Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA.
Clin Orthop Relat Res. 2023 Feb 1;481(2):312-321. doi: 10.1097/CORR.0000000000002354. Epub 2022 Aug 16.
Advanced care planning documents provide a patient's healthcare team and loved ones with guidance on patients' treatment preferences when they are unable to advocate for themselves. A substantial proportion of patients will die within a few months of experiencing a hip fracture, but despite the importance of such documents, patients undergoing surgery for hip fracture seldom have discussions documented in the medical records regarding end-of-life care during their surgical admission. To the best of our knowledge, the proportion of patients older than 65 years treated with surgery for hip fractures who have advanced care planning documents in their electronic medical record (EMR) has not been explored, neither has the association between socioeconomic status and the presence of those documents in the EMR. Determining this information can help to identify opportunities to promote advanced care planning.
QUESTIONS/PURPOSES: (1) What percentage of patients older than 65 years who undergo hip fracture surgery have completed advanced care planning documents uploaded in the EMR before or during their surgical hospitalization, or at any timepoint (before admission, during admission, and after admission)? (2) Are patients from distressed communities less likely to have advanced care planning documents in the EMR than patients from wealthier communities, after controlling for economic well-being as measured by the Distressed Communities Index? (3) What percentage of patients older than 65 years with hip fractures who died during their hospitalization for hip fracture surgery had advanced care planning documents uploaded in the EMR?
This was a retrospective, comparative study conducted at two geographically distinct hospitals: one urban Level I trauma center and one suburban Level II trauma center. Between 2017 and 2021, these two centers treated 850 patients for hip fractures. Among those patients, we included patients older than 65 years who were treated with open reduction and internal fixation, intramedullary nailing, hemiarthroplasty, or THA for a fragility fracture of the proximal femur. Based on that, 83% (709 of 850) of patients were eligible; a further 6% (52 of 850) were excluded because they had codes other than ICD-9 820 or ICD-10 S72.0, and another 2% (17 of 850) had incomplete datasets, leaving 75% (640 of 850) for analysis here. Most patients with incomplete datasets were in the prosperous Distressed Communities Index category. Among patients included in this study, the average age was 82 years, 70% (448 of 640) were women, and regarding the Distressed Communities Index, 32% (203 of 640) were in the prosperous category, 25% (159 of 640) were in the comfortable category, 15% (99 of 640) were in the mid-tier category, 5% (31 of 640) were in the at-risk category, and 23% (145 of 640) were in the distressed category. The primary outcome included the presence of advanced care planning documents (advanced directives, healthcare power of attorney, or physician orders for life-sustaining treatment) in the EMR before surgery, during the surgical admission, or at any time. The Distressed Communities Index was used to indicate economic well-being, and patients were identified as being in one of five Distressed Communities Index categories (prosperous, comfortable, mid-tier, at-risk, and distressed) based on ZIP Code. An exploratory analysis was conducted to determine variables associated with the presence of advanced care planning documents in the EMR. A multivariate regression was then performed for patients who did or did not have advanced care planning documents in their medical record at any time. The results are presented as ORs with the associated 95% confidence interval (CI).
Nine percent (55 of 640) of patients had advanced care planning documents in the EMR preoperatively or during their surgical admission, and 22% (142 of 640) of patients had them in the EMR at any time. After controlling for potential confounding variables such as age, laterality (left or right hip), hospital type, and American Society of Anesthesiologists (ASA) classification, we found that patients in Distressed Communities Index categories other than prosperous had ORs lower than 0.7, with patients in the distressed category (OR 0.4 [95% CI 0.2 to 0.7]; p < 0.01) and comfortable category (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.01) having a substantially lower odds of having advanced care planning documents in their EMR. Patients aged 86 to 95 years (OR 1.9 [95% CI 1.1 to 3.4]), those 96 years and older (OR 4.0 [95% CI 1.7 to 9.5]), and those with a higher ASA classification (OR 1.6 [95% CI 1.1 to 2.3]) had a higher odds of having advanced care planning documents in the EMR at any time. Among 14 patients who experienced in-hospital mortality, two had advanced care planning documents uploaded into their EMR, whereas 12 of 14 who died in the hospital did not have advanced care planning documents uploaded into their EMR.
Orthopaedic surgeons should counsel patients regarding the risk for postoperative complications after fragility hip fracture surgery and engage in shared decision-making regarding advanced care planning documents with patients or, if the patients are unable, with their families. Additionally, implementing virtual education about advanced care planning documents and using easy-to-read forms may facilitate the completion of advanced care planning documents by patients older than 65 years, especially patients with low economic well-being. Limitations of this study include having a restricted number of patients in the at-risk and mid-tier Distressed Communities Index categories and a restricted number of patients identifying as non-White races/ethnicities. Future research should evaluate the effect of advanced care document presence in the EMR on end-of-life care intensity in patients treated for fragility hip fractures.
Level III, therapeutic study.
高级医疗护理计划文件为患者的医疗团队和亲人提供了指导，以了解患者在无法为自己发声时的治疗偏好。很大一部分患者会在经历髋部骨折后的几个月内死亡，但尽管此类文件非常重要，接受髋部骨折手术的患者在其住院期间很少有记录表明他们在手术期间的临终关怀。据我们所知，在接受手术治疗髋部骨折的 65 岁以上患者中，有多少人在电子病历 (EMR) 中拥有高级医疗护理计划文件，以及社会经济地位与 EMR 中这些文件的存在之间的关联，这两个问题都尚未得到探索。确定这些信息有助于发现促进高级医疗护理计划的机会。
问题/目的：(1) 有多少接受髋部骨折手术的 65 岁以上患者在手术住院期间或之前（包括入院前、入院期间和出院后）上传了 EMR 中的高级医疗护理计划文件？(2) 在控制经济幸福感（以 Distressed Communities Index 衡量）后，来自贫困社区的患者拥有 EMR 中高级医疗护理计划文件的可能性是否低于来自富裕社区的患者？(3) 在因髋部骨折手术住院期间死亡的 14 名 65 岁以上髋部骨折患者中，有多少人上传了 EMR 中的高级医疗护理计划文件？
这是一项在两个地理位置不同的医院进行的回顾性、比较性研究：一个是城市一级创伤中心，另一个是郊区二级创伤中心。在 2017 年至 2021 年期间，这两个中心共治疗了 850 名髋部骨折患者。在这些患者中，我们纳入了接受切开复位内固定术、髓内钉固定术、半髋关节置换术或 THA 治疗股骨近端脆性骨折的年龄大于 65 岁的患者。在此基础上，83%（850 名患者中的 709 名）的患者符合纳入标准；另有 6%（850 名患者中的 52 名）因 ICD-9 820 或 ICD-10 S72.0 以外的代码而被排除；另有 2%（850 名患者中的 17 名）的数据集不完整，因此有 75%（850 名患者中的 640 名）的数据可用于分析。大多数数据集不完整的患者都在繁荣的 Distressed Communities Index 类别中。在本研究纳入的患者中，平均年龄为 82 岁，70%（640 名患者中的 448 名）为女性，关于 Distressed Communities Index，32%（640 名患者中的 203 名）处于繁荣类别，25%（640 名患者中的 159 名）处于舒适类别，15%（640 名患者中的 99 名）处于中等类别，5%（640 名患者中的 31 名）处于风险类别，23%（640 名患者中的 145 名）处于贫困类别。主要结局包括手术前、手术期间或任何时间 EMR 中是否存在高级医疗护理计划文件（高级指令、医疗保健授权书或维持生命治疗的医生医嘱）。Distressed Communities Index 用于表示经济幸福感，患者根据邮政编码被确定为五个 Distressed Communities Index 类别（繁荣、舒适、中等、风险和贫困）之一。进行了一项探索性分析，以确定与 EMR 中存在高级医疗护理计划文件相关的变量。然后对任何时间都有或没有 EMR 中高级医疗护理计划文件的患者进行多变量回归。结果以比值比 (OR) 及其相关 95%置信区间 (CI) 呈现。
9%（640 名患者中的 55 名）的患者在 EMR 中有高级医疗护理计划文件，22%（640 名患者中的 142 名）的患者在 EMR 中有文件。在控制年龄、侧别（左髋或右髋）、医院类型和美国麻醉医师协会 (ASA) 分级等潜在混杂变量后，我们发现除了繁荣类别的 Distressed Communities Index 类别之外，其他类别的患者的 OR 均低于 0.7，而贫困类别的患者（OR 0.4 [95%CI 0.2 至 0.7]；p<0.01）和舒适类别的患者（OR 0.5 [95%CI 0.3 至 0.9]；p=0.01）拥有高级医疗护理计划文件的几率明显较低。年龄在 86 至 95 岁（OR 1.9 [95%CI 1.1 至 3.4]）、96 岁及以上（OR 4.0 [95%CI 1.7 至 9.5]）和 ASA 分级较高（OR 1.6 [95%CI 1.1 至 2.3]）的患者在任何时间都有更高的几率拥有 EMR 中的高级医疗护理计划文件。在 14 名住院期间死亡的患者中，有 2 名患者的 EMR 中有上传高级医疗护理计划文件，而在 14 名在医院死亡的患者中，有 12 名患者的 EMR 中没有上传高级医疗护理计划文件。
骨科医生应就脆性髋部骨折手术后的术后并发症风险向患者进行咨询，并与患者（如果患者无法参与，则与患者的家属）就高级医疗护理计划文件进行共同决策，或者如果患者无法参与，则与患者的家属进行共同决策。此外，实施高级医疗护理计划文件的虚拟教育并使用易于阅读的表格可能有助于 65 岁以上患者，特别是经济状况不佳的患者完成高级医疗护理计划文件。本研究的局限性包括风险类别的 Distressed Communities Index 类别和非白人种族/民族的患者数量有限。未来的研究应评估 EMR 中高级医疗文件的存在对接受脆性髋部骨折治疗的患者临终关怀强度的影响。
III 级，治疗性研究。
