk patients (P = .046). Discussion Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality. Conclusion Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients. Level of Evidence Prognostic Level III.
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Affiliation(s)
- Sanjit R Konda
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, NY, USA.,Jamaica Hospital Medical Center, Queens, NY, USA
| | - Joseph R Johnson
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, NY, USA
| | - Erin A Kelly
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, NY, USA
| | - Jeffrey Chan
- Jamaica Hospital Medical Center, Queens, NY, USA
| | | | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, NYU Langone Medical Center, NY, USA.,Jamaica Hospital Medical Center, Queens, NY, USA
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