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Association of Clinical Outcomes With Surgical Repair of Hip Fracture vs Nonsurgical Management in Nursing Home Residents With Advanced Dementia
Associated Data
Abstract
Importance
The decision whether to surgically repair a hip fracture in nursing home (NH) residents with advanced dementia can be challenging.
Objective
To compare outcomes, including survival, among NH residents with advanced dementia and hip fracture according to whether they underwent surgical repair.
Design
Retrospective cohort study using nationwide Medicare claims data linked with Minimum Data Set (MDS) assessments from 1/1/2008 to 12/31/2013.
Setting
Nursing Home
Participants
3,083 NH residents with advanced dementia and hip fracture not enrolled in hospice.
Methods
Residents with advanced dementia were identified using the MDS. Medicare claims were used to identify hip fracture, and to determine whether the fracture was managed surgically. Survival between surgical and non-surgical residents was compared using multivariable Cox proportional hazards with inverse probability of treatment weighting (IPTW). Among six-month survivors, documented pain, antipsychotic, physical restraint use, pressure ulcers, and ambulatory status were compared between surgical and non-surgical groups.
Results
Among 3,083 residents with advanced dementia and hip fracture (mean age 84.2 years, 79.2% female, 28.5% ambulatory), 2,615 (84.8%) underwent surgical repair. By six months, 31.5% and 53.8% of surgically and non-surgically managed residents died, respectively. After IPTW modeling, surgically managed residents were less likely to die compared to residents without surgery (aHR, 0.88, 95% confidence interval (CI) 0.79, 0.98). Among 2,007 residents who survived 6 months, residents with surgery versus non-surgical management had less documented pain (29.0% versus 30.9%) and fewer pressure ulcers (11.2% versus 19.0%). In IPTW models, surgically managed residents reported less pain (aHR 0.78, 95% CI 0.61, 0.99) and pressure ulcers (aHR 0.64, 95% CI 0.47, 0.86). There was no difference between antipsychotic and physical restraint use between the groups. Few survivors remained ambulatory (10.7% of surgically managed versus 4.8% without surgery).
Conclusions and Relevance
Surgical repair of a hip fracture was associated with lower mortality among NH residents with advanced dementia and should be considered together with the residents’ goals of care in management decisions. Pain and other adverse outcomes were common regardless of surgical management, suggesting the need for broad improvements in the quality of care provided to NH residents with advanced dementia and hip fracture.
INTRODUCTION
Hip fractures occur commonly among nursing home (NH) residents.1,2 Hip fractures are typically managed with surgical repair, as a non-operative approach is associated with poor short-term mortality and functional recovery.3 However, the decision to undergo surgical repair versus a palliative approach is less straightforward among residents with advanced dementia because at baseline, they have profound cognitive and functional disability and a limited life expectancy.
Management decisions for NH residents with advanced dementia should be guided by the goal of care as articulated by their health care proxy. Prior research indicates that the majority of these proxies prioritize comfort-focused care, and only a minority opt for life-prolonging care.4 To make informed decisions that are aligned with preferences, evidence regarding the outcomes of treatment options is necessary. No prior studies have examined whether surgical repair of a hip fracture is associated with increased survival or reduced adverse outcomes (e.g., pain) in NH residents with advanced dementia. In the absence of evidence, hip fractures remain the exceptional sentinel event for which a surgical approach is often sought, even when the goal of care is comfort.
A randomized clinical trial of surgery versus non-surgical approach in persons with advanced dementia and hip fracture is unlikely to be conducted due to ethical and feasibility concerns. Thus, this study’s objective was to leverage nationwide Minimum Data Set (MDS) assessments linked to Medicare claims to conduct a cohort study comparing outcomes between NH residents with advanced dementia who did and did not undergo surgical repair of a hip fracture, including survival, pain, antipsychotic and physical restraint use, pressure ulcer, and ambulatory status.
METHODS
Data Sources
Data were ascertained from the MDS (version 2.0) files linked to the Medicare enrollment files, Parts A, B, and D claims, and hospice claims, from 1/1/2008 to 12/31/2013. The MDS is a comprehensive resident assessment instrument containing over 400 items, and federally mandated on all U.S. NH residents at the time of admission and quarterly thereafter.5 The clinically rich MDS has the advantage of allowing for the adjustment of differences between the surgical and non-surgical groups, as well as the examination of key post-fracture outcomes other than survival. This research was approved by the Institutional Review Board of Hebrew SeniorLife.
Study Design
This retrospective cohort study included long-stay NH residents > 65 years with advanced dementia and hip fracture (Figure 1). To establish this cohort, we first identified 1,257,279 long-stay NHs residents with a full MDS assessment between 1/1/2008 to 12/31/2009 and who were not in hospice. Long-stay was defined as residing in the same NH ≥ 100 with no more than 10 consecutive days outside the facility.
Next, residents who experienced a hip fracture within two years of the full MDS assessment were identified using Medicare claims (n= 45,781) using a validated approach with a positive predictive value of 94%.6 A hip fracture was defined using the International Classification of Diseases, ninth edition (ICD-9) diagnostic codes (820.xx and 733.14) in Part A (inpatient) or B (outpatient) claims. For hospitalized fractures identified using Part A claims, we did not require an accompanying procedural code. For non-hospitalized fractures identified using Part B claims, we required a procedural code for hip fracture management on the same encounter as the diagnostic code, based on a published list of codes.7 We also considered as a hip fracture any Part B diagnostic claim for pelvic or femoral shaft fracture with a procedural code specific to the hip on the same encounter (n=119).
Among residents with hip fracture, we then selected those with advanced dementia using the MDS assessment just prior to the date of the fracture. Advanced Dementia was defined as a Cognitive Performance Scale (CPS)8 of 5 or 6 and diagnosis of “Dementia” or “Alzheimer's Disease.” Advanced dementia residents with do-not-hospitalize (DNH) directives on any MDS one year before the fracture (n=183) were excluded.
Finally, we determined whether residents underwent surgical repair using procedural codes, as done in prior reports.7 Residents with Part A diagnostic claims for hip fracture without a surgical procedural code were considered to have non-surgical management.
Based on an ‘a priori’ assumption that residents who were and were not ambulatory may be fundamentally different in terms of decision-making for surgery and outcomes following fracture, we stratified our analyses according to whether or not the resident could ambulate in a room without assistance based on the MDS assessment just preceding the hip fracture.
Outcomes
All-cause mortality was ascertained by the Medicare Enrollment File through 2013.
Among residents who survived 6 months, pain, physical restraint use, and pressure ulcers were obtained from the first MDS assessment completed between 120–240 days following the fracture. Pain was assessed using the validated MDS 2.0 pain instrument that relies on nursing assessment, rather than self-report, to capture the frequency and severity of pain in the prior 7 days.9 We categorized pain as present if pain of any severity was noted. Physical restraint use was defined as the use of any trunk, limb, or chair restraint in the past 7 days. Pressure ulcers were defined as any stage 2–4 pressure ulcer. Six month antipsychotic use (all types) was ascertained via Medicare Part D claims. Residents were considered users of antipsychotic drugs if the resident was alive and taking the drug 180 days following the fracture based on the amount and frequency of drug prescribed. In the subset of residents who were ambulatory before the fracture and survived 6 months, we determined ambulatory status between 120–240 days.
Covariates
Resident characteristics potentially related to both the decision to operate and the outcomes of interest based on the literature10 and our clinical expertise were selected as covariates including race (white, black, and other/unknown), the Advanced Dementia Prognostic Tool (ADEPT) score and CPS score (5 versus 6). ADEPT is a validated risk score that estimates 6-month mortality in NH residents with advanced dementia.11 Items in ADEPT include: NH admission date < 90 days (zero for all subjects in this cohort), age, male sex, shortness of breath, bowel incontinence, congestive heart failure, bedfast, pressure ulcer, consumption of < 75% of meals, dependence for all Activities of Daily Living, body mass index < 18.5, and recent weight loss.
Comfort Care after Fracture
To examine the initiation of comfort-focused care after hip fracture, we described the proportion of residents in the surgical and non-surgical groups who had a Medicare Hospice claim or a new DNH order (MDS assessment) in the 180 days following the fracture.
Statistical Approach
All data were analyzed by SAS v9.4. Descriptive statistics were conducted using means with standard deviations for continuous variables and proportions for categorical variables.
Kaplan Meier curves were used to describe survival among residents who did and did not undergo surgery. Cox proportional hazards regression was used to examine the association between surgical repair (main independent variable) and survival before and after adjusting for race, ADEPT score, and dementia severity (CPS 5 or 6). Analyses were done in all residents, and then stratified by pre-fracture ambulatory status.
In the subset of residents who survived six months, logistic regression models were used to examine the association between surgical repair and the following outcomes: pain, antipsychotic use, physical restraint use, and pressure ulcer. Models were adjusted for age, race, dementia severity, ADEPT score, and the pre-fracture status of the examined outcome. In the subset of residents who were ambulatory before the fracture and survived six months, we described ambulatory status between 120–240 days according to whether or not the resident received surgery.
Finally, logistic regression models were used to generate propensity scores that estimated the odds of receiving surgery versus no surgery (covariates listed in Appendix 1). Adjustment for differences in characteristics before the hip fracture was performed using inverse probability of treatment weighting (IPTW) models.
RESULTS
Population
We identified 3,083 long stay residents with advanced dementia and hip fracture, 879 (28.5%) of whom ambulated prior to the fracture. The average age was 84.2 years (+/− 7.1), 79.2% were female, and 85.4% had CPS scores of 5. A total of 2,615 residents (84.8%) underwent surgical repair, whereas 468 (15.2%) did not. Among ambulatory residents, 94.4% (n=830/879) had surgical repair. Table 1 presents the baseline characteristics of the entire cohort and stratified by pre-fracture ambulatory status. Residents managed non-surgically were more often black, female, had BMI < 18.5 kg/m2, had more pressure ulcers, and were totally dependent in ADLs as compared to residents managed surgically.
Table 1
Pre-fracture clinical characteristics of NH residents with advanced dementia and hip fracture, according to whether or not they received surgical repair and stratified by pre-fracture ambulatory status (n (%), unless otherwise stated)
| Overall n=3,083 | Ambulatory n= 879a | Non-ambulatory n= 2,202a | ||||
|---|---|---|---|---|---|---|
| Resident | Surgical | No surgical | Surgical | No surgical | Surgical | No surgical repair |
| Characteristic | repair | repair | repair | repair | repair | n=419 |
| n=2,615 | n=468 | n=830 | n=49 | n= 1,783 | ||
|
| ||||||
| Age, mean yrs (SD) | 84.0 (7.1) | 85.1 (7.5) | 83.1 (6.9) | 83.9 (7.1) | 84.4 (7.1) | 85.3 (7.5) |
|
| ||||||
| Race | ||||||
| White | 2,345 (89.7) | 385 (82.3) | 753 (90.7) | 45 (91.8) | 1,592 (89.3) | 340 (81.1) |
| Black | 178 (6.8) | 63 (13.5) | 48 (5.8) | 2 (4.1) | 129 (7.2) | 61 (14.6) |
| Other | 92 (3.5) | 20 (4.3) | 29 (3.5) | 2 (4.1) | 62 (3.5) | 18 (4.3) |
|
| ||||||
| Female | 2,052 (78.5) | 389 (83.1) | 636 (76.6) | 36 (73.5) | 1,414 (79.3) | 353 (84.2) |
|
| ||||||
| ADEPT scoreb, mean (SD) | 12.4 (2.9) | 14.0 (3.3) | 11.4 (2.6) | 12.8 (3) | 11.8(2.8) | 14.3 (3.2) |
|
| ||||||
| Shortness of breath | 76 (2.9) | 22 (4.7) | 12 (1.4) | 1 (2.0) | 64 (3.6) | 21 (5.0) |
|
| ||||||
| Bedfast | 20 (0.8) | 26 (5.6) | 2 (0.2) | 0 (0) | 18 (1.0) | 26 (6.2) |
|
| ||||||
| Congestive heart failure | 263 (10.1) | 62 (13.2) | 51 (6.1) | 5 (10.2) | 212 (11.9) | 57 (13.6) |
|
| ||||||
| BMI < 18.5 kg/m2 | 274 (10.5) | 80 (17.1) | 74 (8.9) | 8 (16.3) | 200 (11.2) | 72 (17.2) |
|
| ||||||
| Bowel incontinence | 1,579 (60.4) | 363 (77.6) | 359 (43.3) | 21 (42.9) | 1,220 (68.4) | 342 (81.6) |
|
| ||||||
| Consumes < 75% of meals | 712 (27.2) | 112 (23.9) | 196 (23.6) | 11 (22.4) | 516 (28.9) | 101 (24.1) |
|
| ||||||
| Pressure ulcerc | 85 (3.3) | 45 (9.6) | 4 (0.5) | 1 (2.0) | 81 (4.6) | 44 (10.5) |
|
| ||||||
| Activities of Daily Living score=28d | 147 (5.3) | 121 (25.9) | 0 (0) | 0 (0) | 147 (8.2) | 121 (28.9) |
|
| ||||||
| Transfer dependencee | 1453 (55.6) | 384 (82.1) | 105 (12.7) | 8 (16.3) | 1,348 (75.6) | 376 (89.7) |
|
| ||||||
| Cognitive Performance Scalef | ||||||
| 5 | 2,310 (88.3) | 323 (69.0) | 794 (95.7) | 48 (98.0) | 1,514 (84.9) | 275 (65.6) |
| 6 | 305 (11.7) | 145 (31.0) | 36 (4.3) | 1 (2.0) | 269 (15.1) | 144 (34.4) |
Survival
A total of 1,076 residents (34.9%) died within six months, and 1,908 residents (61.9%) died within two years of the fracture (Figure 2). Mortality differences between residents managed with and without surgery were greatest in the first 30 days (11.5% among residents with surgery versus 30.6% among non-surgically managed) (Appendix 2). Median survival was 1.4 years in residents managed with surgery, as compared with 0.4 years in residents managed without surgery. In unadjusted Cox proportional hazards model, surgical repair was associated with a decreased risk of death (HR 0.55, 95% CI 0.49, 0.61; Table 2). In the multivariate model, the association was similar (adjusted HR (aHR) 0.56, 95% CI 0.49, 0.63). In IPTW models, the results were attenuated but remained significant (aHR 0.88, 95% CI 0.79, 0.98). When stratified by pre-fracture ambulatory status, the results were similar: IPTW models, ambulatory, aHR 0.89 (95% CI 0.72, 1.10); non-ambulatory, aHR 0.88 (95% CI 0.78, 0.91).
Survival in NH residents with advanced dementia and hip fracture, according to whether or not they underwent surgical repair (adjusted hazards ratio to describe the association between surgical repair versus no surgery and -mortality: 0.56, 95% confidence intervals 0.49, 0.63)
Table 2
Unadjusted and adjusted mortality in NH residents with advanced dementia and surgical repair of hip fracture compared with no surgical repair, stratified by pre-fracture ambulatory status
| Unadjusted HR (95% CI) | Adjusteda HR (95% CI) | IPTW modelsa (95% CI) | |
|---|---|---|---|
| Overall | 0.55 (0.49, 0.61) | 0.56 (0.49, 0.63) | 0.88 (0.79, 0.98) |
| Ambulatory | 0.50 (0.36, 0.70) | 0.50 (0.36, 0.70) | 0.89 (0.72, 1.10) |
| Non-Ambulatory | 0.57 (0.50, 0.65) | 0.58 (0.51, 0.66) | 0.88 (0.78, 0.99) |
Other Outcomes
A total of 2,007 residents were alive six months following the hip fracture, and 1,794 residents (89.4%) had a valid MDS assessment between 120–240 days following the fracture (mean 170 days ± 24 days). Residents who underwent surgical repair versus those without had less documented pain (29.0% versus 30.9%), greater use of antipsychotic medication (29.5% versus 20.4%), greater physical restraint use (13.0% versus 11.1%), and fewer pressure ulcers (11.2% versus 19.0%) (Table 3). In adjusted Cox proportional hazards models, there was no difference in these secondary outcomes according to surgical repair. In adjusted IPTW models, there was less pain (aHR 0.78, 95% CI 0.61, 0.99) and pressure ulcers (aHR 0.64, 95% CI 0.47, 0.86) among residents managed with surgery.
Table 3
Association between surgical repair versus no surgical repair and pain, restraint use, pressure ulcer, and antipsychotic use in NH residents with advanced dementia and hip fracture who survived 6-months with valid MDS assessment (n=1,794)
| Surgical repair n=1,603 | No surgical repair n=191 | Unadjusted OR (95% CI) | Adjusted ORb (95% CI) | IPTW modelb (95% CI) | |
|---|---|---|---|---|---|
| Pain | 465 (29.0) | 59 (30.9) | 0.91 (0.66, 1.27) | 0.89 (0.63, 1.26) | 0.78 (0.61, 0.99) |
| Antipsychotica use | 529 (29.5) | 44 (20.4) | 1.64 (1.16, 2.32) | 1.43 (0.93, 2.19) | 1.02 (0.76, 1.37) |
| Restraint use | 233 (13.0) | 24 (11.1) | 1.18 (0.75, 1.85) | 1.44 (0.86, 2.40) | 1.83 (1.21, 2.76) |
| Pressure ulcer | 200 (11.2) | 41 (19.0) | 0.52 (0.36, 0.76) | 0.68 (0.45, 1.03) | 0.64 (0.47, 0.86) |
Among the 879 residents who were ambulatory pre-hip fracture, 536 (61.0%) were alive and had a valid MDS assessment between 120–240 days following the fracture. A total of 96.1% (n= 515/536) underwent surgical repair. A greater proportion of residents managed surgically were ambulatory at 6-months versus those without surgery: 55/515 (10.7%) versus 1/21 (4.8%).
Comfort Care after Fracture
Overall, 662 residents (21.5%) utilized hospice within six months following the hip fracture. The mean time to utilize hospice was 56 days (± 49 days). Among residents managed surgically, 19.3% (504/2,615) utilized hospice as compared with 33.8% (158/468) managed non-surgically. Among residents who survived six months, only 1.1% in both the surgical and non-surgical groups acquired a DNH directive.
DISCUSSION
In a large nationwide study of NH residents with advanced dementia and hip fracture, mortality was high, with approximately one third of residents dying within six months. Surgical repair was associated with a significantly lower risk of death and median increased survival of one year as compared to a non-surgical approach. Pain and pressure ulcers were more common in residents managed without surgery. Potentially treatable adverse outcomes, including pain, antipsychotic use, restraint use, and pressures ulcers, were common among residents who survived six months, regardless of whether they were managed surgically. Only a minority of patients who ambulated before their hip fracture were ambulatory at six months, even among those who underwent surgical repair. Despite the high morbidity and mortality in these profoundly impaired residents, only about 20% were referred to hospice, and directives to avoid future hospitalizations were rare.
Our work corroborates and extends previous studies that found a very high mortality in persons with advanced dementia and hip fracture.3,12,13 Prior studies of NH residents or community-dwellers with advanced dementia report 7–12% of persons were managed without surgery,3,13,14 whereas 15% of residents in our study without surgery. These studies estimate six-month mortality following a hip fracture between 36–55%, as compared with 35% in our study. This suggests mortality rate is increased approximately 1.5 to 2-fold in NH residents with advanced dementia and hip fracture compared with advanced dementia residents who do not suffer fracture (18–25%). 11 In comparison, population based studies of hip fracture in older persons, report an approximately 3.5 fold increased risk of death in months 4–6 following the fracture.15
Our findings are also consistent with studies of hip fracture that describe a survival benefit in persons undergoing surgical repair. In both a U.S. and Canadian population based study, NH residents with hip fracture managed without surgery had approximately a two-fold increased mortality over six months.3,14 Neither study reported mortality outcomes specifically among residents with advanced dementia or according to pre-fracture ambulatory status. In our study, both ambulatory and non-ambulatory advanced dementia residents with hip fractures experienced a notable survival advantage within the first 30 days when managed surgically. We cannot discern the reason for this observation, but it is possible that because mortality is greatest immediately following hip fracture, surgical repair with its concomitant treatments (e.g., parenteral fluids) attenuates this risk.
Although we observed a survival benefit in residents who underwent operative repair, it is important to consider other outcomes important to both patients and families in this frail population. Among residents who survived six months, pain was reported in approximately one-third of residents regardless of surgical treatment. Pain is under-reported and undertreated in dementia patients. In a prospective cohort study by Sieber et al, patients with dementia and hip fracture managed surgically received one-third less opioid medications as compared with cognitively intact patients.16 We found pain was more commonly reported among residents managed without surgery. If underreporting of pain occurred more often in surgically managed residents, this could explain our findings. Regardless, our findings suggest there is an opportunity to improve pain management in residents with advanced dementia and hip fracture.
Among six month survivors, the use of antipsychotic drugs and physical restraints was common in both those managed with and without surgery. The frequency of antipsychotic use in our study was similar to estimates by Jung et al, who found that 29% of persons with advanced dementia (CPS 5–6) and hip fracture received an antipsychotic drug prescription during their NH stay.17 Given the adverse effects associated antipsychotic drugs,18 it is important to avoid these medications, whenever possible. Similarly, physical restraints have been associated with injury19 and even mortality20 in NH residents, and should be avoided. Pressure ulcers were documented in 13% of residents who survived six months. Other studies have demonstrated that up to one-third of persons with hip fracture and surgical repair will develop a pressure ulcer, 21 and it is possible that our estimates are low if pressure ulcers are under-reported in the MDS.
Goals of care should drive treatment decisions for NH residents with advanced dementia. Prior work suggests that roughly 60% of proxies of these residents feel only treatments that promote comfort best align with their goals of care, even if that means relinquishing potentially life-prolonging interventions.22 Only 7% of proxies feel the resident would still want very intensive medical care (e.g., mechanical ventilation) with the hope of prolonging survival. The remaining one-third of proxies opt for care that lies somewhere between these extremes, such as potentially curative treatments that are relatively conservative with the goal of maintaining the resident at their baseline health status (e.g., antimicrobials for an infection but not mechanical ventilation). Our findings clearly suggest that surgery would be a reasonable approach for the minority of advanced dementia residents with hip fracture whose primary goal of care remains life prolongation. Our finding that surgical patients may experience less pain and pressure ulcers at six months suggests surgical repair may also promote a goal of comfort. However, we do not know the quality of palliative care provided to these patients, which could potentially ameliorate these issues without surgery.
There are some limitations of our study. Despite our relatively homogenously defined cohort and adjustment for many factors that could influence the relationship between hip fracture management and mortality, unmeasured differences may persist between residents who did and did not undergo surgery that could influence our findings. To attempt to adjust for these unmeasured differences, we used an IPTW approach that included many characteristics that could be related to decision to operate. Despite this approach, we could not include every characteristic potentially related to this decision such as differences in co-morbidities not included in the MDS. Thus, it is possible that residual confounding may persist and that these unmeasured differences between residents with and without surgery, rather than the surgery itself, explains the observed mortality difference between the two groups. Second, misclassification of surgical repair using claims data or cognitive and functional status using the MDS is possible. It is likely that this misclassification is non-differential and may not affect our results. Third, we measured secondary outcomes at a single time point, although they likely fluctuate in the weeks to months following a fracture. Finally, we do not have information on time to surgery, and it is possible that some residents in the non-operative group died before they had the opportunity for surgery. Although we cannot entirely disentangle the effect of these most frail residents on the outcome, our results still provide insight on the anticipated survival differences between the two groups.
Our findings highlight the need to improve the quality of care of provided to NH residents with advanced dementia who suffer a hip fracture. Proxies of these residents should consider the survival benefit of surgery together with the overall goals of care when making the difficult decision of whether to pursue surgery. Discomfort, hazardous interventions (e.g., restraints, antipsychotics), and adverse outcomes (e.g., pressure ulcers) should be minimized, regardless of surgical management or goals of care. Utilization of hospice and directives reflective of a more comfort-focused approach (i.e., DNH) were surprisingly low in this very frail population near the end of life. We encourage greater use of hospice and palliative care services in residents with advanced dementia and hip fracture regardless of surgical repair in an effort to reduce suffering.
Acknowledgments
Funding Sources: This work was funded by grants from the NIA: 1R01AG045441 (SDB) and K24AG033640 (SLM).
Footnotes
These analyses were presented in part as an abstract at the American Geriatrics Society meeting in Long Beach, CA on May 20, 2016.