Original ContributionClinical predictors of postoperative delirium, functional status, and mortality in geriatric patients undergoing non-elective surgery for hip fracture
Introduction
Hip fractures are a common occurrence in the geriatric population and represent a large disease burden [1]. Estimates from United States Medicare data alone suggest there are about 500,000 hip fracture patients per year and this is expected to increase by 12% between 2010 and 2030 due to the projected aging of the population [2]. The majority of geriatric patients experiencing a hip fracture are women; they tend to have multiple comorbidities and they usually have experienced an indoor fall [3]. These patients typically are at high risk for adverse intraoperative and post-operative surgical and anesthetic complications.
Hip fractures are associated with significant post-operative morbidity and mortality, and life expectancy has been shown to be decreased by as much as 25% after a hip fracture [4]. Post-operative complications are commonly seen, with an overall incidence of surgical complications of 9% in one recent study [5]. The most common complications include delirium that is reported to occur between 4 and 53% [6], pneumonia, surgical site infections, myocardial infarction, and new-onset pressure ulcers [5]. Hospital length of stay in patients with complications is increased as a result [7,8], and 30-day readmission rates were at least 10% in one study [9].
These complications have a significant impact on the patient's recovery process, in addition to the emotional and financial burdens incurred. Only 29% of patients return to their pre-fracture levels of independence in activities of daily living at one year [10,11]. Preservation of functional status is integral to a patient's quality of life and independence.
The primary objective of this study was to determine the risk factors for morbidity and mortality associated with hip fractures in the geriatric surgical population. While these effects have been investigated previously in the geriatric population, we focused specifically on the inpatient population who underwent non-elective surgical repair in the newly available Geriatric subset of the American College of Surgeons' (ACS) National Surgical Quality Improvement Program (NSQIP) database. This subset augments the main database with additional perioperative variables and prospectively collected outcomes deemed relevant to the geriatric population. We hypothesized that in the population of geriatric patients who had non-elective surgery for hip fracture, higher rates of post-operative complications and 30-day mortality would be predicted by more advanced age, higher baseline cardiopulmonary comorbidities, poorer baseline functional status, and baseline cognitive impairment.
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Materials and methods
This manuscript adheres to the appropriate STROBE guidelines [12]. This study was approved by the Institutional Review Board at Brigham and Women's Hospital, Boston, MA, and the requirement for written informed consent was waived due to the de-identified nature of the data.
Baseline patient characteristics
Descriptive information about the patients included in this cohort is shown in Table 1. The selected patients were predominantly female (74%), White (89%), and non-Hispanic (92%). Ages were distributed with an increasing proportion of patients in the older subsets (7.3% aged 65–69 vs. 26% aged 90+). Median BMI was 23.4 (IQR 20.9–27.1). Most patients were categorized as ASA PS class 3 (64%), with <1% in class 1 and none in class 5. Prevalent baseline comorbidities included hypertension treated
Discussion
In this study, we investigated post-operative outcomes of geriatric inpatients who underwent non-elective surgical repair of hip fractures in order to determine whether pre-existing conditions such as advanced age, cognitive impairment, higher baseline comorbidities, poor baseline functional status, and baseline cognitive impairment would predict rates of post-operative delirium, worsening of functional status, and increased 30-day mortality. Using the new NSQIP Geriatric Surgery Pilot Project
Financial disclosures
None.
Author contributions
Mark J. Harris: This author conceived of the study design, performed data analysis, and prepared the manuscript for submission.
Ethan Y. Brovman: This author conceived of the study design, acquired the data, helped with the data analysis, and helped revise the manuscript for submission.
Richard D. Urman: This author conceived of the study design and helped revise the manuscript for submission.
Declaration of competing interest
None.
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