Mary Forte

Geographic Variation in Device Use for Intertrochanteric Hip Fractures

BACKGROUND Hip fractures in the elderly are a common and costly problem, with intertrochanteric fractures accounting for almost half of these fractures. Most intertrochanteric fractures are treated with either a plate-and-screw device or an intramedullary nail device. We assessed the degree of geographic variation in use of intramedullary nailing for intertrochanteric femoral fractures among Medicare beneficiaries between 2000 and 2002. METHODS Medicare 100% files (hospital and physician claims, and enrollment) for 2000 through 2002 were used to identify beneficiaries, sixty-five years of age or older, who had undergone inpatient surgery for the treatment of an intertrochanteric femoral fracture with a plate-and-screw device or an intramedullary nail. We used multiple logistic regression analysis to model the use of an intramedullary nail (as opposed to a plate-and-screw device) by state and year, after adjusting for patient age, sex, race, subtrochanteric fracture, comorbidities, and Medicaid-administered assistance. The odds ratios of receiving an intramedullary nail device are reported. The adjusted state rates of intramedullary nailing per 100 Medicare patients with an intertrochanteric fracture are reported for 2000 through 2002. RESULTS In this study, 212,821 claims for operations to treat patients with an intertrochanteric fracture from 2000 through 2002 met the inclusion criteria. There was considerable geographic variation in intramedullary nail use by state across all years. The mean adjusted intramedullary nailing rate per 100 Medicare patients with an intertrochanteric fracture increased nationally from 7.84 in 2000 to 16.98 in 2002. In 2000, surgeons in sixteen states used an intramedullary nail in fewer than one of every twenty Medicare patients with an intertrochanteric fracture. By 2002, surgeons in only two states used an intramedullary nail in fewer than one of every twenty patients with an intertrochanteric fracture, and in eight states they used an intramedullary nail in more than one of every four patients with an intertrochanteric fracture. CONCLUSIONS There was substantial geographic variation in the use of intramedullary nailing by state from 2000 through 2002 that was largely not explained by patient-related factors.

Evidence Summary: Systematic Review of Surgical Treatments for Geriatric Hip Fractures

BACKGROUND There is a growing body of literature on surgical treatments for elderly patients with a hip fracture and the effects of various surgical procedures on complications and postoperative outcomes. No single review has previously summarized the literature on the effects of surgical procedures on outcomes after treatment across all types of hip fractures. We conducted a comprehensive systematic literature review to organize the clinical evidence for patient-centered outcomes across all types of geriatric hip fractures. METHODS We searched MEDLINE, the Cochrane Database of Systematic Reviews, Scirus, and ClinicalTrials.gov for randomized clinical trials and observational studies published between 1985 and 2008. We also manually searched reference lists from relevant systematic reviews. RESULTS We found eighty-four [corrected] articles representing seventy-four [corrected] unique, randomized, controlled trials, including thirty-three [corrected] on femoral neck fractures, forty on intertrochanteric fractures, and one on subtrochanteric fractures. Nine observational studies addressed the link between patient characteristics and outcome variables by fracture type. Age, sex, prefracture functioning, and cognitive impairment are related to mortality and functional outcomes. Fracture type does not appear to be independently related to patient outcomes. Mortality, pain, function, and quality of life did not differ by surgical implant class, or by implants within a class. Neither the randomized controlled trials nor the observational literature include the full complement of potential covariates that can impact treatment outcomes after treatment. CONCLUSIONS The broader questions about the relationship of patient factors, fracture type, and specific treatments to the outcomes of mortality, functional status, and quality of life cannot be addressed with the existing literature. Research should include comprehensive conceptual models that capture complete sets of important independent variables. Studies of musculoskeletal outcomes, including hip fracture, require well-defined patient groups and consistent use of validated outcome measures.

Ninety-Day Mortality After Intertrochanteric Hip Fracture: Does Provider Volume Matter?

BACKGROUND Research on the relationship between orthopaedic volume and outcomes has focused almost exclusively on elective arthroplasty procedures. Geriatric patients who have sustained an intertrochanteric hip fracture are older and have a heavier comorbidity burden in comparison with patients undergoing elective arthroplasty; therefore, any advantage of provider volume in terms of mortality could be overwhelmed by the severity of the hip fracture condition itself. This study examined the association between surgeon and hospital volumes of procedures performed for the treatment of intertrochanteric hip fractures in Medicare beneficiaries and inpatient through ninety-day postoperative mortality. METHODS The Medicare 100% files of hospital and physician claims plus the beneficiary enrollment files for 2000 through 2002 identified beneficiaries who were sixty-five years of age or older and who underwent inpatient surgery for the treatment of an intertrochanteric hip fracture with internal fixation. Provider volumes of intertrochanteric hip fracture cases were calculated with use of unique surgeon and hospital provider numbers in the claims. Fixed effects regression analysis using generalized estimating equations was used to model the association between hospital and surgeon intertrochanteric hip fracture volume and inpatient through ninety-day mortality, controlling for age, sex, race, Charlson comorbidity score, subtrochanteric fracture, prefracture nursing home residence, Medicaid-administered assistance, surgical device, and year. The unadjusted inpatient, thirty, sixty, and ninety-day mortality rates and adjusted relative risks are reported. RESULTS Between March 1, 2000, and December 31, 2002, 192,365 claims met inclusion criteria and matched with provider information. The unadjusted inpatient, thirty-day, sixty-day, and ninety-day mortality rates were 2.91%, 7.92%, 12.34%, and 15.19%, respectively. Patients managed at lower-volume hospitals had significantly higher (10% to 20%) adjusted risks of inpatient mortality than those managed at the highest-volume hospitals. By sixty days postoperatively, the increased mortality risk persisted only among patients managed at the lowest-volume hospitals (six cases per year or fewer). Patients who were managed by surgeons who treated an average of two or three cases per year had the highest mortality risks when compared with patients managed by the highest-volume surgeons. CONCLUSIONS Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures. Unlike the situation with elective arthroplasty procedures, our findings do not indicate a need to direct patients with routine hip fractures exclusively to high-volume centers, although the higher mortality rates found in the lowest-volume hospitals warrant further investigation.

Provider Factors Associated with Intramedullary Nail Use for Intertrochanteric Hip Fractures

BACKGROUND Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures. METHODS Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported. RESULTS There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors. CONCLUSIONS The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospitals burden of their choices for higher cost devices under the Medicare payment system.

Bigger Data, Bigger Problems.

Summary: Clinical studies frequently lack the ability to reliably answer their research questions because of inadequate sample sizes. Underpowered studies are subject to multiple sources of bias, may not represent the larger population, and are regularly unable to detect differences between treatment groups. Most importantly, an underpowered study can lead to incorrect conclusions. Big data can be used to address many of these concerns, enabling researchers to answer questions with increased certainty and less likelihood of bias. Big datasets, such as The National Hip Fracture Database in the United Kingdom and the Swedish Hip Arthroplasty Registry, collect valuable clinical information that can be used by researchers to guide patient care and inform policy makers, chief executives, commissioners, and clinical staff. The range of research questions that can be examined is directly related to the quality and complexity of the data, which is positively associated with the cost of the data. However, technological advancements have unlocked new possibilities for efficient data capture and widespread opportunities to merge massive datasets, particularly in the setting of national registries and administrative data.

Inpatient pulmonary embolism after elective primary total hip and knee arthroplasty in the United States.

BACKGROUND The incidence of inpatient pulmonary embolism in patients who have elective primary hip and knee arthroplasty in the United States is unknown. Prior studies have included patients with cancer, trauma, or revisions. The goal of this study was to determine the incidence and risks of inpatient pulmonary embolism after elective arthroplasty by type of procedure. METHODS We used the 1998 to 2009 Healthcare Cost and Utilization Project Nationwide Inpatient Sample for this retrospective cohort study. Patients who were sixty years of age or older and underwent elective primary total hip or knee arthroplasty were included. The study variable was the type of arthroplasty: total hip, total knee, or two joints. Inpatient pulmonary embolism was the primary outcome; mortality was secondary. Logistic regression determined the adjusted odds ratios of inpatient pulmonary embolism by procedure, adjusting for age, sex, Charlson Comorbidity Index, atrial fibrillation, and surgical indication. RESULTS Records represented 5,044,403 hospital discharges after primary total hip or knee arthroplasty. Total knee arthroplasty comprised 66% of the admissions. Less than 5% of patients had two joint procedures. The overall incidence of pulmonary embolism was 0.358% (95% confidence interval [CI], 0.338, 0.378). The incidence of pulmonary embolism differed by procedure and was highest among patients who had two-joint arthroplasty (0.777%; 95% CI, 0.677, 0.876), was lowest in recipients of total hip arthroplasty (0.201%; 95% CI, 0.179, 0.223), and was intermediate in patients who had total knee arthroplasty (0.400%; 95% CI, 0.377, 0.423). The adjusted odds ratios of pulmonary embolism in patients who had two joint procedures were 3.89 times higher than among patients who had total hip arthroplasty, controlling for other factors. CONCLUSIONS Elective total knee arthroplasty is associated with a higher incidence and odds of inpatient pulmonary embolism than is total hip arthroplasty; multiple procedures pose the highest risk for pulmonary embolism and associated mortality.

Systematic Review of Surgical Treatments for Fecal Incontinence.

BACKGROUND: No systematic review has examined the collective randomized and nonrandomized evidence for fecal incontinence treatment effectiveness across the range of surgical treatments. OBJECTIVE: The purpose of this study was to assess the efficacy, comparative effectiveness, and harms of surgical treatments for fecal incontinence in adults. DATA SOURCES: Ovid MEDLINE, EMBASE, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and the Cochrane Central Register of Controlled Trials, as well as hand searches of systematic reviews, were used as data sources. STUDY SELECTION: Two investigators screened abstracts for eligibility (surgical treatment of fecal incontinence in adults, published 1980–2015, randomized controlled trial or observational study with comparator; case series were included for adverse effects). Full-text articles were reviewed for patient-reported outcomes. We extracted data, assessed study risk of bias, and evaluated strength of evidence for each treatment–outcome combination. INTERVENTIONS: Surgical treatments for fecal incontinence were included interventions. MAIN OUTCOME MEASURES: Fecal incontinence episodes/severity, quality of life, urgency, and pain were measured. RESULTS: Twenty-two studies met inclusion criteria (13 randomized trials and 9 observational trials); 53 case series were included for harms. Most patients were middle-aged women with mixed FI etiologies. Intervention and outcome heterogeneity precluded meta-analysis. Evidence was insufficient for all of the surgical comparisons. Few studies examined the same comparisons; no studies were high quality. Functional improvements varied; some authors excluded those patients with complications or lost to follow-up from analyses. Complications ranged from minor to major (infection, bowel obstruction, perforation, and fistula) and were most frequent after the artificial bowel sphincter (22%–100%). Major surgical complications often required reoperation; few required permanent colostomy. LIMITATIONS: Most evidence is intermediate term, with small patient samples and substantial methodologic limitations. CONCLUSIONS: Evidence was insufficient to support clinical or policy decisions for any surgical treatments for fecal incontinence in adults. More invasive surgical procedures had substantial complications. The lack of compliance with study reporting standards is a modifiable impediment in the field. Future studies should focus on longer-term outcomes and attempt to identify subgroups of adults who might benefit from specific procedures.

Rethinking Orthopaedic Decision-Making for Frail Patients with Hip Fracture: Commentary on an article by Marilyn Heng, MD, FRCSC, et al.: "Abnormal Mini-Cog Is Associated with Higher Risk of Complications and Delirium in Geriatric Patients with Fracture".

There are substantial research knowledge gaps regarding orthopaedic outcomes after surgical procedures to treat hip fractures in vulnerable elderly patients. The article by Heng et al. serves to remind us that treating hip fractures must be done thoughtfully. Given the risks related to surgical hip fracture treatment, attention should be paid to treatment decisions for subgroups of high-risk patients. Not all older patients are equally likely to benefit from standard orthopaedic care. Some older adults are at high risk for inpatient hospital complications such as delirium, particularly those with prefracture cognitive impairment. Geriatric hip fractures are associated with high morbidity, mortality, and prolonged functional impairment. At least one-third of patients die within 1 year after a hip fracture and less than one-half ever regain their prefracture level of function. Given this trajectory, efforts such as cognitive screening and other measures of frailty can provide useful insights in planning treatment. Cognitive screening can serve several important roles. It can help surgeons to understand a patient’s ability to understand his or her diagnosis and to be a partner in decision-making. It can also inform surgical decision-making as to the expected demands that each patient may place on a newly stabilized fracture, given the patient’s perceived ability to comply with postoperative functional recommendations. As shown in this article by Heng et al., cognitive status can predict complications, especially perioperative delirium, which, in turn, is a harbinger of increased morbidity and mortality. Patients at high risk should be closely screened preoperatively and postoperatively using programs such as the Hospital Elder Life Program (HELP) for Prevention of Delirium, a multicomponent intervention to prevent delirium in hospitalized older patients. Tools such as the Confusion Assessment Method (CAM) are available in short and long versions. The current study by Heng et al. was conducted in two hospitals that employed a joint practice teamwith active participation of geriatricians to assist in the care management. However, such resources are not widely available. Less well-served orthopaedic programs and sites must determine ways to routinely involve their medical colleagues in postoperative management and, potentially, preoperative decision-making, particularly in the management of frail patients with hip fracture. Impaired cognition should also signal a need to consider what kind of fracture and rehabilitative treatment is best. The MiniCog is a simple screening test. It should be followed up with a more complete cognitive evaluation to assess the level of cognitive impairment. Patients with hip fracture and dementia and/or those admitted from nursing homes have particularly poor medical outcomes and high mortality. More than 25% of elderly patients with hip fracture in the United States have dementia and 20% are admitted from nursing homes; and these proportions are expected to increase as the population ages. Both patient groups were recently identified as hip fracture outcomes research priorities by a panel of U.S. and Canadian hip fracture experts. Patients with hip fracture and dementia have high mortality and poor medical outcomes compared with cognitively intact patients, although the mechanisms that account for their worse medical outcomes remain largely unknown. Patients admitted with hip fractures from nursing homes have double the early mortality of non-nursing home patients, approaching 25% by the third month postoperatively. Hip fracture is associated with excess mortality, even after taking into account prefracture health status, genetic factors, preexisting comorbidities, and lifestyle factors. The highest excess mortality risk seems to be within the first 6 months to 1 year postfracture, with some variation by age and prior health status, although some excess mortality persists beyond that timeframe. There is, of course, the potential for confounding relationships. Preexisting factors such as sex, age, frailty, comorbidity, dementia, and osteoporosis may be associated with fractures themselves, overall and post-fracturemortality, and related problems such as falls. Given the high risk that patients from nursing homes and those with dementia may represent, more attention should be paid to what type of treatment is most beneficial. In what instances should surgical treatment be avoided? Several investigators have described outcomes of nonoperative treatment of hip fractures in the elderly. Given the physiologic stress of surgical fixation of a hip fracture and the increasing number of extremely frail individuals who will sustain these and other fragility fractures, questions regarding the wisdom of operative treatment for these patients remain. Patients with impacted femoral neck fractures, patients who e39(1)

Tranexamic Acid Reduced the Percent of Total Blood Volume Lost During Adolescent Idiopathic Scoliosis Surgery

Background Multilevel posterior spine fusion is associated with significant intraoperative blood loss. Tranexamic acid is an antifibrinolytic agent that reduces intraoperative blood loss. The goal of this study was to compare the percent of total blood volume lost during posterior spinal fusion (PSF) with or without tranexamic acid in patients with adolescent idiopathic scoliosis (AIS). Methods Thirty-six AIS patients underwent PSF in 2011-2014; the last half (n=18) received intraoperative tranexamic acid. We retrieved relevant demographic, hematologic, intraoperative and outcomes information from medical records. The primary outcome was the percent of total blood volume lost, calculated from estimates of intraoperative blood loss (numerator) and estimated total blood volume per patient (denominator, via Nadler’s equations). Unadjusted outcomes were compared using standard statistical tests. Results Tranexamic acid and no-tranexamic acid groups were similar (all p>0.05) in mean age (16.1 vs. 15.2 years), sex (89% vs. 83% female), body mass index (22.2 vs. 20.2 kg/m2), preoperative hemoglobin (13.9 vs. 13.9 g/dl), mean spinal levels fused (10.5 vs. 9.6), osteotomies (1.6 vs. 0.9) and operative duration (6.1 hours, both). The percent of total blood volume lost (TBVL) was significantly lower in the tranexamic acid-treated vs. no-tranexamic acid group (median 8.23% vs. 14.30%, p = 0.032); percent TBVL per level fused was significantly lower with tranexamic acid than without it (1.1% vs. 1.8%, p=0.048). Estimated blood loss (milliliters) was similar across groups. Conclusions Tranexamic acid significantly reduced the percentage of total blood volume lost versus no tranexamic acid in AIS patients who underwent PSF using a standardized blood loss measure. Level of Evidence: 3. Institutional Review Board status: This medical record chart review (minimal risk) study was approved by the University of Minnesota Institutional Review Board.