Outcomes Research in Review

Hip Fracture in Nursing Home Residents with Advanced Dementia: An Opportunity for Palliative Care

Berry SD, Rothbaum RR, Kiel DP, et al. Association of clinical outcomes with surgical repair of hip fractures vs nonsurgical management in nursing home residents with advanced dementia. JAMA Intern Med. 2018;178:774-780.


 

References

Study Overview

Objective. To compare clinical outcomes (mortality, pain, physical restraint use, pressure ulcer, antipsychotic drug use) in long-term care nursing home (NH) residents with advanced dementia and hip fracture who underwent surgical repair or nonsurgical management.

Design. A retrospective cohort study utilizing nationwide Medicare (Parts A, B, D and hospice) claims data linked with Centers for Medicare & Medicaid Services Minimum Data Set (MDS version 2.0) assessments.

Setting and participants. Long-stay NH residents older than 65 years with advanced dementia (defined as being assigned to Cognitive Performance Scale category 5 or 6 and a diagnosis of dementia or Alzheimer disease) and without a do not hospitalize (DNH) directive before hip fracture were identified by using MDS assessments completed from January 1, 2008 to December 31, 2013. Medicare (Part A – inpatient, or Part B – outpatient) claims data was then used to identify those residents who experienced a hip fracture within 2 years of the full MDS assessment using the International Classification of Diseases, Ninth Revision diagnostic codes. Procedure codes were used to determine whether a resident who experienced hip fracture underwent surgical repair.

Main outcome measures. The main outcome measure was all-cause mortality after hip fracture ascertained by the Medicare Enrollment File through 2013. The secondary outcome measures were documented pain, physical restraint use, pressure ulcers, antipsychotic drug use, and ambulatory status in NH residents who survived 6 months after hip fracture. These outcome measures were captured from the first MDS assessment completed between 120 and 240 days following the fracture or Medicare Part D claims. Documented pain was determined using a validated MDS 2.0 nursing assessment pain instrument within 7 days preceding MDS assessment. Physical restraint use was defined by the use of trunk, limb, or chair restraint within 7 days prior to MDS assessment. Pressure ulcer was defined as any stage 2 to 4 pressure ulcer. Antipsychotic drug use of any medication subclass was determined using Medicare Part D claims data and affirmative if drug was administered 180 days after hip fracture. Ambulatory status between 120 and 240 days following the fracture was determined in a subset of NH residents who were ambulatory before the hip fracture. The utilization of comfort-focused care after hip fracture was determined in NH residents who had a Medicare hospice claim or a new DNH directive in the 180 days after hip fracture.

The differences in survival among NH residents with advanced dementia and hip fracture were described by Kaplan-Meier curves. The association between surgical repair and survival was determined using multivariable Cox proportional hazards for all NH residents and stratified by pre-fracture ambulatory status. In those who survived 6 months after hip fracture, the associations between surgical repair and outcomes including documented pain, physical restraint use, pressure ulcers, antipsychotic drug use, and ambulatory status were determined using multivariable logistic regression models. Adjustment for differences in characteristics before hip fracture was performed using inverse probability of treatment weighting (IPTW) models.

Main results. 3083 long-stay NH residents with advanced dementia and hip fracture were included in the study. The cohort’s mean age was 84.2 ± 7.1 years, 79.2% were female (n = 2441), and 28.5% were ambulatory before hip fracture (n = 879). Of these NH residents, 84.8% (n = 2615) underwent surgical repair and 15.2% (n = 468) received nonsurgical management. At 6 months after hip fracture, mortality was 31.5% in the surgical group compared to 53.8% in the nonsurgical group. The greatest mortality difference between groups occurred in the first 30 days after hip fracture (11.5% in surgical group versus 30.6% in nonsurgical group). Surgical repair was associated with a decreased risk of death (Cox proportional hazard ratio) in the unadjusted (hazard ratio [HR], 0.55 [95% confidence interval {CI}, 0.49-0.61), multivariable adjusted (adjusted HR, 0.56 [95% CI, 0.49-0.63]), and IPTW (adjusted HR, 0.88 [95% CI, 0.79-0.98]) models. Similarly, surgically treated NH residents were less likely to die than those managed non-surgically when mortality was stratified by pre-fracture ambulatory status.

Among NH residents who survived 6 months after hip fracture, those who underwent surgical repair compared with those who received nonsurgical management had less documented pain (29.0% versus 30.9%), fewer pressure ulcers (11.2% versus 19.0%), greater physical restraint use (13.0% versus 11.1%), and greater antipsychotic drug use (29.5% versus 20.4%). In the adjusted IPTW models, surgical repair was associated with less pain (adjusted HR, 0.78 [95% CI, 0.61-0.99]) and fewer pressure ulcers (adjusted HR, 0.64 [95% CI, 0.47-0.86]).

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