Original Research

Timing of Adverse Events Following Geriatric Hip Fracture Surgery: A Study of 19,873 Patients in the American College of Surgeons National Surgical Quality Improvement Program

Publish date: September 27, 2018

References

1. Schilling PL, Hallstrom BR, Birkmeyer JD, Carpenter JE. Prioritizing perioperative quality improvement in orthopaedic surgery. J Bone Joint Surg Am. 2010;92(9):1884-1889. doi:10.2106/jbjs.i.00735.

2. Forte ML, Virnig BA, Swiontkowski MF, et al. Ninety-day mortality after intertrochanteric hip fracture: does provider volume matter? J Bone Joint Surg Am. 2010;92(4):799-806. doi:10.2106/jbjs.h.01204.

3. Pugely AJ, Martin CT, Gao Y, Klocke NF, Callaghan JJ, Marsh JL. A risk calculator for short-term morbidity and mortality after hip fracture surgery. J Orthop Trauma.2014;28(2):63-69. doi:10.1097/BOT.0b013e3182a22744.

4. Bhattacharyya T, Iorio R, Healy WL. Rate of and risk factors for acute inpatient mortality after orthopaedic surgery. J Bone Joint Surg Am. 2002;84-a(4):562-572.

5. Eriksson BI, Lassen MR. Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study. Arch Intern Med. 2003;163(11):1337-1342. doi:10.1001/archinte.163.11.1337.

6. Handoll HH, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev.2002;(4):Cd000305. doi:10.1002/14651858.cd000305.

7. Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in the elderly. Cochrane Database Syst Rev. 2004;(1):Cd001880. doi:10.1002/14651858.CD001880.pub2.

8. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49(5):516-522. doi:10.1046/j.1532-5415.2001.49108.x.

9. Deschodt M, Braes T, Flamaing J, et al. Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation. J Am Geriatr Soc. 2012;60(4):733-739. doi:10.1111/j.1532-5415.2012.03899.x.

10. Marcantonio ER, Palihnich K, Appleton P, Davis RB. Pilot randomized trial of donepezil hydrochloride for delirium after hip fracture. J Am Geriatr Soc. 2011;59 Suppl 2:S282-S288. doi:10.1111/j.1532-5415.2011.03691.x.

11. Parker MJ. Iron supplementation for anemia after hip fracture surgery: a randomized trial of 300 patients. J Bone Joint Surg Am. 2010;92(2):265-269. doi:10.2106/jbjs.i.00883.

12. Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth. 2000;84(4):450-455. doi:10.1093/oxfordjournals.bja.a013468.

13. Bohl DD, Basques BA, Golinvaux NS, Baumgaertner MR, Grauer JN. Nationwide Inpatient Sample and National Surgical Quality Improvement Program give different results in hip fracture studies. Clin Orthop Relat Res. 2014;472(6):1672-1680. doi:10.1007/s11999-014-3559-0.

14. Bohl DD, Grauer JN, Leopold SS. Editor's spotlight/Take 5: nationwide inpatient sample and national surgical quality improvement program give different results in hip fracture studies. Clin Orthop Relat Res. 2014;472(6):1667-1671. doi:10.1007/s11999-014-3595-9.

15. Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/jbjs.m.01490.

16. Levin PE. Apples, oranges, and national databases: commentary on an article by Daniel D. Bohl, MPH, et al.: "Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures.” J Bone Joint Surg Am. 2014;96(23):e198. doi:10.2106/jbjs.n.00890.

17. Basques BA, Bohl DD, Golinvaux NS, Leslie MP, Baumgaertner MR, Grauer JN. Postoperative length of stay and thirty-day readmission following geriatric hip fracture: an analysis of 8,434 patients. J Orthop Trauma. 2015;29(3):e115-e120. doi:10.1097/bot.0000000000000222.

18. Golinvaux NS, Bohl DD, Basques BA, Baumgaertner MR, Grauer JN. Diabetes confers little to no increased risk of postoperative complications after hip fracture surgery in geriatric patients. Clin Orthop Relat Res. 2015;473(3):1043-1051. doi:10.1007/s11999-014-3945-7.

19. Maciejewski ML, Radcliff TA, Henderson WG, et al. Determinants of postsurgical discharge setting for male hip fracture patients. J Rehabil Res Dev. 2013;50(9):1267-1276. doi:10.1682/jrrd.2013.02.0041.

20. Molina CS, Thakore RV, Blumer A, Obremskey WT, Sethi MK. Use of the National Surgical Quality Improvement Program in orthopaedic surgery. Clin Orthop Relat Res.2015;473(5):1574-1581. doi:10.1007/s11999-014-3597-7.

21. Bohl DD, Basques BA, Golinvaux NS, Miller CP, Baumgaertner MR, Grauer JN. Extramedullary compared with intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of 4432 procedures from the ACS NSQIP database. J Bone Joint Surg Am. 2014;96(22):1871-1877. doi:10.2106/jbjs.n.00041.

22. Alosh H, Riley LH 3rd, Skolasky RL. Insurance status, geography, race, and ethnicity as predictors of anterior cervical spine surgery rates and in-hospital mortality: an examination of United States trends from 1992 to 2005. Spine (Phila Pa 1976). 2009;34(18):1956-1962. doi:10.1097/BRS.0b013e3181ab930e.

23. Cahill KS, Chi JH, Day A, Claus EB. Prevalence, complications, and hospital charges associated with use of bone-morphogenetic proteins in spinal fusion procedures. JAMA.2009;302(1):58-66. doi:10.1001/jama.2009.956.

24. Ingraham AM, Richards KE, Hall BL, Ko CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg. 2010;44(1):251-267. doi:10.1016/j.yasu.2010.05.003.

25. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6-16. doi:10.1016/j.jamcollsurg.2009.09.031.

26. ACS-NSQIP. Data Use Agreement. American College of Surgeons Web site. https://www.facs.org/quality-programs/acs-nsqip/participant-use/puf-form. Accessed September 20, 2018.

27. Blacher J, Guerin AP, Pannier B, Marchais SJ, London GM. Arterial calcifications, arterial stiffness, and cardiovascular risk in end-stage renal disease. Hypertension. 2001;38(4):938-942. doi:10.1161/hy1001.096358.

28. Browne JA, Cook C, Olson SA, Bolognesi MP. Resident duty-hour reform associated with increased morbidity following hip fracture. J Bone Joint Surg Am. 2009;91(9):2079-2085. doi:10.2106/jbjs.h.01240.

29. Browne JA, Pietrobon R, Olson SA. Hip fracture outcomes: does surgeon or hospital volume really matter? J Trauma. 2009;66(3):809-814. doi:10.1097/TA.0b013e31816166bb.

30. Menendez ME, Ring D. Failure to rescue after proximal femur fracture surgery. J Orthop Trauma. 2015;29(3):e96-e102. doi:10.1097/bot.0000000000000234.

31. Nikkel LE, Fox EJ, Black KP, Davis C, Andersen L, Hollenbeak CS. Impact of comorbidities on hospitalization costs following hip fracture. J Bone Joint Surg Am. 2012;94(1):9-17. doi:10.2106/jbjs.j.01077.

32. Anderson KL, Koval KJ, Spratt KF. Hip fracture outcome: is there a “July effect”? Am J Orthop. 2009;38(12):606-611.

33. Koval KJ, Rust CL, Spratt KF. The effect of hospital setting and teaching status on outcomes after hip fracture. Am J Orthop. 2011;40(1):19-28.

34. Bacon WE. Secular trends in hip fracture occurrence and survival: age and sex differences. J Aging Health. 1996;8(4):538-553. doi:10.1177/089826439600800404.

35. Orces CH. In-hospital hip fracture mortality trends in older adults: the National Hospital Discharge Survey, 1988-2007. J Am Geriatr Soc. 2013;61(12):2248-2249. doi:10.1111/jgs.12567.

RESULTS

In total, 19,873 geriatric patients undergoing a hip fracture surgery were identified (Table 1). The rates of adverse events ranged from 6.7% for urinary tract infection to 0.6% for pulmonary embolism (Table 2).

Table 1. Patient Population

	Number	Percent
Total	19,873	100.0%
Age
70-74 years	1852	9.3%
75-79 years	2764	13.9%
80-84 years	4328	21.8%
85-89 years	5525	27.8%
≥90 years	5404	27.2%
Sex
Male	5359	27.0%
Female	14,514	73.0%
Body mass index
<30 kg/m²	17,733	89.2%
≥30 kg/m²	2140	10.8%
Functional status
Independent	14,348	72.2%
Dependent	5525	27.8%
Diabetes	3321	16.7%
Congestive heart failure	738	3.7%
Dyspnea on exertion	1542	7.8%
Hypertension	14,265	71.8%
End-stage renal disease	322	1.6%
COPD	2239	11.3%
Current smoker	1506	7.6%

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 2. Patients with Adverse Events Diagnosed During the First 30 postoperative days (N = 19,873)

Adverse Event	Number	Percent	95% CI
Urinary tract infection	1321	6.7%	6.3%-7.0%
Mortality	1240	6.2%	5.9%-6.6%
Pneumonia	771	3.9%	3.6%-4.2%
Sepsis	428	2.2%	2.0%-2.4%
Myocardial infarction	347	1.8%	1.6%-1.9%
Surgical site infection	247	1.2%	1.1%-1.4%
Deep vein thrombosis	199	1.0%	0.9%-1.1%
Stroke	144	0.7%	0.6%-0.8%
Cardiac arrest	136	0.7%	0.6%-0.8%
Pulmonary embolism	126	0.6%	0.5%-0.7%

Abbreviation: CI, confidence interval.

Figure 1 depicts the timing of postoperative adverse events in detail in histograms and timing curves. For the earliest diagnosed adverse events, the rate of adverse events had diminished by postoperative day 30. For the later diagnosed adverse events, the rate of adverse events remained high at postoperative day 30.

Figure 2 provides the summary statistics for adverse events diagnosed in the first 30 postoperative days. The median postoperative day of diagnosis (and the interquartile range) was 3 (1-5) for myocardial infarction, 3 (0-8) for cardiac arrest requiring cardiopulmonary resuscitation, 3 (1-10) for stroke, 4 (2-10) for pneumonia, 4 (2-11) for pulmonary embolism, 7 (2-13) for urinary tract infection, 9 (4-16) for deep vein thrombosis, 9 (4-18) for sepsis, 11 (6-19) for mortality, and 16 (11-22) for surgical site infection.

Figure 3 depicts the timing of adverse events relative to discharge. The proportions of adverse events diagnosed prior to discharge were 81.0% for myocardial infarction, 77.8% for stroke, 76.1% for cardiac arrest requiring cardiopulmonary resuscitation, 71.9% for pulmonary embolism, 71.1% for pneumonia, 58.0% for urinary tract infection, 52.1% for sepsis, 46.9% for deep vein thrombosis, 44.3% for mortality, and 27.6% for surgical site infection.

Table 3 shows the independent risk factors for earlier occurrence of adverse events. Following multivariate stepwise selection of final models, at least 1 patient characteristic was independently associated with the timing of cardiac arrest, stroke, urinary tract infection, deep vein thrombosis, and death. In contrast, no patient characteristics were independently associated with the timing of myocardial infarction, pneumonia, pulmonary embolism, sepsis, and surgical site infection.

Table 3. Timing of Diagnosis of Adverse Events^a

Adverse events and associated baseline characteristic(s)	Median postoperative day of diagnosis with vs without baseline characteristic	P-value^b
Cardiac arrest
End-stage renal disease	1 vs 3	.005
Stroke
Hypertension	4 vs 2	.025
Dependent functional status	2 vs 4	.027
Urinary tract infection
Female sex	6 vs 8	.009
Deep vein thrombosis
Body mass index ≥30 kg/m²	5 vs 10	.015
Death
End-stage renal disease	10 vs 11	.031

^aBaseline characteristics that were independently associated with the timing of each adverse event were identified through a backwards stepwise selection process initially including all characteristics listed in Table 1, and sequentially excluding characteristics with the weakest associations until only characteristics with P < .05 remained. Independent associations with the timing of cardiac arrest, stroke, urinary tract infection, deep vein thrombosis, and death are shown. There were no characteristics independently associated with timing of myocardial infarction, pneumonia, pulmonary embolism, sepsis, or surgical site infection; hence, these adverse events are not listed in the table.

^bFrom final Cox proportional hazards models identified through multivariate stepwise selection.

Continue to: DISCUSSION...