Mr Maulik J Gandhi (ST6 T&O) Mr Jan Herman Kuiper Ms Swati Bhasin Mr David J Ford Mr Alastair Marsh Mr Sohail Quraishi

Transcription

1 The Dudley Grid: An evidence-based audit/research tool to investigate mortality risk following a displaced intracapsular hip fracture. How can it be applied in practice? Mr Maulik J Gandhi (ST6 T&O) Mr Jan Herman Kuiper Ms Swati Bhasin Mr David J Ford Mr Alastair Marsh Mr Sohail Quraishi

2 Introduction Aims 1990: 1.26 million hip fractures worldwide 2050: 4.5 million hip fractures worldwide projected Important to identify factors that contribute to higher mortality Pre-, intra-, post-op phases Plan Management Use the prosthesis which best serve the needs of the patient. Identify patient factors that influence mortality risk Make a clinically useful tool that may help in the management of hip fracture patients Objectively assess risk of mortality Objectively assess the likely use of prosthesis Current practice is subjective risk assessment.

3 Our patients

4 Methods Inclusions Patients admitted to Russell Hall Hospital (Dudley, West Midlands) with intracapsular hip fracture between August 2008 and July 2012 Exclusions Follow-up less than a year 562 patients entered into study Hip fracture database reviewed for patients factors Retrospectively scored using Nottingham Hip Fracture Score Walking ability outdoors Walking ability indoors

5 Nottingham Hip Fracture Score (NHFS) Mortality risk scoring system validated at 30 days and 1 year Maxwell, Moran, Moppett. Development and validation of a preoperative scoring system to predict 30 day mortality in patients undergoing hip fracture surgery. British Journal of Anaesthesia. 101 (4): (2008)

6 Outdoor mobility categories Independently predicts mortality risk NHFD outdoor mobility category Mobilise without aids Mobilise with 1 aid Mobilise with 2 aids/frame Wheelchair/Bedbound Outdoor mobility category M1 M2 M3 M4 Consolidated outdoor mobility category A B

7 Results

8 Kaplan Meier Survival Curve (outdoors)

9 Kaplan Meier Survival Curve (indoors)

10 2012 Dudley Group NHS Foundation Trust. All rights reserved. Authored by Mr Maulik J Gandhi

11 Mortality

12 NICE guidance Perform replacement arthroplasty in patients with a displaced intracapsular fracture. Offer THR to patients with a displaced intracapsular fracture who: were able to walk independently out of doors with no more than the use of a stick and are not cognitively impaired and are medically fit for anaesthesia and the operation. Use a proven femoral stem design rather than Austin Moore or Thompson stems for arthroplasties Use cemented implants in patients undergoing surgery with arthroplasty

13 Is this appropriate management?

14 Influence of cement on mortality risk. It was observed there is a significant increase in mortality risk when no cement is used when all the patients are being analysed with a cox proportional hazard Number P value of cases All 478 <0.001* Number P value of cases All 478 <0.001* Consolidated group A * Consolidated group B

15 Is this appropriate management?

16 Is this appropriate? Maulik J Gandhi mj@gandhi.org.uk

17 Is this appropriate?

18 Is this appropriate?

19 Is this appropriate management? Outdoor mobility groups NHFS A M1 M2 M3 M4 B 0 THR THR Uncemented/IF Uncemented/IF 1 THR THR Uncemented/IF Uncemented/IF 2 THR THR Uncemented/IF Uncemented/IF 3 THR THR Uncemented/IF Uncemented/IF 4 THR THR Uncemented/IF Uncemented/IF 5 Cemented Cemented Uncemented/IF Uncemented/IF 6 Cemented Cemented Uncemented/IF Uncemented/IF 7 Cemented Cemented Uncemented/IF Uncemented/IF 8 Cemented Cemented Uncemented/IF Uncemented/IF 9 Cemented Cemented? conservative? conservative 10 Cemented Cemented? conservative? conservative

20 Dilemmas High risk patients who were immobile prior to admission 1. Should they get an operation? 1. Hemiarthroplasty versus internal fixation? 2. Which implant? 3. Use of cement? 2. If managed conservatively? 1. What management plan? 2. Role of an intra-articular local anaesthetic injection We can now design studies looking into the influence of these strategies, whilst standardising patients Look at patients within one grid box/column/row

21 Would this be useful to know Mortality understand local factors and counsel patient/family Incidence help organize rehabilitation and social services Research standardize patients for better quality studies Management objective tool to guide treatment Maulik J Gandhi mj@gandhi.org.uk

22 Our patients

23 THANK YOU Questions?

24 Incidence % of patients M M M M

25 Incidence % of patients A B

26 Incidence Grid Help plan inpatient and outpatient services 69% in outdoor mobility group A Majority should have rehabilitation potential identify rehab bed The remaining should have post hospital care identified e.g. residential/nursing home rather than rely on rehab bed

27 Can you enhance the NHFS?

28 Demographics and observational data Missing values for a factor were managed using a technique described by Tabachnick and Fidell

29 Analysis Primary outcome - patient mortality Cox hazard ratios for each independent factor p<0.05 considered significant n=562 patients entered into study

30 Cox Hazard Ratios higher mortality risk. In CI, if value >1 it increases mortality risk. Number of cases P value Lower CI 0.95 Upper CI 0.95 C NHFS 562 < Age 562 < Admission haemoglobin 495 < Walking ability outdoors Walking ability indoors Consolidated walking ability outdoors Consolidated walking ability indoors 562 < < Gender

31 Why not another scoring system? ASA Shown to lack intra- and inter-observer reliability. (Aronson et al. 2003) NHFS shown to predict mortality (review article Vitale 2012) RISK-VAS, POSSUM and Charlston index predicted ambulation NOT mortality at 3 months (Burgos et al. 2008) Other scoring systems compared The American Society of Anesthesiologists classification, The Barthel index, The Goldman index, The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scoring system, The Charlson index and the Visual Analogue Scale for Risk (RISK-VAS)

32 Maulik J Gandhi mj@gandhi.org.uk

33 They can do it Maulik J Gandhi mj@gandhi.org.uk

34 How they do it Compare an outcome of interest - of car insurance Standardise the risk driver details Standardise the at risk item car details Maulik J Gandhi mj@gandhi.org.uk

35 How we should do it Compare an outcome of interest mortality, length of stay, etc Standardise the risk management plan Standardise the at risk item Dudley Grid box Maulik J Gandhi mj@gandhi.org.uk

36 Maulik J Gandhi mj@gandhi.org.uk