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.
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.