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Surgical repair of hip fractures in nursing home patients
Clinical question: Does surgical repair of hip fractures in nursing home residents with advanced dementia reduce adverse outcomes?
Background: Hip fractures are common in the advanced dementia nursing home population. The benefit of surgical repair is unclear in this population given significant baseline functional disability and limited life expectancy.
Study design: Retrospective cohort study.
Setting: Medicare claims data set.
Synopsis: Among 3,083 nursing home residents with advanced dementia and hip fracture, nearly 85% underwent surgical repair. The 30-day mortality rate in the nonsurgical group was 30.6%, compared with 11.5% in the surgical group. In an adjusted model, the surgical group had decreased risk of death, compared with the nonsurgical group (hazard ratio, 0.88; 95% confidence interval, 0.79-0.98). In additional adjusted models, surgical patients also had decreased risk of pressure ulcers (HR 0.64; 95% CI, 0.47-0.86) and less pain (HR, 0.78; 95% CI, 0.61-0.99). Limitations included the observational nature of the study. Although the models were adjusted, unmeasured confounding may have contributed to the findings.
Bottom line: Surgical repair of hip fractures in nursing home patients with advanced dementia reduces post-fracture mortality, pain, and pressure ulcer risk.
Citation: Berry SD et al. Association of clinical outcomes with surgical repair of hip fracture vs. nonsurgical management in nursing home residents with advanced dementia. JAMA Intern Med. 2018;178(6):774-80.
Dr. Abramowicz is an assistant professor in the division of hospital medicine, University of Colorado, Denver.
Clinical question: Does surgical repair of hip fractures in nursing home residents with advanced dementia reduce adverse outcomes?
Background: Hip fractures are common in the advanced dementia nursing home population. The benefit of surgical repair is unclear in this population given significant baseline functional disability and limited life expectancy.
Study design: Retrospective cohort study.
Setting: Medicare claims data set.
Synopsis: Among 3,083 nursing home residents with advanced dementia and hip fracture, nearly 85% underwent surgical repair. The 30-day mortality rate in the nonsurgical group was 30.6%, compared with 11.5% in the surgical group. In an adjusted model, the surgical group had decreased risk of death, compared with the nonsurgical group (hazard ratio, 0.88; 95% confidence interval, 0.79-0.98). In additional adjusted models, surgical patients also had decreased risk of pressure ulcers (HR 0.64; 95% CI, 0.47-0.86) and less pain (HR, 0.78; 95% CI, 0.61-0.99). Limitations included the observational nature of the study. Although the models were adjusted, unmeasured confounding may have contributed to the findings.
Bottom line: Surgical repair of hip fractures in nursing home patients with advanced dementia reduces post-fracture mortality, pain, and pressure ulcer risk.
Citation: Berry SD et al. Association of clinical outcomes with surgical repair of hip fracture vs. nonsurgical management in nursing home residents with advanced dementia. JAMA Intern Med. 2018;178(6):774-80.
Dr. Abramowicz is an assistant professor in the division of hospital medicine, University of Colorado, Denver.
Clinical question: Does surgical repair of hip fractures in nursing home residents with advanced dementia reduce adverse outcomes?
Background: Hip fractures are common in the advanced dementia nursing home population. The benefit of surgical repair is unclear in this population given significant baseline functional disability and limited life expectancy.
Study design: Retrospective cohort study.
Setting: Medicare claims data set.
Synopsis: Among 3,083 nursing home residents with advanced dementia and hip fracture, nearly 85% underwent surgical repair. The 30-day mortality rate in the nonsurgical group was 30.6%, compared with 11.5% in the surgical group. In an adjusted model, the surgical group had decreased risk of death, compared with the nonsurgical group (hazard ratio, 0.88; 95% confidence interval, 0.79-0.98). In additional adjusted models, surgical patients also had decreased risk of pressure ulcers (HR 0.64; 95% CI, 0.47-0.86) and less pain (HR, 0.78; 95% CI, 0.61-0.99). Limitations included the observational nature of the study. Although the models were adjusted, unmeasured confounding may have contributed to the findings.
Bottom line: Surgical repair of hip fractures in nursing home patients with advanced dementia reduces post-fracture mortality, pain, and pressure ulcer risk.
Citation: Berry SD et al. Association of clinical outcomes with surgical repair of hip fracture vs. nonsurgical management in nursing home residents with advanced dementia. JAMA Intern Med. 2018;178(6):774-80.
Dr. Abramowicz is an assistant professor in the division of hospital medicine, University of Colorado, Denver.
BNP levels and mortality in patients with and without heart failure
Clinical question: Does B-type natriuretic peptide (BNP) have prognostic value outside of heart failure (HF) patients?
Background: BNP levels are influenced by both cardiac and extracardiac stimuli and thus might have prognostic value outside of the traditional use to guide therapy for HF patients.
Study design: Retrospective cohort study of the Vanderbilt electronic health record.
Setting: Vanderbilt University Medical Center, Nashville, Tenn.
Synopsis: The study evaluated 30,487 patients with at least two BNP values for 2002-2015. Within this cohort, 62% of patients did not have a HF diagnosis. Risk of death was elevated in all patients regardless of HF status as BNP values rose. An increase from the 25th to 75th percentile in BNP value was associated with an increased risk of death in non-HF patients (hazard ratio, 2.08; 95% confidence interval, 1.99-2.2). Additionally, in a multivariate analysis BNP was the strongest predictor of death, compared with traditional risk factors in both HF and non-HF patients. The main limitation to this study was the use of ICD codes for diagnosis of HF.
Bottom line: BNP has predictive value for risk of death in non-HF patients; as BNP levels rise, regardless of HF status, so does risk of death.
Citation: York MK et al. B-type natriuretic peptide levels and mortality in patients with and without heart failure. J Am Coll Cardiol. 2018 May 15;71(19):2079-88.
Dr. Abramowicz is an assistant professor in the division of hospital medicine, University of Colorado, Denver.
Clinical question: Does B-type natriuretic peptide (BNP) have prognostic value outside of heart failure (HF) patients?
Background: BNP levels are influenced by both cardiac and extracardiac stimuli and thus might have prognostic value outside of the traditional use to guide therapy for HF patients.
Study design: Retrospective cohort study of the Vanderbilt electronic health record.
Setting: Vanderbilt University Medical Center, Nashville, Tenn.
Synopsis: The study evaluated 30,487 patients with at least two BNP values for 2002-2015. Within this cohort, 62% of patients did not have a HF diagnosis. Risk of death was elevated in all patients regardless of HF status as BNP values rose. An increase from the 25th to 75th percentile in BNP value was associated with an increased risk of death in non-HF patients (hazard ratio, 2.08; 95% confidence interval, 1.99-2.2). Additionally, in a multivariate analysis BNP was the strongest predictor of death, compared with traditional risk factors in both HF and non-HF patients. The main limitation to this study was the use of ICD codes for diagnosis of HF.
Bottom line: BNP has predictive value for risk of death in non-HF patients; as BNP levels rise, regardless of HF status, so does risk of death.
Citation: York MK et al. B-type natriuretic peptide levels and mortality in patients with and without heart failure. J Am Coll Cardiol. 2018 May 15;71(19):2079-88.
Dr. Abramowicz is an assistant professor in the division of hospital medicine, University of Colorado, Denver.
Clinical question: Does B-type natriuretic peptide (BNP) have prognostic value outside of heart failure (HF) patients?
Background: BNP levels are influenced by both cardiac and extracardiac stimuli and thus might have prognostic value outside of the traditional use to guide therapy for HF patients.
Study design: Retrospective cohort study of the Vanderbilt electronic health record.
Setting: Vanderbilt University Medical Center, Nashville, Tenn.
Synopsis: The study evaluated 30,487 patients with at least two BNP values for 2002-2015. Within this cohort, 62% of patients did not have a HF diagnosis. Risk of death was elevated in all patients regardless of HF status as BNP values rose. An increase from the 25th to 75th percentile in BNP value was associated with an increased risk of death in non-HF patients (hazard ratio, 2.08; 95% confidence interval, 1.99-2.2). Additionally, in a multivariate analysis BNP was the strongest predictor of death, compared with traditional risk factors in both HF and non-HF patients. The main limitation to this study was the use of ICD codes for diagnosis of HF.
Bottom line: BNP has predictive value for risk of death in non-HF patients; as BNP levels rise, regardless of HF status, so does risk of death.
Citation: York MK et al. B-type natriuretic peptide levels and mortality in patients with and without heart failure. J Am Coll Cardiol. 2018 May 15;71(19):2079-88.
Dr. Abramowicz is an assistant professor in the division of hospital medicine, University of Colorado, Denver.
