Medical Comanagement of Hip Fracture Patients Is Not Associated with Superior Perioperative Outcomes: A Propensity Score-Matched Retrospective Cohort Analysis of the National Surgical Quality Improvement Project

Hip fractures are a large source of morbidity and mortality in the United States, with >1.5 million patients affected every year.¹ These patients are primarily older adults with a significant burden of associated medical comorbidities.² The outcomes of nonoperative management are poor with regard to mortality,³ although operative management of hip fractures remains associated with a high rate of morbidity and mortality compared with several other surgical procedures, substantial resources remain devoted to the operative repair of hip fractures and to process improvement strategies for perioperative care.

Medical comanagement involves having a second nonsurgical primary team—often an internist, a hospitalist, a geriatrician, or an anesthesiologist—who would follow the patient during the hip fracture admission, and provide daily care directed toward both the hip fracture and its associated management challenges and the patient’s underlying comorbidities. This includes taking a primary or shared role in daily rounding, writing progress notes, writing orders, managing medications and therapies, disposition planning, and discharge. One argument for this practice has centered around an efficiency proposition for surgeons to spend more of their time operating and less time in these tasks of acute care management. The primary argument, though, for medical comanagement has been an outcomes proposition that frail, elderly patients with significant medical comorbidities benefit from a nonsurgeon’s focused attention to their coexisting medical problems and the interaction with the surgical issues posed by operative intervention for hip fracture. A number of previous studies have demonstrated an association between comanagement and improved perioperative outcomes.^4,5 However, the most convincing improvements in several studies have been process indicators (eg, time from admission to surgery, length of stay, nurse/surgeon satisfaction) without significant differences in mortality or major morbidity.^6-8 Several studies were methodologically limited due to the use of historical controls,^9,10 and several were conducted in focused clinical settings (eg, a single tertiary academic center), leaving uncertainty about external validity for other care environments.^6,7 To our knowledge, comanagement has not been examined in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) dataset of hip fracture patients.

The NSQIP database offers a unique tool for clinical outcomes research because its variables are prospectively collected by a trained clinical reviewer at each participating site. Data are deidentified and aggregated into a national database, which has grown from 121 participating sites in 2005 to 708 participating sites in 2017 and now contains data on more than 6.6 million patients. The targeted hip fracture participant use file (PUF) adds additional variables and is available beginning with 2016. Internal audits ensure a high level of data reliability.¹¹ The NSQIP has compared favorably with single-institution morbidity and mortality conference systems,¹² multi-institution clinical databases,¹³ and administrative databases¹⁴ in accurately capturing 30-day outcomes. Unlike other databases, outcomes are recorded within 30 days even if they occur after the initial postoperative discharge. Comanagement is a dedicated variable in the NSQIP hip fracture dataset.

This study sought to examine the effect of medical comanagement on perioperative outcomes in this contemporary NSQIP database.