Article

Treatment choice affects inpatient adverse events and mortality in older aged inpatients with an isolated fracture of the proximal humerus

Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA, USA.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] (Impact Factor: 2.29). 10/2013; 23(6). DOI: 10.1016/j.jse.2013.09.006
Source: PubMed

ABSTRACT

This study tests the null hypothesis that, among patients aged 65 and older admitted to a United States hospital with an isolated fracture of the proximal humerus (no other injuries or fractures), there are no differences between operative (fixation or arthroplasty) and nonoperative treatments with respect to inpatient adverse events, inpatient mortality, and discharge to a long-term care facility rates accounting for comorbidities.
Using a large national database representing an estimated 132,005 patients aged 65 and older admitted to a US hospital with an isolated proximal humerus fracture between 2003 and 2007. Sixty-one percent did not have surgery, 22% were treated with open reduction and internal fixation (ORIF), and 17% were treated with arthroplasty.
The risk of an in hospital adverse event was 21% overall and was 4.4 times greater with arthroplasty and 2.7 times greater with ORIF compared to nonoperative treatment. The risk of in hospital death was 1.8% overall and was 2.8 times greater with ORIF compared to nonoperative treatment. Patients treated operatively were less likely to be discharged to a long-term facility compared to patients treated nonoperatively.
In spite of a tendency to treat the most infirm patients (those that are not discharged to home) nonoperatively, operative treatment (open reduction and internal fixation in particular) is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted to the hospital with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously.

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    • "The observed associations with longer hospital stay and nonroutine discharge may be similarly explained, or they may be a result of the increased morbidity. The higher need for postdischarge rehabilitation care in transfused patients is in accordance with two recent studies by Neuhaus et al. who analysed another national inpatient database [2] [3]. With regard to inpatient mortality, we did not confirm previous findings from observational studies in critical care patients [21] as well as one study of patients with hip fracture [22] who showed increased odds of mortality. "
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    ABSTRACT: Background: The purpose of this study was to assess the relationship between perioperative blood transfusion for proximal humerus fracture and inpatient mortality, adverse events, prolonged hospital stay, and nonroutine disposition. Methods: Among the >55,000 patients with an operatively treated proximal humerus fracture identified in the Nationwide Inpatient Sample between 2008 and 2011, 17% received a perioperative blood transfusion. Multivariable logistic regression analyses addressed the association of blood transfusion with inpatient mortality, adverse events, hospital stay, and nonroutine discharge, accounting for comorbidities and other known confounders. Results: Perioperative blood transfusion for fracture of the proximal humerus was not associated with inhospital death, but it was independently associated with inpatient adverse events (odds ratio (OR) 4.4, 95% confidence interval (CI) 4.2-4.6), prolonged hospital stay (OR 2.8, 95% CI 2.7-2.9), and increased nonroutine discharge (OR 1.8, 95% CI 1.7-1.9). Conclusions: Inpatients with fracture of the proximal humerus who receive transfusion are not more likely to die in hospital, but they do stay longer, experience more adverse events, and are less likely to be discharged home. Additional study is merited to determine if the judicious use of blood transfusion in the perioperative period can decrease inpatient morbidity and health-care resource utilisation.
    Preview · Article · Dec 2014 · Injury
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    ABSTRACT: Background: Delayed surgical treatment of hip fractures is associated with adverse medical outcomes, but it is unclear whether the same is true for proximal humeral fractures. The purpose of this study was to evaluate the relationship between surgical delay for proximal humeral fracture and inpatient adverse events, in-hospital death, prolonged postoperative stay, and nonroutine discharge. Methods: Of the more than 70,000 patients with an operatively treated proximal humeral fracture identified in the Nationwide Inpatient Sample between 2008 and 2011, 87% underwent surgery within 2 days of admission and 13% underwent surgery 3 days or more after admission. Multivariable logistic regression analyses were performed to evaluate the effect of surgical delay on inpatient outcomes and to identify risk factors associated with late surgery. Results: Surgery 3 days or more after admission for fracture of the proximal humerus had no influence on in-hospital death but was independently associated with inpatient adverse events (odds ratio [OR], 2.1; 95% confidence interval [CI], 2.0-2.2), prolonged postoperative stay (OR, 1.7; 95% CI, 1.7-1.9), and increased nonroutine discharge (OR, 2.7; 95% CI, 2.6-2.9). Risk factors for surgery 3 days or more after admission included advanced age, male sex, Elixhauser comorbidity score, polytrauma, Hispanic race or black race, no insurance coverage, low household income, and weekend admission. Conclusions: Even when comorbidities and complexity are controlled for, delaying surgery for proximal humeral fracture is likely to increase inpatient morbidity, postoperative length of stay, and nonroutine discharge. It appears that avoiding nonmedical delays is advantageous.
    No preview · Article · Jun 2014 · Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]
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    ABSTRACT: The number of inpatient admissions for proximal humerus fracture is increasing, but the factors that determine hospitalization are not well documented. We sought to identify predictors of hospital admission among individuals presenting to the emergency department (ED) with a fracture of the proximal humerus.Methods Using the Nationwide Emergency Department Sample for 2010 and 2011, an estimated 285 661 patients were identified and separated into those who were admitted to hospital (19%) and those who were discharged directly home (81%). Multivariable logistic regression modeling was used to identify independent predictors of hospital admission.ResultsFactors associated with admission included increasing age and Charlson comorbidity index, ED visit on a weekday, Medicare and Medicaid insurance, open fracture, injury due to motor vehicle crash, polytrauma, urban teaching hospital, and residence in the Northeast. The lowest ratio of hospital admission to home discharge was noted for uninsured patients (0.09).DiscussionFactors unrelated to medical complexity such as insurance status, geographic region, timing of ED visit, and hospital type are associated with inpatient admission for proximal humerus fracture. Interventions to reduce variation in hospital admission and the influence of nonclinical factors merit attention.Level of EvidenceLevel II, prognostic study.
    No preview · Article · Nov 2014 · American Journal of Emergency Medicine
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