Impact of Preoperative Specialty Consults on Hospitalist Comanagement of Hip Fracture Patients
BACKGROUND: Hip fractures typically occur in frail elderly patients. Preoperative specialty consults, in addition to hospitalist comanagement, are often requested for preoperative risk assessment.
OBJECTIVE: Determine if preoperative specialty consults meaningfully influence management and outcomes in hip fracture patients, while being comanaged by hospitalists DESIGN: Retrospective cohort study
SETTING: Tertiary care hospital in Connecticut
PATIENTS: 491 patients aged 50 years and older who underwent surgery for an isolated fragility hip fracture, defined as one occurring from a fall of a height of standing or less.
INTERVENTION: Presence or absence of a preoperative specialty consult
MEASUREMENTS: Time to surgery (TTS), length of hospital stay (LOS), and postoperative complications
RESULTS: 177 patients had a preoperative specialty consult. Patients with consults were older and had more comorbidities. Most consult recommendations were minor (72.8%); there was a major recommendation only for eight patients (4.5%). Multivariate analysis demonstrates that consults are more likely to be associated with a TTS beyond 24 hours (Odds Ratio [OR] 4.28 [2.79-6.56]) and 48 hours (OR 2.59 [1.52-4.43]), an extended LOS (OR 2.67 [1.78-4.03]), and a higher 30-day readmission rate (OR 2.11 [1.09-4.08]). A similar 30-day mortality rate was noted in both consult and no-consult groups.
CONCLUSIONS: The majority of preoperative specialty consults did not meaningfully influence management and may have potentially increased morbidity by delaying surgery. Our data suggest that unless a hip fracture patient is unstable and likely to require active management by a consultant, such consults offer limited benefit when weighed against the negative impact of surgical delay.
© 2020 Society of Hospital Medicine
Hip fractures in the elderly are associated with significant morbidity and mortality.1 These are typically fragility fractures since they are caused by mechanical forces that would ordinarily not result in a serious injury, such as a fall from or below standing level. The incidence of hip fractures in the United States is expected to increase as the population ages; estimates project 512,000 hip fractures with an associated cost of $16 billion annually by the year 2040.2 Timely surgery is recommended for hip fracture patients as delayed surgery beyond 24 to 48 hours of presentation is associated with increased morbidity and mortality.3-6 Time to surgery (TTS) has been shown to be the major potentially modifiable risk factor in the management of a hip fracture.7
Factors that have been noted to influence TTS include the American Society of Anesthesiologists’ (ASA) score, the day of the week of hospital admission, and preoperative testing.8,9 Preoperative cardiology consultation and subsequent cardiac testing, in particular, can increase the TTS and length of stay (LOS) without changing perioperative management.9,10 In our review of literature, we could not identify any studies specifically looking at the impact of preoperative specialty consults on short-term mortality or comparison of care provided by hospitalists alone versus additionally involving subspecialists such as cardiologists. To our knowledge, there are no studies that have categorized recommendations from a preoperative specialty consult as minor, moderate, or major.
Our study evaluated whether preoperative specialty consults meaningfully change management and influence outcomes for hip fracture patients. At our institution, all hip fracture patients are admitted to the hospitalist service and comanaged with the orthopedic team. The hospitalist physician performs the preoperative evaluation as part of the admission history and physical exam. Preoperative specialty consult(s), if needed, are requested only by the hospitalist team. A consultant such as a cardiologist provides input; however, final management decisions are coordinated by the hospitalist physician.
METHODS
Study Design
We performed a retrospective cohort study of patients aged 50 years and older who underwent surgery for an isolated fragility fracture of the hip at Hartford Hospital, a level one trauma and tertiary care medical center, within the 24-month period from April 2015 to March 2017. Fragility hip fracture is defined as one occurring from a fall of a height of standing or less. A consult referred to a specialty or subspecialty consultation, other than hospital medicine, obtained prior to surgery. Patients with additional skeletal trauma and periprosthetic fractures were excluded. A total of 491 unique patients met the inclusion criteria, and data were obtained from chart review and an orthopedic surgery registry. The Hartford Hospital Institutional Review Board approved this study.
