Contemporary Rates of Preoperative Cardiac Testing Prior to Inpatient Hip Fracture Surgery
Hip fracture is a common reason for urgent inpatient surgery. In the past few years, several professional societies have identified preoperative echocardiography and stress testing for noncardiac surgeries as low-value diagnostics. We utilized data on hospitalizations with a primary diagnosis of hip fracture surgery between 2011 and 2015 from the State Inpatient Databases (SID) of Maryland, New Jersey, and Washington, combined with data on hospital characteristics from the American Hospital Association (AHA). We found that the rate of preoperative ischemic testing is surprisingly but encouragingly low (stress tests 1.1% and cardiac catheterizations 0.5%), which is consistent with studies evaluating the outpatient utilization of these tests for low- and intermediate-risk surgeries. The rate of echocardiograms was 12.6%, which was higher than other published reports. Our findings emphasize the importance of ensuring that quality improvement efforts are directed toward areas where quality improvement is, in fact, needed.
© 2019 Society of Hospital Medicine
Hip fracture is a common reason for unexpected, urgent inpatient surgery in older patients. In 2005, the incidence of hip fracture was 369.0 and 793.5 per 100,000 in men and women respectively.1 These numbers declined over the preceding decade, potentially as a result of bisphosphonate use. Age- and risk-adjusted 30-day mortality rates for men and women in 2005 were approximately 10% and 5%, respectively.
Evidence suggests that timely surgical repair of hip fractures improves outcomes, although the optimal timing is controversial. Guidelines from the American College of Surgeons Committee on Trauma from 2015 recommend surgical intervention within 48 hours for geriatric hip fracures.2 A 2008 systematic review found that operative delay beyond 48 hours was associated with a 41% increase in 30-day all-cause mortality and a 32% increase in one-year all-cause mortality.3 Recent evidence suggests that the rate of complications begins to increase with delays beyond 24 hours.4
There has been a focus over the past decade on overuse of preoperative testing for low- and intermediate-risk surgeries.5-7 Beginning in 2012, the American Board of Internal Medicine initiated the Choosing Wisely® campaign in which numerous societies issued recommendations on reducing utilization of various diagnostic tests, a number of which have focused on preoperative tests. Two groups—the American Society of Anesthesiologists (ASA) and the American Society of Echocardiography (ASE)— issued specific recommendations on preoperative cardiac testing.8 In February 2013, the ASE recommended avoiding preoperative echocardiograms in patients without a history or symptoms of heart disease. In October 2013, the ASA recommended against transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), or stress testing for low- or intermediate-risk noncardiac surgery for patients with stable cardiac disease.
Finally, in 2014, the American College of Cardiology (ACC)/American Heart Association (AHA) issued updated perioperative guidelines for patients undergoing noncardiac surgeries.9 They recommended preoperative stress testing only in a small subset of cases (patients with an elevated perioperative risk of major adverse cardiac event, a poor or unknown functional capacity, or those in whom stress testing would impact perioperative care).
Given the high cost of preoperative cardiac testing, the potential for delays in care that can adversely impact outcomes, and the recent recommendations, we sought to characterize the rates of inpatient preoperative cardiac testing prior to hip fracture surgery in recent years and to see whether recent recommendations to curb use of these tests were temporally associated with changing rates.
METHODS
Overview
We utilized two datasets—the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and the American Hospital Association (AHA) Annual Survey—to characterize preoperative cardiac testing. SID data from Maryland, New Jersey, and Washington State from 2011 through September 2015 were used (the ICD coding system changed from ICD9 to ICD10 on October 1). This was combined with AHA data for these years. We included all hospitalizations with a primary ICD9 procedure code for hip fracture repair—78.55, 78.65, 79.05, 79.15, 79.25, 79.35, 79.45, 79.55, 79.65, 79.75, 79.85, and 79.95. We excluded all observations that involved an interhospital transfer. This study was exempt from institutional review board approval.
