Schairer William W, Lane Joseph M, Halsey David A, Iorio Richard, Padgett Douglas E, McLawhorn Alexander S
Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.
Department of Orthopaedic Surgery, University of Vermont Medical College, South Burlington, VT, USA.
Clin Orthop Relat Res. 2017 Feb;475(2):353-360. doi: 10.1007/s11999-016-4868-2.
Hip fractures are a major public health concern. For displaced femoral neck fractures, the needs for medical services during hospitalization and extending beyond hospital discharge after total hip arthroplasty (THA) may be different than the needs after THA performed for osteoarthritis (OA), yet these differences are largely uncharacterized, and the Medicare Severity Diagnosis-Related Groups system does not distinguish between THA performed for fracture and OA.
QUESTIONS/PURPOSES: (1) What are the differences in in-hospital and 30-day postoperative clinical outcomes for THA performed for femoral neck fracture versus OA? (2) Is a patient's fracture status, that is whether or not a patient has a femoral neck fracture, associated with differences in in-hospital and 30-day postoperative clinical outcomes after THA?
The National Surgical Quality Improvement Program (NSQIP) database, which contains outcomes for surgical patients up to 30 days after discharge, was used to identify patients undergoing THA for OA and femoral neck fracture. OA and fracture cohorts were matched one-to-one using propensity scores based on age, gender, American Society of Anesthesiologists grade, and medical comorbidities. Propensity scores represented the conditional probabilities for each patient having a femoral neck fracture based on their individual characteristics, excluding their actual fracture status. Outcomes of interest included operative time, length of stay (LOS), complications, transfusion, discharge destination, and readmission. There were 42,692 patients identified (41,739 OA; 953 femoral neck fractures) with 953 patients in each group for the matched analysis.
For patients with fracture, operative times were slightly longer (98 versus 92 minutes, p = 0.015), they experienced longer LOS (6 versus 4 days, p < 0.001), and the overall frequency of complications was greater compared with patients with OA (16% versus 6%, p < 0.001). Although the frequency of preoperative transfusions was higher in the fracture group (2.0% versus 0.2%, p = 0.002), the frequency of postoperative transfusion was not different between groups (27% versus 24%, p = 0.157). Having a femoral neck fracture versus OA was strongly associated with any postoperative complication (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1-3.8]; p < 0.001), unplanned readmission (OR, 1.8; 95% CI, 1.0-3.2; p = 0.049), and discharge to an inpatient facility (OR, 1.7; 95% CI, 1.4-2.0; p < 0.001).
Compared with THA for OA, THA for femoral neck fracture is associated with greater rates of complications, longer LOS, more likely discharge to continued inpatient care, and higher rates of unplanned readmission. This implies higher resource utilization for patients with a fracture. These differences exist despite matching of other preoperative risk factors. As healthcare reimbursement moves toward bundled payment models, it would seem important to differentiate patients and procedures based on the resource utilization they represent to healthcare systems. These results show different expected resource utilization in these two fundamentally different groups of patients undergoing hip arthroplasty, suggesting a need to modify healthcare policy to maintain access to THA for all patients.
Level III, therapeutic study.
髋部骨折是一个重大的公共卫生问题。对于移位型股骨颈骨折，全髋关节置换术（THA）后住院期间及出院后的医疗服务需求可能与骨关节炎（OA）患者行THA后的需求不同，但这些差异很大程度上未得到充分描述，且医疗保险严重程度诊断相关分组系统并未区分因骨折和OA而行的THA。
问题/目的：（1）股骨颈骨折患者与OA患者行THA后的住院及术后30天临床结局有何差异？（2）患者的骨折状态，即患者是否有股骨颈骨折，与THA后住院及术后30天临床结局的差异是否相关？
利用国家外科质量改进计划（NSQIP）数据库（该数据库包含出院后30天内手术患者的结局）来识别因OA和股骨颈骨折而行THA的患者。OA组和骨折组根据年龄、性别、美国麻醉医师协会分级和内科合并症，使用倾向评分进行一对一匹配。倾向评分代表每个患者基于其个体特征（不包括其实际骨折状态）发生股骨颈骨折的条件概率。感兴趣的结局包括手术时间、住院时间（LOS）、并发症、输血、出院去向和再入院情况。共识别出42,692例患者（41,739例OA患者；953例股骨颈骨折患者），每组953例患者进行匹配分析。
骨折患者的手术时间稍长（98分钟对92分钟，p = 0.015），住院时间更长（6天对4天，p < 0.001），与OA患者相比，总体并发症发生率更高（16%对6%，p < 0.001）。虽然骨折组术前输血频率更高（2.0%对0.2%，p = 0.002），但两组术后输血频率无差异（27%对24%，p = 0.157）。与OA相比，股骨颈骨折与任何术后并发症（优势比[OR]，2.8；95%置信区间[CI]，2.1 - 3.8；p < 0.001）、计划外再入院（OR，1.8；95% CI，1.0 - 3.2；p = 0.049）以及出院到住院机构（OR，1.7；95% CI，1.4 - 2.0；p < 0.001）密切相关。
与OA患者行THA相比，股骨颈骨折患者行THA的并发症发生率更高、住院时间更长、更可能出院到继续住院治疗机构，且计划外再入院率更高。这意味着骨折患者的资源利用率更高。尽管对其他术前危险因素进行了匹配，但这些差异仍然存在。随着医疗保健报销转向捆绑支付模式，根据患者和手术对医疗系统所代表的资源利用率来区分患者和手术似乎很重要。这些结果表明，在这两组接受髋关节置换术的根本不同的患者中，预期的资源利用率不同，这表明需要修改医疗政策，以确保所有患者都能获得THA治疗。
III级，治疗性研究。
