Radcliff Tiffany A, Henderson William G, Stoner Tamara J, Khuri Shukri F, Dohm Michael, Hutt Evelyn
Colorado REAP to Improve Care Coordination, VA Eastern Colorado Health Care System, 1055 Clermont Street (MS 151), Denver, CO 80220, USA.
J Bone Joint Surg Am. 2008 Jan;90(1):34-42. doi: 10.2106/JBJS.G.00065.
Although more than 1200 hip fracture repairs are performed in United States Department of Veterans Affairs hospitals annually, little is known about the relationship between perioperative care and short-term outcomes for veterans with hip fracture. The purpose of the present study was to test whether perioperative care impacts thirty-day outcomes, with patient characteristics being taken into account.
A national sample of 5683 community-dwelling male veterans with an age of sixty-five years or older who had been hospitalized for the operative treatment of a hip fracture at one of 108 Veterans Administration hospitals between 1998 and 2003 was identified from the National Surgical Quality Improvement Program data set. Operative care characteristics were assessed in relation to thirty-day outcomes (mortality, complications, and readmission to a Veterans Administration facility for inpatient care).
A surgical delay of four days or more after admission was associated with a higher adjusted mortality risk (odds ratio, 1.29; 95% confidence interval, 1.02 to 1.61) but a reduced risk of readmission (odds ratio, 0.70; 95% confidence interval, 0.54 to 0.91). Compared with spinal or epidural anesthesia, general anesthesia was related to a significantly higher risk of both mortality (odds ratio, 1.27; 95% confidence interval, 1.01 to 1.55) and complications (odds ratio, 1.33; 95% confidence interval, 1.15 to 1.53). The type of procedure was not significantly associated with outcome after controlling for other variables in the model. However, a higher American Society of Anesthesiologists Physical Status Classification (ASA class) was associated with worse thirty-day outcomes.
In addition to recognizing the importance of patient-related factors, we identified operative factors that were related to thirty-day surgical outcomes. It will be important to investigate whether modifying operative factors, such as reducing surgical delays to less than four days, can directly improve the outcomes of hip fracture repair.
尽管美国退伍军人事务部医院每年进行超过1200例髋部骨折修复手术，但对于髋部骨折退伍军人围手术期护理与短期预后之间的关系却知之甚少。本研究的目的是在考虑患者特征的情况下，测试围手术期护理是否会影响30天的预后。
从国家外科质量改进计划数据集中，确定了1998年至2003年间在108家退伍军人管理局医院之一因髋部骨折手术治疗而住院的5683名65岁及以上社区居住男性退伍军人的全国样本。评估手术护理特征与30天预后（死亡率、并发症以及再次入住退伍军人管理局设施接受住院治疗）之间的关系。
入院后手术延迟4天或更长时间与调整后的较高死亡风险相关（比值比，1.29；95%置信区间，1.02至1.61），但再次入院风险降低（比值比，0.70；95%置信区间，0.54至0.91）。与脊髓或硬膜外麻醉相比，全身麻醉与显著更高的死亡风险（比值比，1.27；95%置信区间，1.01至1.55）和并发症风险（比值比，1.33；95%置信区间，1.15至1.53）相关。在对模型中的其他变量进行控制后，手术类型与预后无显著关联。然而，较高的美国麻醉医师协会身体状况分类（ASA分级）与较差的30天预后相关。
除了认识到与患者相关因素的重要性外，我们还确定了与30天手术预后相关的手术因素。研究改变手术因素，如将手术延迟缩短至4天以内，是否能直接改善髋部骨折修复的预后将很重要。
