Home, No Follow-Up: Are we ignoring the significance of unplanned clinic attendances, re-admission and mortality in the first 12 months post-operatively in over 65 year olds’ hip fractures treated with DHS fixation?
Introduction
An estimated 80,000 hip fractures are currently admitted annually to UK hospitals [1], a figure which is only expected to rise as the nation’s population continues to age and life expectancy increases [2]. Of these, 34.3% of admitted hip fractures are intertrochanteric and dynamic hip screw fixation (DHS) is the treatment of choice in 79.8% of cases [1]. Statistics demonstrate that 88% of patients who present with a hip fracture are reviewed by an older person specialist within 72 h of admission, however little is known about the quality of care provided to these patients in the community following discharge [1]. Alarmingly, the 2016 National Hip Fracture Database (NHFD) Report states that only 5.6% of UK hospitals involve local community rehabilitation teams in their monthly hip fracture meetings and just 3.4% of hip fracture multidisciplinary meetings have a social worker present [1].<
In 2007, the Best Practice Tariff scheme was introduced in an effort to promote early surgery and involvement of an orthogeriatrician in the care of hip fracture patients. Indeed, overall national 30 day mortality in this patient group has decreased from 10.9% (2007) to 8.5% (2011) since the introduction of the scheme [3]. Paradoxically, limited research has been conducted to identify patient factors that may be associated with an increased risk of post-operative admission and unplanned clinic attendance. Both of these factors confer a significant cost to the patient and the healthcare system. Neck of femur fractures cost the NHS 1 billion pounds annually [1], with the majority of spending attributed to length of inpatient stay (1.5 million bed days per annum in the UK alone) [[1], [4]]. UK cohort studies have demonstrated that up to 19.0% of patients who undergo surgery for an acute hip fracture are re- admitted to hospital within 3 months of the index operation [5]. Unplanned clinic review is also costly, with the average unit cost of a consultant-led trauma and orthopaedics outpatient appointment being 151 pounds [6]. In a time of austerity, prevention of re-admission and unplanned clinic attendance in this patient group is paramount.
Our study’s aim was to identify pre-operative and 12-month post-operative variables (including residence and mobility status) associated with an increased risk of unplanned orthopaedic clinic attendance and unplanned re-admission to hospital. Overall 12- month survival was also correlated to the above variables. Thus, can we identify patients at risk of unplanned clinic attendance and readmission prior to index discharge?
Section snippets
Methods and study design
A prospectively collated database of patients admitted to hospital with an acute hip fracture was initiated in August 2007 and maintained until February 2011. Pre-operative data was collected regarding patient demographics, fracture type and treatment. Place of residence and mobility status was recorded at 0, 1, 4 and 12 months. Inpatient assessment of presence of pressure sores, completion of a falls risk assessment and MDT discussion of patient care was documented. Unplanned attendance to an
Inclusion and exclusion criteria
A total of 1281 hip fractures were identified between August 2007 and February 2011. Only patients over the age of 65 years who underwent DHS fixation for treatment of an acute, non- pathological hip fracture were included in the statistical analysis. Analysis was based on data collected from 648 consecutive hip fracture patients admitted during the study period. Baseline demographics of the study cohort are shown in Table 1.
Statistical analysis
The database was interrogated using SPSS (IBM Corporation, version 24). Qualitative data for mobility and residence status was transformed to categorical data for ease of analysis. Regression analysis was performed with level of significance established at P < 0.05 to identify specific factors that were independently associated with unplanned re-attendance to clinic, acute re-admission to hospital and survival respectively within the first post-operative 12 months.
Unplanned post-operative attendance to clinic
Attendance to clinic was assessed by grouping the case outcomes according to the number of unplanned attendances (Group 1: no attendances, Group 2: 1–2 attendances, Group 3: ≥3 attendances).
Of the 648 cases identified, 153 patients (23.6%) had at least one unplanned attendance to clinic within the first post-operative 12 months. Unscheduled attendance figures and reasons for attendance are displayed in Table 2, Table 3 respectively. Age and presence of pressure ulcers on initial admission was
Discussion
Analysis of our patient group demonstrates the importance of considering demographics such as gender and age as risk factors for mortality and age and presence of pressure sores as risk factors for unplanned clinic attendance. With regards to mortality, patients over the age of 80 were least likely to survive past the first post-operative year with only 64.4% of patients over the age of 80 years alive at 12 months. Only 66.1% of patients with an ASA >2 survived past the first post-operative
Conclusion
Analysis of our patient group demonstrates that presence of pressure sores and being aged 70–79 years are factors associated with increased re-attendance to clinic following DHS fixation for hip fracture. Frequency of re-admission following DHS was not significantly associated with any of the variables considered by our database.
The estimated cost of a consultant-led outpatient appointment is approximately 151 pounds [6]. We can therefore estimate the total cost for our cohort from unplanned
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