Advertisement

Adaptive Risk Modeling: Improving Risk Assessment of Geriatric Hip Fracture Patients Throughout their Hospitalization

  • Garrett W. Esper
    Affiliations
    Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, United States
    Search for articles by this author
  • Ariana T. Meltzer-Bruhn
    Affiliations
    Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, United States
    Search for articles by this author
  • Abhishek Ganta
    Affiliations
    Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, United States

    Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY, United States
    Search for articles by this author
  • Kenneth A. Egol
    Affiliations
    Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, United States

    Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY, United States
    Search for articles by this author
  • Sanjit R. Konda
    Correspondence
    Corresponding author at: NYU Grossman School of Medicine, Chairman of Orthopaedic Surgery, Medisys Health Network; Director of Orthopaedic Trauma, Jamaica Hospital Medical Center; Director of Geriatric Orthopaedic Trauma, NYU Langone Health; 301 E. 17th Street, 14th Floor, New York, NY 10003.
    Affiliations
    Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY, United States

    Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY, United States
    Search for articles by this author
Published:November 14, 2022DOI:https://doi.org/10.1016/j.injury.2022.11.032

      Highlights

      • Adaptive modeling including inpatient complications improves the performance of the STTGMAHIP tool.
      • The STTGMAHIP_ADPTV tool may provide early identification of critically ill patients to improve outcomes.
      • Real-time modulation of a patient's mortality risk profile can inform their requisite level of medical management.
      • Potential for more cost-effective care provides incentive for STTGMAHIP_ADPTV tool usage.
      • The adaptive component of STTGMAHIP_ADPTV tool allows for future iterations and improvement.

      Abstract

      Introduction

      The purpose of this study was twofold: 1. To assess how adaptive modeling, accounting for development of inpatient complications, affects the predictive capacity of the risk tool to predict inpatient mortality for a cohort of geriatric hip fracture patients. 2. To compare how risk triaging of secondary outcomes is affected by adaptive modeling. We hypothesize that adaptive modeling will improve the predictive capacity of the model and improve the ability to risk triage secondary outcomes.

      Methods

      Between October 2014-August 2021, 2421 patients >55 years old treated for hip fracture obtained through low-energy mechanisms were analyzed for demographics, injury details and hospital quality measures. The baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for hip fractures (STTGMAHIP) was calculated in the emergency department setting. A new mortality risk score (STTGMAHIP_ADPTV) was created including inpatient complications. Each models’ predictive ability was compared using DeLong's test. Patients were grouped into quartiles based on their respective STTGMAHIP_ADPTV and comparative analyses were conducted.

      Results

      AUROC comparison demonstrated STTGMAHIP_ADPTV significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP (p < 0.01). STTGMAHIP_ADPTV correctly triaged 80% and 64% of high-risk patients with inpatient and 30-day mortality compared to 64% and 57% for STTGMAHIP. STTGMAHIP_ADPTV quartile stratification demonstrated that the highest risk cohort had the worst mortality outcomes and hospital quality measures. Patients whose risk classification changed from minimal risk using STTGMAHIP to high risk using STTGMAHIP_ADPTV experienced the highest rate of mortality, readmission, ICU admission, with longer lengths of stay and higher hospital costs.

      Discussion

      Adaptive modeling accounting for inpatient complications improves the predictive capacity and risk triaging of the STTGMAHIP tool. Real-time modulation of a patient's mortality risk profile can inform their requisite level of medical management to improve the quality and value of care as patients progress through their index hospitalization. STTGMAHIP_ADPTV can better identify patients at risk for developing complications whose mortality and readmission risk profile increase significantly, allowing their new risk classification to inform higher levels of care. While this may increase length of stay and total costs, it may improve outcomes in both the short and long-term.

      Level of evidence

      III.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Brauer C.A.
        • Coca-Perraillon M.
        • Cutler D.M.
        • Rosen A.B.
        Incidence and mortality of hip fractures in the United States.
        JAMA. 2009; 302: 1573-1579https://doi.org/10.1001/jama.2009.1462
        • Greenstein A.S.
        • Gorczyca J.T.
        Orthopedic surgery and the geriatric patient.
        Clin Geriatr Med. 2019; 35: 65-92https://doi.org/10.1016/j.cger.2018.08.007
        • Knauf T.
        • Hack J.
        • Barthel J.
        • Eschbach D.
        • Schoeneberg C.
        • Ruchholtz S.
        • et al.
        Medical and economic consequences of perioperative complications in older hip fracture patients.
        Arch Osteoporos. 2020; 15: 174https://doi.org/10.1007/s11657-020-00843-z
        • Konda S.R.
        • Seymour R.
        • Manoli A.
        • Gales J.
        • Karunakar M.A.
        • Carolinas Trauma Network Research Group
        Development of a middle-age and geriatric trauma mortality risk score a tool to guide palliative care consultations.
        Bull Hosp Jt Dis. 2013; 74 (2016): 298-305
        • Konda S.R.
        • Lott A.
        • Saleh H.
        • Schubl S.
        • Chan J.
        • Egol K.A.
        How does frailty factor into mortality risk assessment of a middle-aged and geriatric trauma population?.
        Geriatr Orthop Surg Rehabil. 2017; 8: 225-230https://doi.org/10.1177/2151458517735202
        • Konda S.R.
        • Parola R.
        • Perskin C.
        • Egol K.A.
        ASA physical status classification improves predictive ability of a validated trauma risk score.
        Geriatr Orthop Surg Rehabil. 2021; 12 (2151459321989534)https://doi.org/10.1177/2151459321989534
        • Konda S.R.
        • Ranson R.A.
        • Solasz S.J.
        • Dedhia N.
        • Lott A.
        • Bird M.L.
        • et al.
        Modification of a validated risk stratification tool to characterize geriatric hip fracture outcomes and optimize care in a post-COVID-19 world.
        J Orthop Trauma. 2020; 34: e317-e324https://doi.org/10.1097/BOT.0000000000001895
        • Esper G.W.
        • Meltzer-Bruhn A.T.
        • Ganta A.
        • Egol K.A.
        • Konda S.R.
        Seasonality affects elderly hip fracture mortality risk during the COVID-19 pandemic.
        Cureus. 2022; 14: e26530https://doi.org/10.7759/cureus.26530
        • Meltzer-Bruhn A.T.
        • Esper G.W.
        • Herbosa C.G.
        • Ganta A.
        • Egol K.A.
        • Konda S.R.
        The role of smoking and body mass index in mortality risk assessment for geriatric hip fracture patients.
        Cureus. 2022; 14: e26666https://doi.org/10.7759/cureus.26666
        • Morri M.
        • Ambrosi E.
        • Chiari P.
        • Orlandi Magli A.
        • Gazineo D.
        • D’ Alessandro F.
        • et al.
        One-year mortality after hip fracture surgery and prognostic factors: a prospective cohort study.
        Sci Rep. 2019; 9: 18718https://doi.org/10.1038/s41598-019-55196-6
        • Dhanwal D.K.
        • Dennison E.M.
        • Harvey N.C.
        • Cooper C.
        Epidemiology of hip fracture: worldwide geographic variation.
        IJOO. 2011; 45: 15-22https://doi.org/10.4103/0019-5413.73656
        • Colais P.
        • Di Martino M.
        • Fusco D.
        • Perucci C.A.
        • Davoli M.
        The effect of early surgery after hip fracture on 1-year mortality.
        BMC Geriatr. 2015; 15: 141https://doi.org/10.1186/s12877-015-0140-y
        • Goh E.L.
        • Lerner R.G.
        • Achten J.
        • Parsons N.
        • Griffin X.L.
        • Costa P.M.L.
        Complications following hip fracture: results from the world hip trauma evaluation cohort study.
        Injury. 2020; 51: 1331-1336https://doi.org/10.1016/j.injury.2020.03.031
        • Luo Y.
        • Jiang Y.
        • Xu H.
        • Lyu H.
        • Zhang L.
        • Yin P.
        • et al.
        Risk of post-operative cardiovascular event in elderly patients with pre-existing cardiovascular disease who are undergoing hip fracture surgery.
        Int Orthop. 2021; 45: 3045-3053https://doi.org/10.1007/s00264-021-05227-7
        • Eamer G.
        • Al-Amoodi M.J.H.
        • Holroyd-Leduc J.
        • Rolfson D.B.
        • Warkentin L.M.
        • Khadaroo R.G.
        Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients.
        Am J Surg. 2018; 216: 585-594https://doi.org/10.1016/j.amjsurg.2018.04.006
        • Konda S.R.
        • Lott A.
        • Saleh H.
        • Lyon T.
        • Egol K.A.
        Using trauma triage score to risk-stratify inpatient triage, hospital quality measures, and cost in middle-aged and geriatric orthopaedic trauma patients.
        J Orthop Trauma. 2019; 33: 525-530https://doi.org/10.1097/BOT.0000000000001561
        • Bilimoria K.Y.
        • Liu Y.
        • Paruch J.L.
        • Zhou L.
        • Kmiecik T.E.
        • Ko C.Y.
        • et al.
        Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons.
        J Am Coll Surg. 2013; 217 (e1-3): 833-842https://doi.org/10.1016/j.jamcollsurg.2013.07.385
        • Scotton G.
        • Del Zotto G.
        • Bernardi L.
        • Zucca A.
        • Terranova S.
        • Fracon S.
        • et al.
        Is the ACS-NSQIP risk calculator accurate in predicting adverse postoperative outcomes in the emergency setting? An Italian single-center preliminary study.
        World J Surg. 2020; 44: 3710-3719https://doi.org/10.1007/s00268-020-05705-w
        • Dasenbrock H.H.
        • Smith T.R.
        • Gormley W.B.
        • Castlen J.P.
        • Patel N.J.
        • Frerichs K.U.
        • et al.
        Predictive score of adverse events after carotid endarterectomy: the NSQIP registry carotid endarterectomy scale.
        JAHA. 2019; 8e013412https://doi.org/10.1161/JAHA.119.013412
        • Cardoso L.T.
        • Grion C.M.
        • Matsuo T.
        • Anami E.H.
        • Kauss I.A.
        • Seko L.
        • et al.
        Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study.
        Crit Care. 2011; 15 (R28)https://doi.org/10.1186/cc9975
        • Stokes S.M.
        • Scaife C.L.
        • Brooke B.S.
        • Glasgow R.E.
        • Mulvihill S.J.
        • Finlayson S.R.G.
        • et al.
        Hospital costs following surgical complications: a value-driven outcomes analysis of cost savings due to complication prevention.
        Ann Surg. 2022; 275: e375-e381https://doi.org/10.1097/SLA.0000000000004243
        • Ginsberg G.
        • Adunsky A.
        • Rasooly I.
        A cost-utility analysis of a comprehensive orthogeriatric care for hip fracture patients, compared with standard of care treatment.
        Hip Int. 2013; 23: 570-575https://doi.org/10.5301/hipint.5000080
        • Ho W.W.S.
        • Kwan Dai D.L.
        • Liu K.W.
        • Chow K.M.
        • Lau E.
        • Woo J.
        • et al.
        To investigate the effect and cost-effectiveness of implementing an orthogeriatric intervention for elderly patients with acute hip fracture: the experience in Hong Kong.
        J Am Geriatr Soc. 2009; 57: 2153-2154https://doi.org/10.1111/j.1532-5415.2009.02529.x
        • Roche J.J.W.
        • Wenn R.T.
        • Sahota O.
        • Moran C.G.
        Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study.
        BMJ. 2005; 331: 1374https://doi.org/10.1136/bmj.38643.663843.55
        • Folbert E.C.
        • Hegeman J.H.
        • Gierveld R.
        • van Netten J.J.
        • Velde D van der T.
        • Duis H.J.
        • et al.
        Complications during hospitalization and risk factors in elderly patients with hip fracture following integrated orthogeriatric treatment.
        Arch Orthop Trauma Surg. 2017; 137: 507-515https://doi.org/10.1007/s00402-017-2646-6
        • Poh K.S.
        • Lingaraj K.
        Complications and their risk factors following hip fracture surgery.
        J Orthop Surg. 2013; 21 (Hong Kong): 154-157https://doi.org/10.1177/230949901302100207
        • Kistler E.A.
        • Nicholas J.A.
        • Kates S.L.
        • Friedman S.M.
        Frailty and short-term outcomes in patients with hip fracture.
        Geriatr Orthop Surg Rehabil. 2015; 6: 209-214https://doi.org/10.1177/2151458515591170
        • Wilson J.M.
        • Boissonneault A.R.
        • Schwartz A.M.
        • Staley C.A.
        • Schenker M.L.
        Frailty and malnutrition are associated with inpatient postoperative complications and mortality in hip fracture patients.
        J Orthop Trauma. 2019; 33: 143-148https://doi.org/10.1097/BOT.0000000000001386