Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Julie A. Switzer, MD*,
Regions Hospital and University of Minnesota, St. Paul, Minnesota
Posted January 2008
In the paper, "Patient Risk Factors, Operative Care, and
Outcomes Among Older Community-Dwelling Male Veterans with Hip Fracture,"
Radcliffe et al. report data from the Veterans Health Administration National
Surgical Quality Improvement Program data registry (an outcomes database for
patients treated at Veterans Health Administration medical centers), describing
thirty-day outcomes following hip fracture in community-dwelling male veterans
who were provided care through the Veterans Health Administration system from
1998 to 2003. Thirty-day outcomes presented include mortality, complications,
and readmission to a Veterans Health Administration in-patient facility. This level-II
cohort study confirms findings of other studies of patients with hip fracture
in terms of risk factors—both patient-focused and procedure-focused—that may
affect short-term outcomes following surgical repair of hip fracture.
Preoperative, intraoperative, and postoperative data for
5683 men who underwent surgery for treatment of hip fracture at one of 108 Veterans
Health Administration medical centers between 1998 and 2003 were analyzed. Male
veterans with an age of sixty-five years or older who lived in the community
prior to admission and who sustained either an intracapsular or extracapsular
hip fracture were included. Individuals who were institutionalized prior to
fracture were excluded. Statistical analysis included initial univariate
analysis and chi-square analysis. Logistic regression models were then
constructed.
The overall thirty-day mortality rate was 8.2%. Twenty one
percent of patients experienced at least one complication. Seven percent of
individuals who survived the procedure (forty-three individuals died within two
days of the surgery) were readmitted within the month after the surgery.
Mortality rate was increased in the setting of surgical
delay of four days or more after hospital admission, the use of general
anesthesia, older age, and in individuals with higher American Society of
Anesthesiologists Physical Status Classification (ASA) scores. Patients with
greater transfusion requirement also demonstrated increased thirty-day
mortality. The type of procedure was not related to mortality risk after
controlling for other variables.
Increased complications were related to increased surgical
time (>3 hours), general anesthesia, and the requirement of at least one
transfusion. The most common complications were pneumonia and urinary tract
infection (7% prevalence for each).
Congestive heart failure, chronic obstructive pulmonary
disease, and impaired sensorium were the patient characteristics that may have
exerted the greatest effect on all three outcome variables studied (thirty-day
mortality, complications, and readmission).
Hip fracture in the elderly has been described by many,
including the authors, as a "sentinel event" that results in decreased
independence and functionality and increased mortality1. It has been
shown to have an even greater effect on mortality in men than in women,
although there is a relative paucity of data available for men who have
sustained a hip fracture2,3 as compared with the data available for
women.
The authors add substantial depth to the subject of focus on
the perioperative care of elderly patients, and especially men, who have
sustained a hip fracture. This paper provides weight to the argument for
expeditious surgical repair and systems change in the setting of hip fracture. It
substantiates the extensive outcomes data in women following hip fracture. It
underlines the comorbidities and perioperative risk factors (e.g., congestive
heart failure, chronic obstructive pulmonary disease, need for transfusion, or
general anesthesia) that may make a difference in short-term outcome. And, it
confirms that the most common complications following hip fracture repair in
this population are pneumonia and urinary tract infection. In so doing, in this
large population, it adds to the information that surgeons can communicate to
patients and families regarding surgical risks and predicted outcomes. The
strength of the paper, in summary, lies in its power, its focus on the less-studied
population of men with hip fracture, and the challenge it poses to change care-delivery
systems (by demonstrating worse outcome in patients who are made to wait more
than four days for repair of hip fracture and by suggesting worse outcome in
patients who undergo general anesthesia).
The weakness of the paper arises from its descriptive
nature, its lack of new information with regard to care in this population, and
the short-term nature of the follow-up (acknowledged by the authors). Additionally,
readmission rate as an outcome variable, in this population, is compromised, as
the length of delay prior to surgery appears to lead to longer hospitalization
and thus a shorter window for readmission. Finally, the authors do not focus on
the heterogeneity of the population, a concept that may help guide more
specific treatment options in given patient populations4.
All considered, I look forward to hearing more from this
group as they look more closely at the data in this registry and as they more
closely analyze, over a longer postoperative period, separate populations of
veterans who have sustained hip fracture.
*The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.
References
1. Orosz GM, Magaziner J, Hannan EL, Morriso RS, Koval K, Gilbert M, McLaughlin M, Halm EA, Wang JJ, Litke A, Silberzweig SB, Siu AL. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291:1738-43.
2. Orwig DL, Chan J, and Magaziner J. Hip fracture and its consequences: differences between men and women. Orthop Clin North Am. 2006;37:611-22.
3. Wehren LE, Hawkes WG, Orwig DL, Hebel JR, Zimmerman SI, Magaziner J. Gender differences in mortality after hip fracture: the role of infection. J Bone Mineral Res. 2003;18:2231-7.
4. Penrod JD, Litke A, Hawkes WG, Magaziner J, Koval KJ, Doucette JT, Silberzweig SB, Siu AL. Heterogeneity in hip fracture patients: age, functional status, and comorbidity. J Am Geriatr Soc. 2007;55:407-13.
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