Does Comanagement of Patients With Hip Fracture Influence 30-Day Outcomes

Introduction Mortality and morbidity are high for older adults after hip fracture (HF), but patients and surrogate decision makers (SDMs) are typically unaware of the poor prognosis. We developed a novel educational tool, My Hip Fracture (My-HF), to provide patients and SDMs of patients hospitalized with acute HF individualized estimates of their post-HF prognosis. We conducted initial usability testing of My-HF in a sample of patients with HF and SDMs. Materials and Methods My-HF provides information about: 1) anatomy and risk factors for HF; 2) Hip fracture treatment received; 3) individualized predicted risk of adverse events and 4) anticipated discharge trajectory. We conducted a qualitative usability study using a convenience sample of hospitalized, post-operative patients with acute HF or SDMs of patients who lacked decision-making capacity. We used semi-structured interviews to obtain feedback. Thematic analysis was used to identify themes and concepts. Results We conducted interviews with 8 patients and 9 SDMs (mean age of interviewees 70.1 years, 41% female). My-HF was generally well received. Thematic analysis identified legibility and visual appeal, comprehension, numeracy, utility and reflection as prominent themes. Most respondents found My-HF to be useful in improving their understanding of HF and as a potential mechanism for sharing information with other care team members (including family and professionals). Suggestions for improvement of legibility, presentation of the individualized prognosis information and content were identified. Discussion Patients and SDMs are generally accepting of My-HF and found it useful for communicating individualized prognostic information. Feedback identified areas for improvement for future iterations of the tool. Conclusion My-HF presents a means of addressing the gap in understanding of prognosis post-HF as a part of patient-centered care. Further evaluation will be needed to assess the impact of My-HF on patient and SDM reported outcomes as we transition from a paper to smart-phone enabled web application.

Section: Discussionmentioning

confidence: 99%

Qualitative Evaluation of a Novel Educational Tool to Communicate Individualized Hip Fracture Prognostic Information to Patients and Surrogates: My Hip Fracture (My-HF)

Vincent

Wegier

Chien

et al. 2021

“… 10 , 11 , 16 , 17 While interventions and increased knowledge on the risk factors contributing to 30-day mortality have improved outcomes, an understanding of the relative impact of specific risk factors on mortality remains unknown. 10 , 11 , 13 - 16 This study evaluated elderly patients undergoing hemiarthroplasty for femoral neck fractures to compare risk factors and generate a nomogram for understanding their mortality risk.…”

Section: Discussionmentioning

confidence: 99%

“…9,10 Despite attempts to reduce modifiable risk factors and improve medical co-management of patients, femoral neck fractures in elderly patients have high rates of in-hospital and 30-day morbidity and mortality with 1-year mortality rates approaching 35%. [10][11][12][13][14][15] Previous studies have shown decreased mortality and improved functional outcomes by reducing time to operating room for patients with femoral neck fractures. 12,13,[15][16][17] As patients with multiple medical comorbidities need preoperative optimization for efficient time to surgery; understanding risk factors may assist multidisciplinary teams in facilitating pre-operative management.…”

Section: Introductionmentioning

confidence: 99%

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A Nomogram for Predicting 30-day Mortality in Elderly Patients Undergoing Hemiarthroplasty for Femoral Neck Fractures

Crawford

Southam

Matar

et al. 2020

Introduction: Femoral neck fractures in the elderly are increasingly common as a result of a growing geriatric population with 1-year mortality rates approaching 35%. While preoperative medical optimization and early time to surgery have reduced morbidity and mortality, patients with numerous medical comorbidities remain high risk for death in the perioperative period. Identifying those with greatest risk with a scoring system or nomogram may assist multidisciplinary teams in reducing mortality following hemiarthroplasty. Purpose: Identify predictors of 30-day mortality in elderly patients who underwent hemiarthroplasty for a femoral neck fracture to generate a predictive nomogram to determine the probability of post-operative mortality. Methods: Retrospective evaluation using data from the ACS-NSQIP database from 2005 to 2014 with CPT code 27125 for hip hemiarthroplasty. Multiple factors including demographics and comorbidities were compared in patients who experienced 30-day mortality and those who did not. T-test and chi-square tests were used to analyze data and a multivariate model was generated using logistic regression. Results: Advanced age (odds ratio (OR) 1.04), underweight BMI (OR 1.55), male sex (OR 1.80), reduced functional status (OR 2.04), heart failure within 30 days prior to surgery (OR 2.22), American Society of Anesthesiologists grade > 2 (OR > 2.50), disseminated cancer (OR 3.43) were all found to have statistically significant odds ratios for 30-day mortality following hemiarthroplasty. Conclusion: A tool based on easily identifiable risk factors, demographics, and comorbidities was developed that can help predict elderly patients who will experience mortality within 30 days of following hemiarthroplasty. In addition to identifying high risk patients, the nomogram can serve as a counseling tool for physicians to use with patients and their families to assist with better understanding of perioperative mortality risk.

“…1,2 Similar trends and burden from hip fracture management are observed around the world, especially in developed nations. 3 Despite tremendous advances in geriatric fracture care with the advent of geriatric fracture centers and comanagement, [4][5][6][7] osteoporotic hip fractures are associated with high rates of morbidity and mortality to affected patients. [8][9][10][11] Reports of 1-year mortality rates are as high as 84.4% 8 for patients treated nonoperatively and 38% in operative patients.…”

Section: Introductionmentioning

confidence: 99%

POSSUM and P-POSSUM Scoring in Hip Fracture Mortalities

Johns

Strong

Kates

et al. 2020

Self Cite

Introduction: Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) are general surgical tools used to efficiently assess mortality and morbidity risk. Data suggest that these tools can be used in hip fracture patients to predict morbidity and mortality; however, it is unclear what score indicates a significant risk on a case-by-case basis. We examined the POSSUM and P-POSSUM scores in a group of hip fracture mortalities in order to assess their accuracy in identification of similar high-risk patients. Materials and Methods: Retrospective analysis of all consecutive mortalities in hip fracture patients at a single tertiary care center over 2 years was performed. Patient medical records were examined for baseline demographics, fracture characteristics, surgical interventions, and cause of death. Twelve physiological and 6 operative variables were used to retrospectively calculate POSSUM and P-POSSUM scores at the time of injury. Results: Forty-seven hip fracture mortalities were reviewed. Median patient age was 88 years (range: 56-99). Overall, 68.1% (32) underwent surgical intervention. Mean predicted POSSUM morbidity and mortality rates were 73.9% (28%-99%) and 31.1% (5%-83%), respectively. The mean predicted P-POSSUM mortality rate was 26.4% (1%-91%) and 53.2% (25) had a P-POSSUM predicted mortality of >20%. Subgroup analysis demonstrated poor agreement between predicted mortality and observed mortality rate for POSSUM in operative (χ2 = 127.5, P < .00001) and nonoperative cohorts (χ2 = 14.6, P < .00001), in addition to P-POSSUM operative (χ2 = 101.9, P < .00001) and nonoperative (χ2 = 11.9, P < .00001) scoring. Discussion/Conclusion: Hip fracture patients are at significant risk of both morbidity and mortality. A reliable, replicable, and accurate tool to represent the expected risk of such complications could help facilitate clinical decision-making to determine the optimal level of care. Screening tools such as POSSUM and P-POSSUM have limitations in accurately identifying high-risk hip fracture patients.