Impact of Preoperative Specialty Consults on Hospitalist Comanagement of Hip Fracture Patients
BACKGROUND: Hip fractures typically occur in frail elderly patients. Preoperative specialty consults, in addition to hospitalist comanagement, are often requested for preoperative risk assessment.
OBJECTIVE: Determine if preoperative specialty consults meaningfully influence management and outcomes in hip fracture patients, while being comanaged by hospitalists DESIGN: Retrospective cohort study
SETTING: Tertiary care hospital in Connecticut
PATIENTS: 491 patients aged 50 years and older who underwent surgery for an isolated fragility hip fracture, defined as one occurring from a fall of a height of standing or less.
INTERVENTION: Presence or absence of a preoperative specialty consult
MEASUREMENTS: Time to surgery (TTS), length of hospital stay (LOS), and postoperative complications
RESULTS: 177 patients had a preoperative specialty consult. Patients with consults were older and had more comorbidities. Most consult recommendations were minor (72.8%); there was a major recommendation only for eight patients (4.5%). Multivariate analysis demonstrates that consults are more likely to be associated with a TTS beyond 24 hours (Odds Ratio [OR] 4.28 [2.79-6.56]) and 48 hours (OR 2.59 [1.52-4.43]), an extended LOS (OR 2.67 [1.78-4.03]), and a higher 30-day readmission rate (OR 2.11 [1.09-4.08]). A similar 30-day mortality rate was noted in both consult and no-consult groups.
CONCLUSIONS: The majority of preoperative specialty consults did not meaningfully influence management and may have potentially increased morbidity by delaying surgery. Our data suggest that unless a hip fracture patient is unstable and likely to require active management by a consultant, such consults offer limited benefit when weighed against the negative impact of surgical delay.
© 2020 Society of Hospital Medicine
Statistical Analysis
The main analyses compared the two patient subgroups (with or without preoperative specialty consults) around outcome measures. Primary outcome measures were TTS, LOS, complications, and consult resulting in a change in perioperative management. Secondary outcome measures were 30-day readmit, return to OR, and mortality. A preliminary analysis was conducted to explore distributions for TTS and LOS. As expected, none met the assumptions of normality and were thus analyzed with Wilcoxon ranked-sum tests. The other outcomes were dichotomous and analyzed with chi-square tests of proportion or Fisher’s exact test when the expected cell frequencies were too low. Dichotomized variables for TTS (within 24 hours and 48 hours) and LOS (within five days, the median LOS for this cohort) were calculated and subsequently analyzed with additional chi-square tests of proportion or Fisher’s exact test13. To explore the effect of preoperative specialty consults independent of potential confounders, logistic regression analyses predicting each of the dichotomous outcomes were conducted with age and CCI used as predictors in addition to the main variable of whether or not there was a preoperative specialty consult. Since the CCI and ASA scores were highly intercorrelated, only the former was chosen for the multivariate analyses based on the consistent algorithm used to calculate CCI.
Additional analyses with the subgroup of patients with a preoperative specialty consult explored whether the consult was reasonable, the relative strength of resulting recommendation and whether it resulted in a change in management. The statistical approach used was the same as for the other dichotomous outcomes. All analyses used 0.05 as the level of statistical significance; SPSSv21 (IBM, Armonk, New York) was the statistical software used.
The sample size for this retrospective analysis was determined by the available number of patients meeting the inclusion criteria. An a priori power calculation was done to determine if the expected volume would be sufficient for the multivariate analysis; the presence of a complication was selected for calculation. Based on an expected volume of approximately 500 and an estimate of a 10% serious complication rate, it was determined that the sample could support the analysis of up to five predictor variables, sufficient for the main variable and four potential confounders; this was considered adequate.14 Propensity scoring was considered but did not offer any advantages to logistic regression because we only had two observed covariates: CCI and age.
RESULTS
A total of 491 unique patients met our inclusion criteria, 177 patients had a preoperative specialty consult. Of these 177 patients, 24 patients had more than one consult; hence, the total number of consults was 201. Most of the consults were cardiology (159). Others were Infectious disease (11), Pulmonology (10), Neurology (7), and Miscellaneous (14, which included Nephrology, Gastroenterology, Hematology, and Oncology).
No significant differences were found between the consult and no-consult groups with respect to gender, race, body mass index, type of anesthesia, and day of the week of surgery. We did note that patients with a consult were older and had a significantly higher CCI and ASA score (Table 2).
Initial analyses compared those with and without consults unadjusted for other factors with respect to TTS, LOS, 30-day readmission rate, 30-day return to OR rate, and 30-day mortality rate. The median TTS was 22.1 hours for the no-consult group compared with 34.3 hours for the consult group. The percentage of patients with TTS within 24 hours was higher (58.6% compared with 23.7%) and TTS within 48 hours was higher (90.1% compared to 76.8%) if there was no consult. The median LOS was five days for the no-consult group compared with six days for the consult group. There was no difference in complications between the two groups. Patients with consults were more likely to have a readmission (Table 3). No association was found between the type of consult (cardiology, pulmonary, etc.) and outcomes.
In the main analyses adjusted for potential confounders of age and CCI, consults were more likely to be independently associated with TTS beyond 24 hours, TTS beyond 48 hours, an extended LOS, and a higher 30-day readmission rate. CCI independently predicted a higher LOS, 30-day mortality rate, and serious complication rate. Similarly, age predicted 30-day mortality. Consults were not independently associated with 30-day mortality (Table 4).
Of the 177 patients with one or more consults, 163 (92%) were deemed reasonable. Of the patients, 129 (72.8%) had minor, 40 (22.6%) moderate, and 8 (4.5%) major recommendations as a result of the consultation. There was an identifiable change in perioperative management for 66 (37%) patients with consults. The independent review done for interrater reliability examined the entire dataset. This review demonstrated the following percent agreements: 99.4% for if the consult was indicated (kappa = 0.962), 97.7% for the consult outcome classification (minor, moderate, or major; kappa = 0.947), and 94.4% for if the intervention resulted in a change in management (kappa = 0.878).
While reviewing our subset of cardiology consults, we noted moderate or major recommendations from a cardiologist only in cases where an active cardiac condition was suspected by the hospitalist requesting the consult. Only eight patients in our study had major recommendations from a consult, of which, three underwent aortic valvuloplasty and one patient each underwent the following: pericardial window for tamponade, cholecystostomy tube placement to treat acute cholecystitis, thoracentesis, endoscopic retrograde cholangiopancreatography for obstructive jaundice, and inferior vena cava filter placement for acute pulmonary embolism. All these procedures were done prior to hip fracture repair. Interestingly, 42 out of the 177 patients in our consult group had a preoperative echocardiogram performed, with only three patients with critical aortic stenosis undergoing valvuloplasty preoperatively.
