Orthopedics

Feature Article 

Age Alone Does Not Predict Complications, Length of Stay, and Cost for Patients Older Than 90 Years With Hip Fractures

Ariana Lott, MD; Rebekah Belayneh, MD; Jack Haglin, BS; Sanjit R. Konda, MD; Kenneth A. Egol, MD

Abstract

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 2019; 42(1):e51–e55.]

Abstract

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 2019; 42(1):e51–e55.]

Given the aging population, hip fractures are becoming an increasing concern for orthopedic surgery and the health care system as a whole. In recent years, nonagenarians (individuals 90 years and older) have experienced the fastest population growth compared with all other age groups.1 In addition, these individuals are at a heightened risk for hip fracture, as adults older than 85 years have been cited to have a 10 times greater likelihood of sustaining a hip fracture when compared with individuals between 65 and 69 years.2 This heightened risk is reflected in admission trends, as there were more than 125,000 hospital admissions for hip fractures among individuals older than 80 years in the United States alone in 2011.3

These elderly patients, particularly those older than 90 years, constitute a challenging subgroup of hip fracture patients. Nonagenarians tend to carry more comorbidities, and several reports have shown that these patients have an increased risk of postoperative complications and poorer outcomes when compared with younger patients.4–6 However, the reported evidence regarding patients older than 90 years with hip fractures is inconclusive, and the true risk profile and cost of treatment of these patients remain unclear. Further, no study has reported the difference in cost of treating nonagenarian patients with hip fractures compared with younger patients. With increasing attention and initiatives being aimed at providing high-value care, risk profiles, costs, and outcomes must be further evaluated and better defined on an age-stratified level for patients with hip fractures. Considering the relatively high cost and mortality associated with hip fractures in the elderly, the purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years to better allocate and focus limited resources to a targeted, at-risk patient population.

Materials and Methods

This institutional review board–approved study analyzed a consecutive series of patients with hip fractures treated operatively who presented to 1 academic medical center between October 2014 and September 2016. Patients were included if they presented with a hip fracture (femoral neck, intertrochanteric, subtrochanteric, and periprosthetic) and were treated operatively during their index admission. Patient demographics, comorbidities, American Society of Anesthesiologists classification, time between presentation and surgery, length of stay, procedure performed, and inpatient complications were analyzed. Comorbidities were analyzed using the Charlson Comorbidity Index. Procedures were divided into closed reduction and internal fixation, open reduction and internal fixation, and arthroplasty. Complications included acute renal failure, surgical site infection, urinary tract infection, acute anemia, sepsis, pneumonia, deep venous thrombosis/pulmonary embolism, acute myocardial infarction, stroke, decubitus ulcer, acute respiratory failure, cardiac arrest, and death. One-year mortality data were obtained. Total direct variable costs of admission were obtained from the hospital finance department. The authors'; institution considered these financial data proprietary information. Thus, all cost data were reported as a proportion of the mean total direct variable cost of care for the patients younger than 90 years (“x”). Outcomes were compared between patients 90 years and older and patients younger than 90 years, with P<.05 considered statistically significant.

Results

A total of 500 patients with hip fractures treated operatively were included in this study. There were 109 (21.8%) patients 90 years or older (mean, 94.0±2.6 years; range, 90–101 years) and 391 (78.2%) patients 60 to 89 years (mean, 78.9±8.0 years). There was no difference in sex, fracture type, anesthesia type, or operation performed between the 2 groups, with most of the patients sustaining intertrochanteric hip fractures in both groups treated with open reduction and internal fixation (Table 1). There was also no difference in Charlson Comorbidity Index between the 2 groups, with a mean of 1.4±1.6 in the younger than 90 years cohort and 1.2±1.3 in the 90 years and older cohort (P=.167). The mean American Society of Anesthesiologists score was 3.0±0.7 for the younger than 90 years cohort compared with 3.1±0.7 for the 90 years and older cohort (P=.038). Although statistically significant, this difference was not clinically significant. There was no difference in length of stay between the 2 cohorts. The mean length of stay was 7.8±4.3 days for patients 90 years and older and 7.6±4.2 days for patients younger than 90 years (P=.552) (Table 2). In addition, there was no observed difference in time to surgery, surgical blood loss, need for transfusion, or perioperative complications between patients older than 90 years and patients between 60 and 89 years (Table 2). The mean number of complications was 1.0±1.1 in the younger than 90 years cohort compared with 1.2±1.1 in the 90 years and older cohort (P=.103) (Table 2).

Demographics, Fracture Details, and Procedure Details

Table 1:

Demographics, Fracture Details, and Procedure Details

Hospital Quality Measures, Cost of Care, and Discharge Disposition

Table 2:

Hospital Quality Measures, Cost of Care, and Discharge Disposition

The incidence of individual complications, notably inpatient mortality, was also no different between the cohorts. Although observed perioperative complications were similar between cohorts, the need for transfer to the stepdown unit/intensive care unit was greater in the 90 years and older cohort (33.0% vs 20.7%, P=.007). Regarding inpatient admission costs, there was no difference in total mean cost of admission between the 2 patient cohorts: $1.00x±$0.54x for the younger cohort and $0.97x±$0.43x for the older cohort (P=.574). However, the post-discharge location was different between the 2 cohorts, with only 7.3% of patients older than 90 years discharged home compared with 19.9% of patients between 60 and 89 years (P=.002). Finally, there was a significantly higher 1-year mortality rate in the 90 years and older cohort (13.8% vs 6.1%, P=.009) (Table 3).

Incidence of Individual Complications and Mortality

Table 3:

Incidence of Individual Complications and Mortality

Discussion

In this study, patients 90 years and older with hip fractures treated operatively were not at an increased risk for longer admissions or more perioperative complications compared with younger patients. In addition, they did not have costlier in-patient admissions when compared with patients younger than 90 years. However, these patients were more likely to be admitted to post-acute care facilities and had a greater 1-year mortality rate than their younger counterparts.

This analysis showed no increased risk of longer hospitalizations for patients 90 years and older, with the mean length of stay for both cohorts being approximately 8 days. In addition, there was no delay to surgery in the 90 years and older cohort, with the 2 groups having similar times between presentation and surgery. Previous studies of older patients who undergo hip fracture fixation present conflicting results regarding length of stay. Shah et al7 analyzed 850 patients older than 65 years with hip fractures treated operatively from 1 academic medical institution, concluding that patients older than 90 years had significantly longer stays (25.1 days) compared with younger patients (23.1 days). A second analysis of patients from 2 teaching hospitals in the Netherlands also suggested increased stays for patients older than 90 years, citing that they were more likely to have stays of greater than 11 days.5 This analysis, however, does not cite a comparison of mean stays.5 In contrast, Manoli et al8 reported that in a cohort of more than 168,000 patients with hip fractures, those between 81 and 99 years of age had longer stays by 0.23 to 0.31 days depending on fracture pattern. No increase was found for patients 100 years and older when compared with those younger than 100 years. The stays presented in the current analysis (7.6 days in the younger than 90 years cohort and 7.8 days in the 90 years and older cohort) are shorter than those in the studies by Shah et al7 and Vochteloo et al5 and are more consistent with the analysis by Manoli et al.8

Like length of stay, previous analyses have differed on the incidence of complications in hip fracture patients older than 90 years. Miller et al9 studied 722 patients from 1 institution between 2000 and 2010, reporting no difference in overall complication rates between patients 51 and 89 years and patients 90 years or older. However, there were a greater number of cardiac complications in the patients older than 90 years reported in this study. This increased incidence of cardiac complications is similar to that reported in the study by Vochteloo et al,5 which also showed an increased rate of delirium in the patients older than 90 years. By contrast, Shah et al7 reported that being 90 years or older was not predictive of having a postoperative complication. Although the current authors did not find any difference in acute myocardial infarction between the 2 cohorts, they did not specifically analyze the other cardiac complications that were included in the study by Miller et al,9 such as arrhythmia, congestive heart failure exacerbations, or unexplained hypotension.

In contrast to previous studies,5,7,9 the current authors did not find an increased risk of inpatient mortality in patients older than 90 years, with only 1 death in the 90 years and older cohort (0.9%) and 7 deaths in the younger than 90 years cohort (1.8%). In addition, the overall rate of inpatient mortality was lower than those previously reported. For example, Miller et al9 reported a 4.5% inpatient mortality rate in patients older than 90 years. Possible explanations include the decreased stay seen in the current analysis and that the current cohort was most likely healthier than other previously analyzed groups. The low 1-year mortality rate observed in this cohort supports the latter explanation.

To the authors'; knowledge, this is the first inpatient cost analysis of patients older than 90 years compared with younger patients with hip fractures. With the increasingly cost-conscious health care environment, many physicians and hospitals are seeking ways to identify high-cost patients. Unlike elective surgical patients, trauma patients, such as geriatric patients with hip fractures, are unable to be optimized prior to admission. Therefore, the ability to identify higher-risk patients who will have increased inpatient admission costs is crucial to provide high-quality, cost-conscious care. This study suggests that age alone should not be used as a risk stratification tool for these geriatric patients with hip fractures and that surgeons should instead be mindful of the underlying comorbidities of these patients during risk assessment.

Finally, 1 aspect of hip fracture care that has become increasingly important in light of proposed and current bundle payment programs is use of post-acute care facilities.10 It is estimated that more than 90% of Medicare beneficiaries use post-acute care after hospitalization for an acute hip fracture.11,12 This is consistent with the current results: patients 90 years and older were less likely to be discharged home than patients younger than 90 years, with only 7.3% of the former being discharged home. The high cost of this post-acute care has also been well documented in the hip fracture literature, with patients having an average length of stay ranging from 15 to 27 days.13–15

This study had several limitations. Although these data were collected prospectively, they were reviewed retrospectively. Further, the data were collected from 1 urban academic medical center. Although this center includes a tertiary care center and a level 1 trauma center, these results, particularly the cost data, may not be directly applicable to other hospitals with patient populations different from the current patient population. In addition, socioeconomic factors were not analyzed in this study. Further analysis of these factors is necessary to determine if they are confounding risk factors for length of stay, complications, and admission costs. Finally, this study included an analysis of only the index admission for these patients. Further analysis will need to be performed to ascertain differences between patients 90 years and older and those younger than 90 years after hospitalization.

Conclusion

Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. Although patient risk factors influence patient outcomes and the cost of care, this study suggests that age alone cannot be used to predict these poor outcomes or high cost of care. However, future efforts should be focused on decreasing the use of post-acute care in this cohort of patients. Possible interventions include more family involvement and increased use of hospital resources or equipment or services that make home discharge more feasible for these at-risk patients. This will become increasingly important as hip fracture care is incorporated into bundled payment of care models.

References

  1. Fansa A, Huff S, Ebraheim N. Prediction of mortality in nonagenarians following the surgical repair of hip fractures. Clin Orthop Surg. 2016;8(2):140–145. doi:10.4055/cios.2016.8.2.140 [CrossRef]
  2. Samelson EJ, Zhang Y, Kiel DP, Hannan MT, Felson DT. Effect of birth cohort on risk of hip fracture: age-specific incidence rates in the Framingham study. Am J Public Health. 2002;92(5):858–862. doi:10.2105/AJPH.92.5.858 [CrossRef]
  3. Yelin E, Weinstein S, King T. The burden of musculoskeletal diseases in the United States. Semin Arthritis Rheum. 2016;46(3):259–260. doi:10.1016/j.semarthrit.2016.07.013 [CrossRef]
  4. D';Apuzzo MR, Pao AW, Novicoff WM, Browne JA. Age as an independent risk factor for postoperative morbidity and mortality after total joint arthroplasty in patients 90 years of age or older. J Arthroplasty. 2014;29(3):477–480. doi:10.1016/j.arth.2013.07.045 [CrossRef]
  5. Vochteloo AJ, Borger van der Burg BL, Tuinebreijer WE, et al. Do clinical characteristics and outcome in nonagenarians with a hip fracture differ from younger patients?Geriatr Gerontol Int.2013;13(1):190–197. doi:10.1111/j.1447-0594.2012.00885.x [CrossRef]
  6. Kirkland LL, Kashiwagi DT, Burton MC, Cha S, Varkey P. The Charlson Comorbidity Index score as a predictor of 30-day mortality after hip fracture surgery. Am J Med Qual. 2011;26(6):461–467. doi:10.1177/1062860611402188 [CrossRef]
  7. Shah MR, Aharonoff GB, Wolinsky P, Zuckerman JD, Koval KJ. Outcome after hip fracture in individuals ninety years of age and older. J Orthop Trauma. 2003;17(suppl 8):6S–11S. doi:10.1097/00005131-200309001-00003 [CrossRef]
  8. Manoli A III, Driesman A, Marwin RA, Konda S, Leucht P, Egol KA. Short-term outcomes following hip fractures in patients at least 100 years old. J Bone Joint Surg Am. 2017;99(13):68E. doi:10.2106/JBJS.16.00697 [CrossRef]
  9. Miller AG, Bercik MJ, Ong A. Nonagenarian hip fracture: treatment and complications. J Trauma Acute Care Surg. 2012;72(5):1411–1415. doi:10.1097/TA.0b013e318246f3f8 [CrossRef]
  10. Centers for Medicare & Medicaid Services. Bundled Payments for Care Improvement (BPCI) initiative: general information. https://innovation.cms.gov/initiatives/bundled-payments. Accessed March 13, 2018.
  11. Buntin MB, Colla CH, Deb P, Sood N, Escarce JJ. Medicare spending and outcomes for postacute care for stroke and hip fracture. Med Care. 2010;48(9):776–784. doi:10.1097/MLR.0b013e3181e359df [CrossRef]
  12. Nguyen-Oghalai TU, Kuo YF, Zhang DD, Graham JE, Goodwin JS, Ottenbacher KJ. Discharge setting for patients with hip fracture: trends from 2001 to 2005. J Am Geriatr Soc. 2008;56(6):1063–1068. doi:10.1111/j.1532-5415.2008.01688.x [CrossRef]
  13. Burgers PT, Hoogendoorn M, Van Woensel EA, et al. Total medical costs of treating femoral neck fracture patients with hemior total hip arthroplasty: a cost analysis of a multicenter prospective study. Osteoporos Int. 2016;27(6):1999–2008. doi:10.1007/s00198-016-3484-z [CrossRef]
  14. Nikitovic M, Wodchis WP, Krahn MD, Cadarette SM. Direct health-care costs attributed to hip fractures among seniors: a matched cohort study. Osteoporos Int. 2013;24(2):659–669. doi:10.1007/s00198-012-2034-6 [CrossRef]
  15. Mallinson T, Deutsch A, Bateman J, et al. Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair. Arch Phys Med Rehabil. 2014;95(2):209–217. doi:10.1016/j.apmr.2013.05.031 [CrossRef]

Demographics, Fracture Details, and Procedure Details

FactorCohortP

<90 Years Old (N=391)90 Years Old (N=109)
Age, mean±SD, y78.9±8.094.0±2.6<.001
Female, No. (%)272 (69.6)84 (77.1).126
Charlson Comorbidity Index, mean±SD1.4±1.61.2±1.3.167
American Society of Anesthesiologists score, mean±SD3.0±0.73.1±0.7.038
Fracture type, No. (%).249
  Intertrochanteric181 (46.3)61 (56.0)
  Femoral neck177 (45.3)43 (39.4)
  Subtrochanteric23 (5.9)4 (3.7)
  Periprosthetic10 (2.5)1 (0.9)
Procedure type, No. (%).607
  Closed reduction and percutaneous pinning40 (10.2)8 (7.3)
  Open reduction and internal fixation232 (59.4)69 (63.3)
  Arthroplasty119 (30.4)32 (29.4)
Spinal anesthesia, No. (%)124 (31.7)42 (38.5).181

Hospital Quality Measures, Cost of Care, and Discharge Disposition

MeasureCohortP

<90 Years Old (N=391)90 Years Old (N=109)
Length of stay, mean±SD, d7.6±4.27.8±4.3.552
Surgical blood loss, mean±SD, mL186.0±155.4156.1±173.4.129
Time from presentation to surgery, mean±SD, d1.6±1.11.8±1.3.228
Need for transfusion, No. (%)165 (42.2)56 (51.4).088
Complications, mean±SD, No.1.0±1.11.2±1.1.103
Transfer to the stepdown unit/intensive care unit, No. (%)81 (20.7)36 (33.0).007
Total cost of care, mean±SD, $1.00x±0.54x0.97x±0.43x.574
Discharged home, No. (%)78 (19.9)8 (7.3).002

Incidence of Individual Complications and Mortality

ComplicationCohort, No. (%)P

<90 Years Old (N=391)90 Years Old (N=109)
Sepsis14 (3.6)3 (2.8)1.000
Pneumonia30 (7.7)8 (7.3).908
Deep venous thrombosis/pulmonary embolism12 (3.1)4 (3.7).760
Acute myocardial infarction11 (2.8)4 (3.7).750
Acute kidney injury39 (10.0)15 (13.8).260
Stroke2 (0.5)0 (0.0)1.000
Surgical site infection0 (0.0)1 (0.9).218
Decubitus ulcer14 (3.6)5 (4.6).579
Urinary tract infection54 (13.8)23 (21.1).062
Acute respiratory failure39 (10.0)13 (11.9).555
Acute anemia183 (46.8)57 (52.3).310
Cardiac arrest3 (0.8)1 (0.9)1.000
Inpatient mortality7 (1.8)1 (0.9)1.000
1-year mortality24 (6.1)15 (13.8).009
Authors

The authors are from the Orthopedic Department (AL, RB, JH, SRK, KAE), NYU Langone Health, New York, and Jamaica Hospital Medical Center (SRK), Queens, New York.

Dr Lott, Dr Belayneh, Mr Haglin, and Dr Konda have no relevant financial relationships to disclose. Dr Egol is a paid consultant for and receives royalties from Exactech.

Correspondence should be addressed to: Kenneth A. Egol, MD, Orthopedic Department, NYU Langone Health, 301 E 17th St, Ste 1402, New York, NY 10003 ( Kenneth.Egol@nyumc.org).

Received: March 23, 2018
Accepted: July 18, 2018
Posted Online: November 14, 2018

10.3928/01477447-20181109-05

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