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CDC releases guidelines for pediatric mTBI
and should base management and prognostication on clinical decision-making tools and symptom rating scales, according to new practice guidelines issued by a working group of the Centers for Disease Control and Prevention (JAMA Pediatrics. 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2853.
The guidelines were released simultaneously with a systematic review, conducted by the same authors, of the existing literature regarding pediatric mTBI (JAMA Pediatrics 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2847). As the evaluators sorted through the literature to find high-quality studies for this population, the funnel rapidly narrowed: From an initial pool of over 15,000 studies conducted between 1990 and 2015, findings from just 75 studies were eventually included in the systematic review.
The review’s findings formed the basis for the guidelines and allowed Angela Lumba-Brown, MD, a pediatric emergency medicine physician at Stanford (Calif.) University, and her coauthors to ascribe a level of confidence in the inference from study data for a given recommendation. Recommendations also are categorized by strength and accordingly indicate that clinicians “should” or “may” follow them. Exceptions are carved out for practices, such as the use of hypertonic 3% saline solution for acute headache in the ED, that should not be used outside research settings.
In the end, the guidelines cover 19 main topics, sorted into guidance regarding the diagnosis, prognosis, and management and treatment of mTBI in children.
Diagnosis
The recommendations regarding mTBI diagnosis center around determining which children are at risk for significant intracranial injury (ICI). The guidelines recommend, with moderate confidence, that clinicians usually should not obtain a head CT for children with mTBI. Validated clinical decision rules should be used for risk stratification to determine which children can safely avoid imaging and which children should be considered for head CT, wrote Dr. Lumba-Brown and her coauthors. Magnetic resonance imaging is not recommended for initial evaluation of mTBI, nor should skull radiographs be ordered in the absence of clinical suspicion for skull fracture.
From the systematic review, Dr. Lumba-Brown and her colleagues found that several risk factors taken together may mean that significant ICI is more likely. These include patient age younger than 2 years; any vomiting, loss of consciousness, or amnesia; a severe mechanism of injury, severe or worsening headache, or nonfrontal scalp hematoma; a Glasgow Coma Scale (GCS) score of less than 15; and clinical suspicion for skull fracture. Clinicians should give consideration to the risks of ionizing radiation to the head, and balance this against their assessment of risk for severe – and perhaps actionable – injury.
A validated symptom rating scale, used in an age-appropriate way, should be used as part of the evaluation of children with mTBI. For children aged 6 and older, the Graded Symptom Checklist is an appropriate tool within 2 days after injury, while the Post Concussion Symptom Scale as part of computerized neurocognitive testing can differentiate which high school athletes have mTBI when used within 4 days of injury, according to the guidelines, which also identify other validated symptom rating scales.
The guidelines authors recommend, with high confidence, that serum biomarkers should not be used outside of research settings in the diagnosis of mTBI in children at present.
Prognosis
Families should be counseled that symptoms mostly resolve within 1-3 months for up to 80% of children with mTBI, but families also should know that “each child’s recovery from mTBI is unique and will follow its own trajectory,” wrote Dr. Lumba-Brown and her coauthors, in a moderate-strength recommendation.
Some factors have been associated with slower recovery from mTBI, and either upon evaluation for mTBI or in routine sports examinations, families should be told about this potential if risk factors are present, said the guidelines, although the evidence supporting the associations is of “varying strength,” wrote Dr. Lumba-Brown and her coauthors. Children with previous mTBIs and those with a history of premorbid neurologic and psychiatric problems, learning problems, or family and social stress all may have delayed recovery. For children with ICI, lower cognitive ability also is associated with delayed recovery.
Demographic factors such as lower socioeconomic status and being of Hispanic ethnicity also may increase the risk for delayed mTBI recovery. Older children and adolescents may recover more slowly. Those with more severe initial presentation and more symptoms in the immediate post-mTBI phase also may have a slower recovery course, said Dr. Lumba-Brown and her coauthors.
A validated prediction rule can be used in the ED to gather information about these discrete risk factors to guide family counseling, according to the guidelines, which note that research has found that “an empirically derived set of risk factors predicted the risk of persistent post-concussion symptoms at 28 days” for children seen in the ED with mTBI.
During the recovery phase, a combination of tools should be used to track recovery from mTBI; these can include validated symptom scales, validated cognitive testing, reaction time measures, and, in adolescent athletes, balance testing. Using a combination of tools is a valuable strategy, the researchers wrote. “No single assessment tool is strongly predictive of outcome in children with mTBI,” they noted.
When prognosis is poor, or recovery is not proceeding as expected, clinicians should have a low threshold for initiating other interventions and referrals.
Management and treatment
Although the guideline authors acknowledged significant knowledge gaps in all areas of pediatric mTBI diagnosis and management, evidence is especially scant for best practices for treatment, rest, and return to play and school after a child sustains mTBI, said Dr. Lumba-Brown and her coauthors.
However, families should be given information about warning signs for serious head injury and how to monitor symptoms, as well as information about mTBI and the expected recovery course. Other forward-looking instructions should cover the importance of preventing new head injuries, managing the gradual return to normal cognitive and physical activities, and clear instructions regarding return to school and recreational activities. The guideline authors made a strong recommendation to provide this information, with high confidence in the data.
However, little strong evidence points the way to a clear set of criteria for when children are ready for school, play, and athletic participation. These decisions must be customized to the individual child, and decision making, particularly about return to school and academic activities, should be a collaborative affair, with schools, clinicians, and families all communicating to make sure the pace of return to normal life is keeping pace with the child’s recovery. “Because postconcussive symptoms resolve at different rates in different children after mTBI, individualization of return-to-school programming is necessary,” wrote Dr. Lumba-Brown and her coauthors.
The guideline authors cite evidence that “suggests that early rest (within the first 3 days) may be beneficial but that inactivity beyond this period for most children may worsen their self-reported symptoms.”
Psychosocial support may be beneficial for certain children, wrote the researchers, drawing on evidence showing that such support is beneficial in frank TBI, and is probably beneficial in mTBI.
Active rehabilitation as tolerated is recommended after an initial period of rest, with exertion kept to a level that does not exacerbate symptoms. Children should not participate in contact activities until symptoms are fully resolved.
A posttraumatic headache that is severe or worsens in the ED should prompt consideration of emergent neuroimaging, according to the guidelines. In the postacute phase, however, children can have nonopioid analgesia, although parents should know about such risks as rebound headache. When chronic headache follows a mTBI, the guidelines recommend that clinicians refer patients for a multidisciplinary evaluation that can assess the many factors – including analgesic overuse – that can be contributors.
Drawing on the larger body of adult TBI research, the authors recommend that insufficient or disordered sleep be addressed, because “the maintenance of appropriate sleep and the management of disrupted sleep may be a critical target of treatment for the child with mTBI.”
Children who suffer a mTBI may experience cognitive dysfunction as a direct result of injury to the brain or secondary to the effects of other symptoms such as sleep disruptions, headache pain, fatigue, or low tolerance of frustration. Clinicians may want to perform or refer their patients for a neuropsychological evaluation to determine what is causing the cognitive dysfunction, the authors said.
Dr. Lumba-Brown and her coauthors, who formed the CDC’s Pediatric Mild Traumatic Brain Injury Guideline Workgroup, also recommended that clinicians use the term “mild traumatic brain injury” to describe head injuries that cause confusion or disorientation, without loss of consciousness, or loss of consciousness of up to 30 minutes or less, or posttraumatic amnesia of less than 24 hours duration, and that are associated with a GCS of 13-15 by 30 minutes after injury or at the time of initial medical assessment. This practice, they said, may reduce the risk of misinterpretation by medical professionals and the public that can occur when the terms “mTBI,” “concussion,” and “minor head injury” all may refer to the same injury.
The CDC has developed a suite of materials to assist both health care providers and the public in guideline implementation. The agency also is using its HEADS UP campaign to publicize the guidelines and related materials, and plans ongoing evaluation of the guidelines and implementation materials.
Many study authors, including Dr. Lumba-Brown, had relationships with medical device or pharmaceutical companies. The systematic review and guideline development were funded by the CDC.
A growing realization that mTBI can have persistent and significant deleterious effects has informed medical and public attitudes toward concussion in children, which now results in almost 1 million annual ED visits.
Progress at the laboratory bench has elucidated much of the neurometabolic cascade that occurs with the insult of mTBI, and has allowed researchers to document the path of brain healing after injury. Neuroimaging now can go beyond static images to trace neural networks and detect previously unseen and subtle functional deficits engendered by mTBI.
In particular, 21st century magnetic resonance imaging (MRI) has shown increased sensitivity over CT alone. In the TRACK-TBI study, over one in four patients whose CTs were read as normal had MRI findings consistent with trauma-induced pathology. Both multimodal MRI and serum biomarkers show promise, although more research regarding their utility is needed, particularly in the case of proteomic biomarkers.
Still, high-quality studies of pediatric mTBI are scant, and translation of burgeoning research into clinical practice is severely impeded by the numerous knowledge gaps that exist in the field.
Dr. Lumba-Brown and her colleagues have synthesized research that supports a neurobiopsychosocial model of mTBI in children that comes into play most prominently in the postacute phase, when non–injury-related factors such as demographics, socioeconomic status, and premorbid psychological conditions are strong mediators of the recovery trajectory.
With children as with adults, scant research guides the path forward for treatment and recovery from mTBI. For children, clinicians are still grappling with issues surrounding return to full participation in the academic and recreational activities of the school environment.
Data from two currently active studies should help light the way forward, however. The TRACK-TBI study, funded by the National Institutes of Health, will include almost 200 children among its 2,700 enrollees who have sustained all levels of TBI.
The Concussion Assessment, Research, and Education (CARE) Consortium is funded jointly by the National College Athletic Association and the Department of Defense. Between student athletes and military cadets, over 40,000 individuals are now part of the study.
The two studies’ testing modalities and methodologies align, offering the opportunity for a powerful pooled analysis that includes civilians, athletes, and those in the military.
Until then, these guidelines provide a way forward to an individualized approach to the best care for a child with mTBI.
Michael McCrea, PhD, is professor of neurology and neurosurgery, and director of brain injury research at the Medical College of Wisconsin, Milwaukee. Geoff Manley, MD, PhD, is professor of neurologic surgery at the University of California, San Francisco. Neither author reported conflicts of interest. These remarks were drawn from an editorial accompanying the guidelines and systematic review (JAMA Pediatrics. 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2846).
A growing realization that mTBI can have persistent and significant deleterious effects has informed medical and public attitudes toward concussion in children, which now results in almost 1 million annual ED visits.
Progress at the laboratory bench has elucidated much of the neurometabolic cascade that occurs with the insult of mTBI, and has allowed researchers to document the path of brain healing after injury. Neuroimaging now can go beyond static images to trace neural networks and detect previously unseen and subtle functional deficits engendered by mTBI.
In particular, 21st century magnetic resonance imaging (MRI) has shown increased sensitivity over CT alone. In the TRACK-TBI study, over one in four patients whose CTs were read as normal had MRI findings consistent with trauma-induced pathology. Both multimodal MRI and serum biomarkers show promise, although more research regarding their utility is needed, particularly in the case of proteomic biomarkers.
Still, high-quality studies of pediatric mTBI are scant, and translation of burgeoning research into clinical practice is severely impeded by the numerous knowledge gaps that exist in the field.
Dr. Lumba-Brown and her colleagues have synthesized research that supports a neurobiopsychosocial model of mTBI in children that comes into play most prominently in the postacute phase, when non–injury-related factors such as demographics, socioeconomic status, and premorbid psychological conditions are strong mediators of the recovery trajectory.
With children as with adults, scant research guides the path forward for treatment and recovery from mTBI. For children, clinicians are still grappling with issues surrounding return to full participation in the academic and recreational activities of the school environment.
Data from two currently active studies should help light the way forward, however. The TRACK-TBI study, funded by the National Institutes of Health, will include almost 200 children among its 2,700 enrollees who have sustained all levels of TBI.
The Concussion Assessment, Research, and Education (CARE) Consortium is funded jointly by the National College Athletic Association and the Department of Defense. Between student athletes and military cadets, over 40,000 individuals are now part of the study.
The two studies’ testing modalities and methodologies align, offering the opportunity for a powerful pooled analysis that includes civilians, athletes, and those in the military.
Until then, these guidelines provide a way forward to an individualized approach to the best care for a child with mTBI.
Michael McCrea, PhD, is professor of neurology and neurosurgery, and director of brain injury research at the Medical College of Wisconsin, Milwaukee. Geoff Manley, MD, PhD, is professor of neurologic surgery at the University of California, San Francisco. Neither author reported conflicts of interest. These remarks were drawn from an editorial accompanying the guidelines and systematic review (JAMA Pediatrics. 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2846).
A growing realization that mTBI can have persistent and significant deleterious effects has informed medical and public attitudes toward concussion in children, which now results in almost 1 million annual ED visits.
Progress at the laboratory bench has elucidated much of the neurometabolic cascade that occurs with the insult of mTBI, and has allowed researchers to document the path of brain healing after injury. Neuroimaging now can go beyond static images to trace neural networks and detect previously unseen and subtle functional deficits engendered by mTBI.
In particular, 21st century magnetic resonance imaging (MRI) has shown increased sensitivity over CT alone. In the TRACK-TBI study, over one in four patients whose CTs were read as normal had MRI findings consistent with trauma-induced pathology. Both multimodal MRI and serum biomarkers show promise, although more research regarding their utility is needed, particularly in the case of proteomic biomarkers.
Still, high-quality studies of pediatric mTBI are scant, and translation of burgeoning research into clinical practice is severely impeded by the numerous knowledge gaps that exist in the field.
Dr. Lumba-Brown and her colleagues have synthesized research that supports a neurobiopsychosocial model of mTBI in children that comes into play most prominently in the postacute phase, when non–injury-related factors such as demographics, socioeconomic status, and premorbid psychological conditions are strong mediators of the recovery trajectory.
With children as with adults, scant research guides the path forward for treatment and recovery from mTBI. For children, clinicians are still grappling with issues surrounding return to full participation in the academic and recreational activities of the school environment.
Data from two currently active studies should help light the way forward, however. The TRACK-TBI study, funded by the National Institutes of Health, will include almost 200 children among its 2,700 enrollees who have sustained all levels of TBI.
The Concussion Assessment, Research, and Education (CARE) Consortium is funded jointly by the National College Athletic Association and the Department of Defense. Between student athletes and military cadets, over 40,000 individuals are now part of the study.
The two studies’ testing modalities and methodologies align, offering the opportunity for a powerful pooled analysis that includes civilians, athletes, and those in the military.
Until then, these guidelines provide a way forward to an individualized approach to the best care for a child with mTBI.
Michael McCrea, PhD, is professor of neurology and neurosurgery, and director of brain injury research at the Medical College of Wisconsin, Milwaukee. Geoff Manley, MD, PhD, is professor of neurologic surgery at the University of California, San Francisco. Neither author reported conflicts of interest. These remarks were drawn from an editorial accompanying the guidelines and systematic review (JAMA Pediatrics. 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2846).
and should base management and prognostication on clinical decision-making tools and symptom rating scales, according to new practice guidelines issued by a working group of the Centers for Disease Control and Prevention (JAMA Pediatrics. 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2853.
The guidelines were released simultaneously with a systematic review, conducted by the same authors, of the existing literature regarding pediatric mTBI (JAMA Pediatrics 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2847). As the evaluators sorted through the literature to find high-quality studies for this population, the funnel rapidly narrowed: From an initial pool of over 15,000 studies conducted between 1990 and 2015, findings from just 75 studies were eventually included in the systematic review.
The review’s findings formed the basis for the guidelines and allowed Angela Lumba-Brown, MD, a pediatric emergency medicine physician at Stanford (Calif.) University, and her coauthors to ascribe a level of confidence in the inference from study data for a given recommendation. Recommendations also are categorized by strength and accordingly indicate that clinicians “should” or “may” follow them. Exceptions are carved out for practices, such as the use of hypertonic 3% saline solution for acute headache in the ED, that should not be used outside research settings.
In the end, the guidelines cover 19 main topics, sorted into guidance regarding the diagnosis, prognosis, and management and treatment of mTBI in children.
Diagnosis
The recommendations regarding mTBI diagnosis center around determining which children are at risk for significant intracranial injury (ICI). The guidelines recommend, with moderate confidence, that clinicians usually should not obtain a head CT for children with mTBI. Validated clinical decision rules should be used for risk stratification to determine which children can safely avoid imaging and which children should be considered for head CT, wrote Dr. Lumba-Brown and her coauthors. Magnetic resonance imaging is not recommended for initial evaluation of mTBI, nor should skull radiographs be ordered in the absence of clinical suspicion for skull fracture.
From the systematic review, Dr. Lumba-Brown and her colleagues found that several risk factors taken together may mean that significant ICI is more likely. These include patient age younger than 2 years; any vomiting, loss of consciousness, or amnesia; a severe mechanism of injury, severe or worsening headache, or nonfrontal scalp hematoma; a Glasgow Coma Scale (GCS) score of less than 15; and clinical suspicion for skull fracture. Clinicians should give consideration to the risks of ionizing radiation to the head, and balance this against their assessment of risk for severe – and perhaps actionable – injury.
A validated symptom rating scale, used in an age-appropriate way, should be used as part of the evaluation of children with mTBI. For children aged 6 and older, the Graded Symptom Checklist is an appropriate tool within 2 days after injury, while the Post Concussion Symptom Scale as part of computerized neurocognitive testing can differentiate which high school athletes have mTBI when used within 4 days of injury, according to the guidelines, which also identify other validated symptom rating scales.
The guidelines authors recommend, with high confidence, that serum biomarkers should not be used outside of research settings in the diagnosis of mTBI in children at present.
Prognosis
Families should be counseled that symptoms mostly resolve within 1-3 months for up to 80% of children with mTBI, but families also should know that “each child’s recovery from mTBI is unique and will follow its own trajectory,” wrote Dr. Lumba-Brown and her coauthors, in a moderate-strength recommendation.
Some factors have been associated with slower recovery from mTBI, and either upon evaluation for mTBI or in routine sports examinations, families should be told about this potential if risk factors are present, said the guidelines, although the evidence supporting the associations is of “varying strength,” wrote Dr. Lumba-Brown and her coauthors. Children with previous mTBIs and those with a history of premorbid neurologic and psychiatric problems, learning problems, or family and social stress all may have delayed recovery. For children with ICI, lower cognitive ability also is associated with delayed recovery.
Demographic factors such as lower socioeconomic status and being of Hispanic ethnicity also may increase the risk for delayed mTBI recovery. Older children and adolescents may recover more slowly. Those with more severe initial presentation and more symptoms in the immediate post-mTBI phase also may have a slower recovery course, said Dr. Lumba-Brown and her coauthors.
A validated prediction rule can be used in the ED to gather information about these discrete risk factors to guide family counseling, according to the guidelines, which note that research has found that “an empirically derived set of risk factors predicted the risk of persistent post-concussion symptoms at 28 days” for children seen in the ED with mTBI.
During the recovery phase, a combination of tools should be used to track recovery from mTBI; these can include validated symptom scales, validated cognitive testing, reaction time measures, and, in adolescent athletes, balance testing. Using a combination of tools is a valuable strategy, the researchers wrote. “No single assessment tool is strongly predictive of outcome in children with mTBI,” they noted.
When prognosis is poor, or recovery is not proceeding as expected, clinicians should have a low threshold for initiating other interventions and referrals.
Management and treatment
Although the guideline authors acknowledged significant knowledge gaps in all areas of pediatric mTBI diagnosis and management, evidence is especially scant for best practices for treatment, rest, and return to play and school after a child sustains mTBI, said Dr. Lumba-Brown and her coauthors.
However, families should be given information about warning signs for serious head injury and how to monitor symptoms, as well as information about mTBI and the expected recovery course. Other forward-looking instructions should cover the importance of preventing new head injuries, managing the gradual return to normal cognitive and physical activities, and clear instructions regarding return to school and recreational activities. The guideline authors made a strong recommendation to provide this information, with high confidence in the data.
However, little strong evidence points the way to a clear set of criteria for when children are ready for school, play, and athletic participation. These decisions must be customized to the individual child, and decision making, particularly about return to school and academic activities, should be a collaborative affair, with schools, clinicians, and families all communicating to make sure the pace of return to normal life is keeping pace with the child’s recovery. “Because postconcussive symptoms resolve at different rates in different children after mTBI, individualization of return-to-school programming is necessary,” wrote Dr. Lumba-Brown and her coauthors.
The guideline authors cite evidence that “suggests that early rest (within the first 3 days) may be beneficial but that inactivity beyond this period for most children may worsen their self-reported symptoms.”
Psychosocial support may be beneficial for certain children, wrote the researchers, drawing on evidence showing that such support is beneficial in frank TBI, and is probably beneficial in mTBI.
Active rehabilitation as tolerated is recommended after an initial period of rest, with exertion kept to a level that does not exacerbate symptoms. Children should not participate in contact activities until symptoms are fully resolved.
A posttraumatic headache that is severe or worsens in the ED should prompt consideration of emergent neuroimaging, according to the guidelines. In the postacute phase, however, children can have nonopioid analgesia, although parents should know about such risks as rebound headache. When chronic headache follows a mTBI, the guidelines recommend that clinicians refer patients for a multidisciplinary evaluation that can assess the many factors – including analgesic overuse – that can be contributors.
Drawing on the larger body of adult TBI research, the authors recommend that insufficient or disordered sleep be addressed, because “the maintenance of appropriate sleep and the management of disrupted sleep may be a critical target of treatment for the child with mTBI.”
Children who suffer a mTBI may experience cognitive dysfunction as a direct result of injury to the brain or secondary to the effects of other symptoms such as sleep disruptions, headache pain, fatigue, or low tolerance of frustration. Clinicians may want to perform or refer their patients for a neuropsychological evaluation to determine what is causing the cognitive dysfunction, the authors said.
Dr. Lumba-Brown and her coauthors, who formed the CDC’s Pediatric Mild Traumatic Brain Injury Guideline Workgroup, also recommended that clinicians use the term “mild traumatic brain injury” to describe head injuries that cause confusion or disorientation, without loss of consciousness, or loss of consciousness of up to 30 minutes or less, or posttraumatic amnesia of less than 24 hours duration, and that are associated with a GCS of 13-15 by 30 minutes after injury or at the time of initial medical assessment. This practice, they said, may reduce the risk of misinterpretation by medical professionals and the public that can occur when the terms “mTBI,” “concussion,” and “minor head injury” all may refer to the same injury.
The CDC has developed a suite of materials to assist both health care providers and the public in guideline implementation. The agency also is using its HEADS UP campaign to publicize the guidelines and related materials, and plans ongoing evaluation of the guidelines and implementation materials.
Many study authors, including Dr. Lumba-Brown, had relationships with medical device or pharmaceutical companies. The systematic review and guideline development were funded by the CDC.
and should base management and prognostication on clinical decision-making tools and symptom rating scales, according to new practice guidelines issued by a working group of the Centers for Disease Control and Prevention (JAMA Pediatrics. 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2853.
The guidelines were released simultaneously with a systematic review, conducted by the same authors, of the existing literature regarding pediatric mTBI (JAMA Pediatrics 2018 Sep 4. doi: 10.1001/jamapediatrics.2018.2847). As the evaluators sorted through the literature to find high-quality studies for this population, the funnel rapidly narrowed: From an initial pool of over 15,000 studies conducted between 1990 and 2015, findings from just 75 studies were eventually included in the systematic review.
The review’s findings formed the basis for the guidelines and allowed Angela Lumba-Brown, MD, a pediatric emergency medicine physician at Stanford (Calif.) University, and her coauthors to ascribe a level of confidence in the inference from study data for a given recommendation. Recommendations also are categorized by strength and accordingly indicate that clinicians “should” or “may” follow them. Exceptions are carved out for practices, such as the use of hypertonic 3% saline solution for acute headache in the ED, that should not be used outside research settings.
In the end, the guidelines cover 19 main topics, sorted into guidance regarding the diagnosis, prognosis, and management and treatment of mTBI in children.
Diagnosis
The recommendations regarding mTBI diagnosis center around determining which children are at risk for significant intracranial injury (ICI). The guidelines recommend, with moderate confidence, that clinicians usually should not obtain a head CT for children with mTBI. Validated clinical decision rules should be used for risk stratification to determine which children can safely avoid imaging and which children should be considered for head CT, wrote Dr. Lumba-Brown and her coauthors. Magnetic resonance imaging is not recommended for initial evaluation of mTBI, nor should skull radiographs be ordered in the absence of clinical suspicion for skull fracture.
From the systematic review, Dr. Lumba-Brown and her colleagues found that several risk factors taken together may mean that significant ICI is more likely. These include patient age younger than 2 years; any vomiting, loss of consciousness, or amnesia; a severe mechanism of injury, severe or worsening headache, or nonfrontal scalp hematoma; a Glasgow Coma Scale (GCS) score of less than 15; and clinical suspicion for skull fracture. Clinicians should give consideration to the risks of ionizing radiation to the head, and balance this against their assessment of risk for severe – and perhaps actionable – injury.
A validated symptom rating scale, used in an age-appropriate way, should be used as part of the evaluation of children with mTBI. For children aged 6 and older, the Graded Symptom Checklist is an appropriate tool within 2 days after injury, while the Post Concussion Symptom Scale as part of computerized neurocognitive testing can differentiate which high school athletes have mTBI when used within 4 days of injury, according to the guidelines, which also identify other validated symptom rating scales.
The guidelines authors recommend, with high confidence, that serum biomarkers should not be used outside of research settings in the diagnosis of mTBI in children at present.
Prognosis
Families should be counseled that symptoms mostly resolve within 1-3 months for up to 80% of children with mTBI, but families also should know that “each child’s recovery from mTBI is unique and will follow its own trajectory,” wrote Dr. Lumba-Brown and her coauthors, in a moderate-strength recommendation.
Some factors have been associated with slower recovery from mTBI, and either upon evaluation for mTBI or in routine sports examinations, families should be told about this potential if risk factors are present, said the guidelines, although the evidence supporting the associations is of “varying strength,” wrote Dr. Lumba-Brown and her coauthors. Children with previous mTBIs and those with a history of premorbid neurologic and psychiatric problems, learning problems, or family and social stress all may have delayed recovery. For children with ICI, lower cognitive ability also is associated with delayed recovery.
Demographic factors such as lower socioeconomic status and being of Hispanic ethnicity also may increase the risk for delayed mTBI recovery. Older children and adolescents may recover more slowly. Those with more severe initial presentation and more symptoms in the immediate post-mTBI phase also may have a slower recovery course, said Dr. Lumba-Brown and her coauthors.
A validated prediction rule can be used in the ED to gather information about these discrete risk factors to guide family counseling, according to the guidelines, which note that research has found that “an empirically derived set of risk factors predicted the risk of persistent post-concussion symptoms at 28 days” for children seen in the ED with mTBI.
During the recovery phase, a combination of tools should be used to track recovery from mTBI; these can include validated symptom scales, validated cognitive testing, reaction time measures, and, in adolescent athletes, balance testing. Using a combination of tools is a valuable strategy, the researchers wrote. “No single assessment tool is strongly predictive of outcome in children with mTBI,” they noted.
When prognosis is poor, or recovery is not proceeding as expected, clinicians should have a low threshold for initiating other interventions and referrals.
Management and treatment
Although the guideline authors acknowledged significant knowledge gaps in all areas of pediatric mTBI diagnosis and management, evidence is especially scant for best practices for treatment, rest, and return to play and school after a child sustains mTBI, said Dr. Lumba-Brown and her coauthors.
However, families should be given information about warning signs for serious head injury and how to monitor symptoms, as well as information about mTBI and the expected recovery course. Other forward-looking instructions should cover the importance of preventing new head injuries, managing the gradual return to normal cognitive and physical activities, and clear instructions regarding return to school and recreational activities. The guideline authors made a strong recommendation to provide this information, with high confidence in the data.
However, little strong evidence points the way to a clear set of criteria for when children are ready for school, play, and athletic participation. These decisions must be customized to the individual child, and decision making, particularly about return to school and academic activities, should be a collaborative affair, with schools, clinicians, and families all communicating to make sure the pace of return to normal life is keeping pace with the child’s recovery. “Because postconcussive symptoms resolve at different rates in different children after mTBI, individualization of return-to-school programming is necessary,” wrote Dr. Lumba-Brown and her coauthors.
The guideline authors cite evidence that “suggests that early rest (within the first 3 days) may be beneficial but that inactivity beyond this period for most children may worsen their self-reported symptoms.”
Psychosocial support may be beneficial for certain children, wrote the researchers, drawing on evidence showing that such support is beneficial in frank TBI, and is probably beneficial in mTBI.
Active rehabilitation as tolerated is recommended after an initial period of rest, with exertion kept to a level that does not exacerbate symptoms. Children should not participate in contact activities until symptoms are fully resolved.
A posttraumatic headache that is severe or worsens in the ED should prompt consideration of emergent neuroimaging, according to the guidelines. In the postacute phase, however, children can have nonopioid analgesia, although parents should know about such risks as rebound headache. When chronic headache follows a mTBI, the guidelines recommend that clinicians refer patients for a multidisciplinary evaluation that can assess the many factors – including analgesic overuse – that can be contributors.
Drawing on the larger body of adult TBI research, the authors recommend that insufficient or disordered sleep be addressed, because “the maintenance of appropriate sleep and the management of disrupted sleep may be a critical target of treatment for the child with mTBI.”
Children who suffer a mTBI may experience cognitive dysfunction as a direct result of injury to the brain or secondary to the effects of other symptoms such as sleep disruptions, headache pain, fatigue, or low tolerance of frustration. Clinicians may want to perform or refer their patients for a neuropsychological evaluation to determine what is causing the cognitive dysfunction, the authors said.
Dr. Lumba-Brown and her coauthors, who formed the CDC’s Pediatric Mild Traumatic Brain Injury Guideline Workgroup, also recommended that clinicians use the term “mild traumatic brain injury” to describe head injuries that cause confusion or disorientation, without loss of consciousness, or loss of consciousness of up to 30 minutes or less, or posttraumatic amnesia of less than 24 hours duration, and that are associated with a GCS of 13-15 by 30 minutes after injury or at the time of initial medical assessment. This practice, they said, may reduce the risk of misinterpretation by medical professionals and the public that can occur when the terms “mTBI,” “concussion,” and “minor head injury” all may refer to the same injury.
The CDC has developed a suite of materials to assist both health care providers and the public in guideline implementation. The agency also is using its HEADS UP campaign to publicize the guidelines and related materials, and plans ongoing evaluation of the guidelines and implementation materials.
Many study authors, including Dr. Lumba-Brown, had relationships with medical device or pharmaceutical companies. The systematic review and guideline development were funded by the CDC.
FROM JAMA PEDIATRICS
ARRIVE: What are the perinatal and maternal consequences of labor induction at 39 weeks compared with expectant management?
WHAT DOES THIS MEAN FOR PRACTICE?
- Induction of labor at 39 weeks in low-risk nulliparas, irrespective of Bishop score, seems to be a reasonable option to be included in route of delivery discussions with patients as part of the principle of shared decision-making.
- The data in this trial would suggest that such an approach not only reduces adverse perinatal outcomes but also may reduce the need for subsequent cesarean delivery.
Updates to EULAR hand OA management recommendations reflect current evidence
Updated EULAR recommendations on the management of hand osteoarthritis include five overarching principles as well as two new recommendations that reflect new research in the field.
The task force, led by Margreet Kloppenburg, MD, PhD, of the department of rheumatology at Leiden (the Netherlands) University Medical Center, noted that a decade had passed since the first recommendations were published in 2007.
“It was timely to update the recommendations, as many new studies had emerged during this period. In light of this new evidence, many of the 2007 recommendations were modified and new recommendations were added,” wrote Dr. Kloppenburg and her colleagues. The recommendations were published online in Annals of the Rheumatic Diseases.
They noted that the recommendations were targeted to all health professionals across primary and secondary care but also aimed to inform patients about their disease to “support shared decision making.”
In line with other EULAR sets of management recommendations, the update included five overarching principles that cover treatment goals, information and education for patients, individualization of treatment, shared decision making between clinicians and patients, and the need to take into consideration a multidisciplinary and multimodal (pharmacologic and nonpharmacologic) treatment approach.
The authors noted that for a long time hand OA was a “forgotten disease” and this was reflected by the paucity of clinical trials in the area. As a direct consequence, previous recommendations were based on expert opinion rather than evidence.
However, new data allowed the task force to recommend not to treat patients with hand OA with conventional synthetic or biologic disease-modifying antirheumatic drugs (DMARDs). The recommendation achieved the strongest level of evidence and a high level of agreement from the 19-member expert panel, which included 2 patient research partners. The authors said the recommendation was based on newer studies that demonstrated a lack of efficacy of csDMARDs and bDMARDs.
The authors also advised adapting the long-term follow-up of patients with hand OA to individual needs, although they noted this was based on expert opinion alone and that in the absence of a disease-modifying treatment, the goal of follow-up differs from that of many other rheumatic diseases. Individual needs will dictate the degree of follow-up required, based on the severity of symptoms, presence of erosive disease, reevaluation of the use of pharmacologic therapy, and a patient’s wishes and expectations. They also noted that “for most patients, standard radiographic follow-up is not useful at this moment” and that “follow-up does not necessarily have to be performed by a rheumatologist.
“Follow-up will likely increase adherence to nonpharmacological therapies like exercise or orthoses, and provides an opportunity for reevaluation of treatment,” they wrote.
The recommendations advise offering education and training in ergonomic principles and exercises to patients to improve function and muscle strength, as well as considering the use of orthoses in some patients.
Treatment recommendations suggested preferring topical treatments over systemic treatments and that oral analgesics, particularly NSAIDs, should be considered for a limited duration. The authors advised that chondroitin sulfate may be used in patients for pain relief and improvement in functioning and that intra-articular glucocorticoids should not generally be used but may be considered in patients with painful interphalangeal joints. Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain.
The recommendations were funded by EULAR. Several of the authors reported receiving consultancy fees and/or honoraria as well as research funding from industry.
SOURCE: Kloppenburg M et al. Ann Rheum Dis. 2018 Aug 28. doi: 10.1136/annrheumdis-2018-213826.
EULAR has updated its 2007 guidelines for the management of hand osteoarthritis. I find the recommendations helpful, and I have no disagreements.
The authors performed a systematic literature review that was more complete than the original guidelines. In addition, the methodology in developing the guidelines was updated utilizing the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system to guide the expert opinion. The manuscript presents recommendations that are carefully supported in the text. To understand guidelines, one really needs to read the text.
The update lists a set of research questions, similar to the 2007 recommendations.
The authors group their therapeutic recommendations according to nonpharmacologic, pharmacologic, and surgical approaches, as well as about the need for follow-up. The three nonpharmacologic recommendations include education and training, exercise and muscle strengthening, and the use of orthoses. The pharmacologic approach includes topical therapy as a first-line, oral NSAIDs and analgesics, chondroitin sulfate, and intra-articular injections. There is a negative recommendation for the use of biologics. The surgical recommendation is directed at the relief of pain. The last recommendation emphasizes the need for follow-up and individual care.
The differences between the recommendations include the removal of acetaminophen as a first-line therapy. Indeed, it seems to be barely recommended at all. In addition, there is an emphasis on topical therapy, particularly NSAIDs. The authors are equivocal on the recommendations for intra-articular therapy. Paraffin and local heat are no longer included. The recommendation against biologic therapy is new. They included agents used for rheumatoid arthritis, such as methotrexate, in this negative recommendation.
These new recommendations are an update of guidelines that are over 10 years old. They are practical and helpful. Unfortunately, more research is needed as the present day therapy is often inadequate.
Roy D. Altman, MD, is professor emeritus of medicine in the division of rheumatology and immunology at the University of California, Los Angeles. He is a consultant to Ferring, Flexion, GlaxoSmithKline, Novartis, Olatec, Pfizer, and Sorrento Therapeutics.
EULAR has updated its 2007 guidelines for the management of hand osteoarthritis. I find the recommendations helpful, and I have no disagreements.
The authors performed a systematic literature review that was more complete than the original guidelines. In addition, the methodology in developing the guidelines was updated utilizing the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system to guide the expert opinion. The manuscript presents recommendations that are carefully supported in the text. To understand guidelines, one really needs to read the text.
The update lists a set of research questions, similar to the 2007 recommendations.
The authors group their therapeutic recommendations according to nonpharmacologic, pharmacologic, and surgical approaches, as well as about the need for follow-up. The three nonpharmacologic recommendations include education and training, exercise and muscle strengthening, and the use of orthoses. The pharmacologic approach includes topical therapy as a first-line, oral NSAIDs and analgesics, chondroitin sulfate, and intra-articular injections. There is a negative recommendation for the use of biologics. The surgical recommendation is directed at the relief of pain. The last recommendation emphasizes the need for follow-up and individual care.
The differences between the recommendations include the removal of acetaminophen as a first-line therapy. Indeed, it seems to be barely recommended at all. In addition, there is an emphasis on topical therapy, particularly NSAIDs. The authors are equivocal on the recommendations for intra-articular therapy. Paraffin and local heat are no longer included. The recommendation against biologic therapy is new. They included agents used for rheumatoid arthritis, such as methotrexate, in this negative recommendation.
These new recommendations are an update of guidelines that are over 10 years old. They are practical and helpful. Unfortunately, more research is needed as the present day therapy is often inadequate.
Roy D. Altman, MD, is professor emeritus of medicine in the division of rheumatology and immunology at the University of California, Los Angeles. He is a consultant to Ferring, Flexion, GlaxoSmithKline, Novartis, Olatec, Pfizer, and Sorrento Therapeutics.
EULAR has updated its 2007 guidelines for the management of hand osteoarthritis. I find the recommendations helpful, and I have no disagreements.
The authors performed a systematic literature review that was more complete than the original guidelines. In addition, the methodology in developing the guidelines was updated utilizing the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system to guide the expert opinion. The manuscript presents recommendations that are carefully supported in the text. To understand guidelines, one really needs to read the text.
The update lists a set of research questions, similar to the 2007 recommendations.
The authors group their therapeutic recommendations according to nonpharmacologic, pharmacologic, and surgical approaches, as well as about the need for follow-up. The three nonpharmacologic recommendations include education and training, exercise and muscle strengthening, and the use of orthoses. The pharmacologic approach includes topical therapy as a first-line, oral NSAIDs and analgesics, chondroitin sulfate, and intra-articular injections. There is a negative recommendation for the use of biologics. The surgical recommendation is directed at the relief of pain. The last recommendation emphasizes the need for follow-up and individual care.
The differences between the recommendations include the removal of acetaminophen as a first-line therapy. Indeed, it seems to be barely recommended at all. In addition, there is an emphasis on topical therapy, particularly NSAIDs. The authors are equivocal on the recommendations for intra-articular therapy. Paraffin and local heat are no longer included. The recommendation against biologic therapy is new. They included agents used for rheumatoid arthritis, such as methotrexate, in this negative recommendation.
These new recommendations are an update of guidelines that are over 10 years old. They are practical and helpful. Unfortunately, more research is needed as the present day therapy is often inadequate.
Roy D. Altman, MD, is professor emeritus of medicine in the division of rheumatology and immunology at the University of California, Los Angeles. He is a consultant to Ferring, Flexion, GlaxoSmithKline, Novartis, Olatec, Pfizer, and Sorrento Therapeutics.
Updated EULAR recommendations on the management of hand osteoarthritis include five overarching principles as well as two new recommendations that reflect new research in the field.
The task force, led by Margreet Kloppenburg, MD, PhD, of the department of rheumatology at Leiden (the Netherlands) University Medical Center, noted that a decade had passed since the first recommendations were published in 2007.
“It was timely to update the recommendations, as many new studies had emerged during this period. In light of this new evidence, many of the 2007 recommendations were modified and new recommendations were added,” wrote Dr. Kloppenburg and her colleagues. The recommendations were published online in Annals of the Rheumatic Diseases.
They noted that the recommendations were targeted to all health professionals across primary and secondary care but also aimed to inform patients about their disease to “support shared decision making.”
In line with other EULAR sets of management recommendations, the update included five overarching principles that cover treatment goals, information and education for patients, individualization of treatment, shared decision making between clinicians and patients, and the need to take into consideration a multidisciplinary and multimodal (pharmacologic and nonpharmacologic) treatment approach.
The authors noted that for a long time hand OA was a “forgotten disease” and this was reflected by the paucity of clinical trials in the area. As a direct consequence, previous recommendations were based on expert opinion rather than evidence.
However, new data allowed the task force to recommend not to treat patients with hand OA with conventional synthetic or biologic disease-modifying antirheumatic drugs (DMARDs). The recommendation achieved the strongest level of evidence and a high level of agreement from the 19-member expert panel, which included 2 patient research partners. The authors said the recommendation was based on newer studies that demonstrated a lack of efficacy of csDMARDs and bDMARDs.
The authors also advised adapting the long-term follow-up of patients with hand OA to individual needs, although they noted this was based on expert opinion alone and that in the absence of a disease-modifying treatment, the goal of follow-up differs from that of many other rheumatic diseases. Individual needs will dictate the degree of follow-up required, based on the severity of symptoms, presence of erosive disease, reevaluation of the use of pharmacologic therapy, and a patient’s wishes and expectations. They also noted that “for most patients, standard radiographic follow-up is not useful at this moment” and that “follow-up does not necessarily have to be performed by a rheumatologist.
“Follow-up will likely increase adherence to nonpharmacological therapies like exercise or orthoses, and provides an opportunity for reevaluation of treatment,” they wrote.
The recommendations advise offering education and training in ergonomic principles and exercises to patients to improve function and muscle strength, as well as considering the use of orthoses in some patients.
Treatment recommendations suggested preferring topical treatments over systemic treatments and that oral analgesics, particularly NSAIDs, should be considered for a limited duration. The authors advised that chondroitin sulfate may be used in patients for pain relief and improvement in functioning and that intra-articular glucocorticoids should not generally be used but may be considered in patients with painful interphalangeal joints. Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain.
The recommendations were funded by EULAR. Several of the authors reported receiving consultancy fees and/or honoraria as well as research funding from industry.
SOURCE: Kloppenburg M et al. Ann Rheum Dis. 2018 Aug 28. doi: 10.1136/annrheumdis-2018-213826.
Updated EULAR recommendations on the management of hand osteoarthritis include five overarching principles as well as two new recommendations that reflect new research in the field.
The task force, led by Margreet Kloppenburg, MD, PhD, of the department of rheumatology at Leiden (the Netherlands) University Medical Center, noted that a decade had passed since the first recommendations were published in 2007.
“It was timely to update the recommendations, as many new studies had emerged during this period. In light of this new evidence, many of the 2007 recommendations were modified and new recommendations were added,” wrote Dr. Kloppenburg and her colleagues. The recommendations were published online in Annals of the Rheumatic Diseases.
They noted that the recommendations were targeted to all health professionals across primary and secondary care but also aimed to inform patients about their disease to “support shared decision making.”
In line with other EULAR sets of management recommendations, the update included five overarching principles that cover treatment goals, information and education for patients, individualization of treatment, shared decision making between clinicians and patients, and the need to take into consideration a multidisciplinary and multimodal (pharmacologic and nonpharmacologic) treatment approach.
The authors noted that for a long time hand OA was a “forgotten disease” and this was reflected by the paucity of clinical trials in the area. As a direct consequence, previous recommendations were based on expert opinion rather than evidence.
However, new data allowed the task force to recommend not to treat patients with hand OA with conventional synthetic or biologic disease-modifying antirheumatic drugs (DMARDs). The recommendation achieved the strongest level of evidence and a high level of agreement from the 19-member expert panel, which included 2 patient research partners. The authors said the recommendation was based on newer studies that demonstrated a lack of efficacy of csDMARDs and bDMARDs.
The authors also advised adapting the long-term follow-up of patients with hand OA to individual needs, although they noted this was based on expert opinion alone and that in the absence of a disease-modifying treatment, the goal of follow-up differs from that of many other rheumatic diseases. Individual needs will dictate the degree of follow-up required, based on the severity of symptoms, presence of erosive disease, reevaluation of the use of pharmacologic therapy, and a patient’s wishes and expectations. They also noted that “for most patients, standard radiographic follow-up is not useful at this moment” and that “follow-up does not necessarily have to be performed by a rheumatologist.
“Follow-up will likely increase adherence to nonpharmacological therapies like exercise or orthoses, and provides an opportunity for reevaluation of treatment,” they wrote.
The recommendations advise offering education and training in ergonomic principles and exercises to patients to improve function and muscle strength, as well as considering the use of orthoses in some patients.
Treatment recommendations suggested preferring topical treatments over systemic treatments and that oral analgesics, particularly NSAIDs, should be considered for a limited duration. The authors advised that chondroitin sulfate may be used in patients for pain relief and improvement in functioning and that intra-articular glucocorticoids should not generally be used but may be considered in patients with painful interphalangeal joints. Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain.
The recommendations were funded by EULAR. Several of the authors reported receiving consultancy fees and/or honoraria as well as research funding from industry.
SOURCE: Kloppenburg M et al. Ann Rheum Dis. 2018 Aug 28. doi: 10.1136/annrheumdis-2018-213826.
FROM ANNALS OF THE RHEUMATIC DISEASES
Benign MS is real in small minority of patients
Nearly 3% of patients with multiple sclerosis (MS) are estimated to have a truly benign course of disease over at least 15 years without the use of disease-modifying therapy, based on findings from a U.K. population-based study that also showed how poorly benign disease tracks with disability measures and lacks agreement between patients and physicians.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of EDSS [Expanded Disability Status Scale]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” Emma Clare Tallantyre, MD, of Cardiff (Wales) University, and her colleagues wrote in the Journal of Neurology, Neurosurgery & Psychiatry.
Dr. Tallantyre and her colleagues found that, of 1,049 patients with disease duration longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those 200, 60 were clinically assessed and 9 (15%) were found to have truly benign MS, defined as having an EDSS less than 3.0 and having no significant fatigue, mood disturbance, cognitive impairment, or disruption to employment in the absence of disease-modifying therapy at least 15 years after symptom onset.
The investigators extrapolated these data to estimate that 30 patients in the study population of 1,049 had truly benign MS, for a prevalence of 2.9%. However, of the 60 patients who were clinically assessed, 39 thought they had benign MS based on the lay definition provided: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” the investigators wrote.
SOURCE: Tallantyre EC et al. J Neurol Neurosurg Psychiatry. 2018 Sep 3. doi: 10.1136/jnnp-2018-318802.
Nearly 3% of patients with multiple sclerosis (MS) are estimated to have a truly benign course of disease over at least 15 years without the use of disease-modifying therapy, based on findings from a U.K. population-based study that also showed how poorly benign disease tracks with disability measures and lacks agreement between patients and physicians.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of EDSS [Expanded Disability Status Scale]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” Emma Clare Tallantyre, MD, of Cardiff (Wales) University, and her colleagues wrote in the Journal of Neurology, Neurosurgery & Psychiatry.
Dr. Tallantyre and her colleagues found that, of 1,049 patients with disease duration longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those 200, 60 were clinically assessed and 9 (15%) were found to have truly benign MS, defined as having an EDSS less than 3.0 and having no significant fatigue, mood disturbance, cognitive impairment, or disruption to employment in the absence of disease-modifying therapy at least 15 years after symptom onset.
The investigators extrapolated these data to estimate that 30 patients in the study population of 1,049 had truly benign MS, for a prevalence of 2.9%. However, of the 60 patients who were clinically assessed, 39 thought they had benign MS based on the lay definition provided: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” the investigators wrote.
SOURCE: Tallantyre EC et al. J Neurol Neurosurg Psychiatry. 2018 Sep 3. doi: 10.1136/jnnp-2018-318802.
Nearly 3% of patients with multiple sclerosis (MS) are estimated to have a truly benign course of disease over at least 15 years without the use of disease-modifying therapy, based on findings from a U.K. population-based study that also showed how poorly benign disease tracks with disability measures and lacks agreement between patients and physicians.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of EDSS [Expanded Disability Status Scale]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” Emma Clare Tallantyre, MD, of Cardiff (Wales) University, and her colleagues wrote in the Journal of Neurology, Neurosurgery & Psychiatry.
Dr. Tallantyre and her colleagues found that, of 1,049 patients with disease duration longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those 200, 60 were clinically assessed and 9 (15%) were found to have truly benign MS, defined as having an EDSS less than 3.0 and having no significant fatigue, mood disturbance, cognitive impairment, or disruption to employment in the absence of disease-modifying therapy at least 15 years after symptom onset.
The investigators extrapolated these data to estimate that 30 patients in the study population of 1,049 had truly benign MS, for a prevalence of 2.9%. However, of the 60 patients who were clinically assessed, 39 thought they had benign MS based on the lay definition provided: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” the investigators wrote.
SOURCE: Tallantyre EC et al. J Neurol Neurosurg Psychiatry. 2018 Sep 3. doi: 10.1136/jnnp-2018-318802.
FROM THE JOURNAL OF NEUROLOGY, NEUROSURGERY & PSYCHIATRY
Time-to-Surgery for Definitive Fixation of Hip Fractures: A Look at Outcomes Based Upon Delay
ABSTRACT
The morbidity and mortality after hip fracture in the elderly are influenced by non-modifiable comorbidities. Time-to-surgery is a modifiable factor that may play a role in postoperative morbidity. This study investigates the outcomes and complications in the elderly hip fracture surgery as a function of time-to-surgery.
Using the American College of Surgeons-National Surgical Quality Improvement Program data from 2011 to 2012, a study population was generated using the Current Procedural Terminology codes for percutaneous or open treatment of femoral neck fractures (27235, 27236) and fixation with a screw and side plate or intramedullary fixation (27244, 27245) for peritrochanteric fractures. Three time-to-surgery groups (<24 hours to surgical intervention, 24-48 hours, and >48 hours) were created and matched for surgery type, sex, age, and American Society of Anesthesiologists class. Time-to-surgery was then studied for its effect on the post-surgical outcomes using the adjusted regression modeling.
A study population of 6036 hip fractures was created, and 2012 patients were assigned to each matched time-to-surgery group. The unadjusted models showed that the earlier surgical intervention groups (<24 hours and 24-48 hours) exhibited a lower overall complication rate (P = .034) compared with the group waiting for surgery >48 hours. The unadjusted mortality rates increased with delay to surgical intervention (P = .039). Time-to-surgery caused no effect on the return to the operating room rate (P = .554) nor readmission rate (P = .285). Compared with other time-to-surgeries, the time-to-surgery of >48 hours was associated with prolonged total hospital length of stay (10.9 days) (P < .001) and a longer surgery-to-discharge time (hazard ratio, 95% confidence interval: 0.74, 0.69-0.79) (P < .001). Adjusted analyses showed no time-to-surgery related difference in complications (P = .143) but presented an increase in the total length of stay (P < .001) and surgery-to-discharge time (P < .001).
Timeliness of surgical intervention in a comorbidity-adjusted population of elderly hip fracture patients causes no effect on the overall complications, readmissions, nor 30-day mortality. However, time-to-surgery of >48 hours is associated with costly increase in the total length of stay, including an increased post-surgery-to-discharge time.
Continue to: Despite the best efforts to optimize surgical care...
Despite the best efforts to optimize surgical care and postoperative rehabilitation following hip fracture, elderly patients feature alarmingly high in-hospital and 1-year mortality rates of 4.35% to 9.2%1-4 and 36%,5 respectively. Those who survive are unlikely to return to independent living, with only 17% of the patients following hip fracture being able to walk independently 6 months postoperatively, and 12% being able to climb stairs6. Possibly, these poor outcomes reflect a preoperative medical comorbidity burden rather than a measure of medical or surgical quality. Given the absence of consensus regarding optimal time-to-surgery, treating physicians often opt to delay surgical intervention for the purposes of medically optimizing highly comorbid patients without significant data to suggest clinical benefit of such practice.
Numerous investigators have attempted to identify the modifiable risk factors for complication after surgical care of elderly hip fracture patients. However, consensus guidelines of care are missing. This condition is largely due to the difficulties in effectively modifying preoperative demographic and medical comorbidities on a semi-urgent basis. However, timeliness to surgery is one area for study that the care team can affect. Although time-to-surgery is dependent on multiple factors, including time of presentation, day of week of admission, difficulties with scheduling, and administrative delays, the care team plays a role in hastening or retarding time-to-surgery. Several studies have considered various time cut-offs (24, 48, 72, and 120 hours) to define early intervention, but none have defined a specific role for early or delayed surgery. Several investigators have discovered a positive association between delayed time-to-surgery and mortality;4,8-14 however, the most rigorously conducted studies that stringently control for preoperative comorbidities and demographics conclude that variance in time-to-surgery causes no effect on the in-hospital or 1-year mortality risk.1-3,15-18
Other investigators have shown that with early surgical intervention for hip fracture, patients experience shorter hospital stays,1,3,16,17,19-22 less days in pain,19 decreased risk of decubitus ulcers,15,17,19,22 and an increased likelihood of independence following fracture,22-25 regardless of preoperative medical status. Despite this evidence of improved outcomes with early surgery, 40% to 54% of hip fracture patients in the United States experience surgical delays of more than 24 to 48 hours. Additionally, with the recent (2013) national estimates of cost per day spent in the hospital falling between $1791 to $2289,26 minimizing the days spent in the hospital would likely lead to significant cost-savings, presuming no adverse effect on health-related outcomes. To this end, we hypothesize that the value (outcomes per associated cost)7 of hip fracture surgical care can be positively influenced by minimizing surgical wait-times. We assessed the effect of early surgical intervention, within 24 or 48 hours of presentation, on 30-day mortality, postoperative morbidity, hospital length of stay, and readmission rates in a comorbidity-adjusted population from a nationally representative cohort.
Continue to: METHODS AND MATERIALS...
METHODS AND MATERIALS
This study used the data from the American College of Surgeon-National Surgical Quality Improvement Program (ACS-NSQIP) database. With over 258 participating hospitals, this database has been widely used to identify national trends in various surgical specialties.27-34 The database includes information from participants in 43 states with hospitals ranging from rural community hospitals to large academic centers. Each site employs surgical clinical reviewers who are rigorously trained to collect data through chart review and discussion with the treating surgeon and/or patient,35 allowing for the use of robust and quality data with proven inter-rater reliability.36,37
Using the 2011 to 2012 NSQIP database, we used primary Current Procedural Terminology codes to identify all patients who underwent percutaneous (27235) or open (27236) fixation of femoral neck fractures; and fixation with a screw and side plate (27244) or intramedullary fixation (27245) for peritrochanteric fractures. The sample was divided into 3 time-to-surgery groups (<24 hours from presentation to surgery, 24-48 hours, and >48 hours) which were matched for fracture type (femoral neck or peritrochanteric), sex, age (under 75 years or ≥75 years), and American Society of Anesthesiologists (ASA) class used as a surrogate for severity of medical infirmary. The subjects were randomly matched 1:1:1 to create 3 statistically equivalent time-to-surgery groups using Proc SurveySelect (SAS version 9.2, SAS Institute).
Generalized linear models using logit link function for binary variables and identity link function for normally distributed characteristics were used to compare the 3 time-to-surgery groups. Descriptive statistics are presented as counts and percentages or least-square means with standard deviations. Preoperative lab values that were not normally distributed were log transformed and presented in their original scales with median values and 25th to 75th percentiles. Outcomes were similarly modeled.
Total hospital stay was modeled with a negative binomial distribution. Proportional hazards models were used to model the time from operating room (OR) to discharge, censoring patients who died before discharge, with results presented as hazard ratios (HR) and 95% confidence intervals (CI) (Figure). The assumption of the proportional hazards was tested using a Wald test. Using this model, a HR of <1 denotes a longer postoperative hospital stay, as a longer hospital stay decreases the “risk” for discharge.
All models were adjusted for confounders, including race, body mass index (BMI), hypertension, chronic obstructive pulmonary disease, cancer, bleeding disorders, transfusion within 72 hours before surgery, preoperative levels of creatinine, platelet count, white blood cells (WBCs), hematocrit anesthesia type, and wound infection. These covariates were selected based upon their observed relationship to the studied outcomes and time-to-surgery groups, and were evaluated across the models for all outcomes for consistency and clarity. All statistical analyses were run at a type I error rate of 5% and performed in SAS version 9.2 software.
Continue to: RESULTS...
RESULTS
A study population of 6036 hip fractures was identified and divided into 3 groups of 2012 subjects each based upon time-to-surgery. The groups were successfully matched for surgery type, age (≥75 years old), gender, and ASA class. In each group, 594 of the 2012 (29.5%) patients were male, 1525 (75.8%) were ≥75 years of age, 9 (.5%) were ASA Class I, 269 (13.4%) were ASA Class II, 1424 (70.8%) were ASA class III, and 309 (15.4%) were ASA class IV.
Significant differences in preoperative comorbidity burden and preoperative lab values were identified between the 3 cohorts. Increased time-to-surgery was associated with differences in race (P < .001), elevated BMI (P = .010), higher rates of congestive heart failure (P < .001), hypertension medication (P = .020), bleeding disorders (P < .001), blood transfusion within 72 hours of surgery (P < .001), and systemic sepsis (P = .001). Delay to surgery was also associated with lower preoperative sodium (P = .005), blood urea nitrogen (P = .013), serum WBC (P < .001), hematocrit (P < .001), and platelets (P < .001) (Table 1).
The unadjusted analyses revealed no association between time-to-surgery and return to OR (P = .554) nor readmission (P = .285). However, increasing time-to-surgery was associated with an increase in overall complications (P = .034), total length of hospital stay (P < .001), and 30-day mortality (P = .039) (Table 2).
Table 2. Estimated Event Rates from Matched Cohorts (Unadjusted)
| Time From Presentation to Definitive Fixation | |||
Outcomes | <24 hours | 24-48 hours | >48 hours | P-value |
Overall complication rate | 15.30% | 15.30% | 17.90% | 0.034 |
Total length of stay | 5.4 | 6.7 | 10.9 | <0.001 |
(mean days, 95% confidence interval) | (5.2, 5.7) | (6.5, 7.0) | (10.3, 11.5) | |
Time from OR to discharge | -ref- | 0.96 | 0.74 | <0.001 |
(Hazard ratio) | (0.90,1.02) | (0.69, 0.79) | ||
Return to OR | 2.40% | 2.40% | 2.00% | 0.554 |
Readmission | 9.60% | 8.40% | 8.30% | 0.285 |
30-day mortality rate | 5.80% | 5.30% | 7.20% | 0.039 |
Abbreviation: OR, operating room.
The adjusted analysis controlling for preoperative demographic and comorbidity variables revealed trends toward the increased overall complications and 30-day mortality with increased time-to-surgery; these trends showed no statistical significance (P = .143 and P = .08). No statistical relationship was observed between return to OR nor readmission and time-to-surgery. Increasing time-to-surgery remained significantly associated with the increased total length of hospital stay (P < .001). The adjusted analysis also revealed that the delay of >48 hours in time-to-surgery resulted in a longer surgery-to-discharge time (P < .001) (Table 3). No evidence of violation of the proportional hazards assumption was observed in the unadjusted nor adjusted clustered proportional hazards models (Wald test, P = .27 and P = .25, respectively).
Table 3. Estimated Event Rates from Matched Cohorts (Adjusteda)
| Time from Presentation to Definitive Fixation | |||
Outcomes | <24 hours | 24-48 hours | >48 hours | P-value |
Overall complication rate | 11.70% | 10.70% | 12.60% | 0.143 |
Total length of stay | 4.2 | 5.1 | 7.6 | <0.001 |
(mean days, 95% confidence interval) | (4.0, 4.5) | (4.8, 5.5) | (7.1, 8.3) | |
Time from OR to discharge | -ref- | 1.03 | 0.87 | <0.001 |
(Hazard ratio) | (0.97, 1.09) | (0.81, 0.92) | ||
Return to OR | 2.10% | 2.10% | 1.60% | 0.541 |
Readmission | 7.20% | 6.40% | 6.00% | 0.304 |
30-day mortality rate | 4.20% | 3.70% | 5.20% | 0.08 |
aModel adjusted for race, hypertension medication, cancer, bleeding disorders, transfusion within 72 hours before surgery, emergency status, wound infection, anesthesia type (general), body mass index (18.5-25), history of chronic obstructive pulmonary disease, and preoperative levels of creatinine, platelet count, white blood cell count, and hematocrit.
Continue to: DISCUSSION...
DISCUSSION
Previous research has demonstrated an association between age,3,4,25 comorbidity burden,1,3,25 gender,3,4 and ASA class4,18,21 with outcomes following hip fractures and serves as the basis of our matched analysis statistical methodology in assessing the effect of time-to-surgery on the outcome following hip fracture surgery. Prior investigators have also established the positive correlation between increased preoperative comorbidity burden and delay in time-to-surgery.10,15 This finding was confirmed in our unadjusted comparison of 3 time-to-surgery groups. However, prior investigations have not established a clear association between time-to-surgical intervention and postoperative morbidity and mortality.1,15,16,18,20,38 This study utilized a nationally representative dataset known for its data integrity and from which 6036 patients with surgically treated hip fractures, matched for surgery type, age, gender, and ASA class (a surrogate for severity of medical infirmary), were studied using adjusted regression modeling to afford an isolated statistical assessment of the effect of time-to-surgery on outcomes following hip fracture surgery.
Despite a large sample size and rigorous statistical methodology, for many outcome measures, our results show no support for the early or late operative intervention following hip fracture. We found no difference in 30-day mortality, readmission rate, nor total complication rate between the 3 time-to-surgery cohorts. This result indicates that the care of elderly patients following hip fracture is inherently complicated and that perioperative complication risk is probably only modestly modifiable by best medical practices, including optimizing time from clinical presentation to surgery.
As expected, patients who experienced longer delays from presentation to surgery were on average, more comorbid and more likely to yield abnormal preoperative lab values. However, in the adjusted analysis, delay in time-to-surgery, presumably for medical management, was not found to be associated with improved outcomes. In the same adjusted analysis, we uniquely identified that in the patients whose surgeries were delayed for more than 48 hours, the time from surgery-to-discharge was significantly increased. As a result, these patients spent extra days in the hospital both preoperatively and postoperatively, but without any corollary improvement in the outcomes.
Continue to: Recent estimates of the cost of hospital admission...
Recent estimates of the cost of hospital admission is approximated nationally at $2000/day.26 Although our data fail to support the formal cost-analysis of the effect of time-to-surgery in hip fracture care, a simple value-based analysis indicates that quality is preserved (no difference in outcome), whereas costly hospital days are eliminated with earlier surgery. The value in elderly hip fracture care. defined as the outcomes relative to the costs,7 is ultimately optimized by earlier time-to-surgery.
Although using a large, multi-institutional database is advantageous for finding population-based trends that are representative of a large cohort, using the ACS-NSQIP database features its limitations. Our analysis was limited to the defined scope of NSQIP and nature of the injury, whereas root cause for delay was not available for study. We were unable to identify which patients were delayed for administrative reasons or surgical convenience and which were delayed for medical optimization. Participation in the ACS-NSQIP database is voluntary, and no randomized hospital sampling was conducted. Participating hospitals were de-identified in the database. As expected, we were unable to identify the specific institution-based hip fracture protocols that may affect the outcomes following treatment for these fractures. Further, socioeconomic information and payer-status are unavailable for the study. Additionally, observations are limited to 30 days postoperative, and we cannot comment on longer-term outcomes. Finally, discharge disposition and functional outcome data are not represented, and we were unable to correlate time-to-surgery and functional recovery. However, previous studies have established that delay in time-to-surgery following hip fractures is negatively correlated with functional outcomes.22-25
Nevertheless, the ACS-NSQIP database remains one of the largest American surgical databases available, and includes care centers from nearly every state with variable demographics including rural, urban, and academic centers. The ACS performs broad-based inter-rater reliability audits on every participating site and has found an overall disagreement rate of only 1.8%. As such, although discrepancies exist between the complete patient chart and the data entered, the data found in the ACS-NSQIP database are reliable and considered a valid source of study.34,35 The large sample size, quality of data collection, wide geographic representation, and varied hospital types within the dataset possibly make our findings relevant in the majority of American healthcare settings.
CONCLUSION
This study demonstrates an associated increased length of hospital stay, including the increased time from surgery-to-discharge, in patients with hip fractures whose surgical intervention is delayed for >48 hours after presentation. Given the prior evidence that early surgical intervention improves the functional outcomes and the current evidence that surgical delay for any cause increases costly hospital length of stay without corollary improvement in the outcomes, a value-based assessment of hip fracture care argues for early surgical intervention whenever possible. Our findings should inform physician, institution, and policy maker value-based decision making regarding the best practices in geriatric hip fracture care.
1. Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155(4):226-233. doi:10.7326/0003-4819-155-4-201108160-00006.
2. Verbeek DO, Ponsen KJ, Goslings JC, Heetveld MJ. Effect of surgical delay on outcome in hip fracture patients: a retrospective multivariate analysis of 192 patients. Int Orthop. 2008;32(1):13-18. doi:10.1007/s00264-006-0290-9.
3. Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009;91(7):922-927. doi:10.1302/0301-620X.91B7.22446.
4. Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury. 2013;44(6):726-729. doi:10.1016/j.injury.2012.08.025.
5. Zuckerman JD. Hip fracture. N Engl J Med. 1996;334(23):1519-1525. doi:10.1056/NEJM199606063342307.
6. Marottoli RA, Berkman LF, Cooney LM Jr. Decline in physical function following hip fracture. J Am Geriatr Soc. 1992;40(9):861-866. doi:10.1111/j.1532-5415.1992.tb01980.x.
7. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481. doi:10.1056/NEJMp1011024.
8. Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. 2008;90(1):34-42. doi:10.2106/JBJS.G.00065.
9. Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care. 2007;19(3):170-176. doi:10.1093/intqhc/mzm003.
10. Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br. 2005;87(3):361-366. doi:10.1302/0301-620X.87B3.15300.
11. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am. 2005;87(3):483-489. doi:10.2106/JBJS.D.01796.
12. Holt G, Smith R, Duncan K, McKeown DW. Does delay to theatre for medical reasons affect the peri-operative mortality in patients with a fracture of the hip? J Bone Joint Surg Br. 2010;92(6):835-841. doi:10.1302/0301-620X.92B6.24463.
13. Pioli G, Lauretani F, Davoli ML, et al. Older people with hip fracture and IADL disability require earlier surgery. J Gerontol A Biol Sci Med Sci. 2012;67(11):1272-1277. doi:10.1093/gerona/gls097.
14. Mackenzie DG, Wild S, Muir R. Mortality associated with delay in operation after hip fracture: Scottish data provide additional information. BMJ. 2006;332(7549):1093. doi:10.1136/bmj.332.7549.1093.
15. Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112(9):702-709. doi:10.1016/S0002-9343(02)01119-1.
16. Majumdar SR, Beaupre LA, Johnston DW, Dick DA, Cinats JG, Jiang HX. Lack of association between mortality and timing of surgical fixation in elderly patients with hip fracture: results of a retrospective population-based cohort study. Med Care. 2006;44(6):552-559. doi:10.1097/01.mlr.0000215812.13720.2e.
17. Hommel A, Ulander K, Bjorkelund KB, Norrman PO, Wingstrand H, Thorngren KG. Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year. Injury. 2008;39(10):1164-1174. doi:10.1016/j.injury.2008.01.048.
18. Rae HC, Harris IA, McEvoy L, Todorova T. Delay to surgery and mortality after hip fracture. ANZ J Surg. 2007;77(10):889-891. doi:10.1111/j.1445-2197.2007.04267.x.
19. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291(14):1738-1743. doi:10.1001/jama.291.14.1738.
20. Bergeron E, Lavoie A, Moore L, et al. Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems? J Trauma. 2006;60(4):753-757. doi:10.1097/01.ta.0000214649.53190.2a.
21. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005;87(8):1123-1126. doi:10.1302/0301-620X.87B8.16357.
22. Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am. 2008;90(7):1436-1442. doi:10.2106/JBJS.G.00890.
23. Hoenig H, Rubenstein LV, Sloane R, Horner R, Kahn K. What is the role of timing in the surgical and rehabilitative care of community-dwelling older persons with acute hip fracture? Arch Intern Med. 1997;157(5):513-520.
24. Doruk H, Mas MR, Yildiz C, Sonmez A, Kýrdemir V. The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly. Arch Gerontol Geriatr. 2004;39(2):179-185. doi:10.1016/j.archger.2004.03.004.
25. Yonezawa T, Yamazaki K, Atsumi T, Obara S. Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients. J Orthop Sci Off J Jpn Orthop Assoc. 2009;14(5):566-573. doi:10.1007/s00776-009-1380-5.
26. Henry J Kaiser Family Foundation. Hospital adjusted expenses per inpatient day by ownership. https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed March 14, 2013.
27. Belmont PJ Jr, Davey S, Orr JD, Ochoa LM, Bader JO, Schoenfeld AJ. Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program. J Am Coll Surg. 2011;213(3):370-378. doi:10.1016/j.jamcollsurg.2011.05.019.
28. Davis SS Jr, Husain FA, Lin E, Nandipati KC, Perez S, Sweeney JF. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg. 2013;216(1):96-104. doi:10.1016/j.jamcollsurg.2012.08.014.
29. Gart MS, Smetona JT, Hanwright PJ, et al. Autologous options for postmastectomy breast reconstruction: a comparison of outcomes based on the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2013;216(2):229-238. doi:10.1016/j.jamcollsurg.2012.11.003.
30. Greenblatt DY, Rajamanickam V, Pugely AJ, Heise CP, Foley EF, Kennedy GD. Short-term outcomes after laparoscopic-assisted proctectomy for rectal cancer: results from the ACS NSQIP. J Am Coll Surg. 2011;212(5):844-854. doi:10.1016/j.jamcollsurg.2011.01.005.
31. Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Callaghan JJ. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am. 2013;95(3):193-199. doi:10.2106/JBJS.K.01682.
32. Rao RD. Risk factors for complications and mortality after spine surgery assessed with the NSQIP database: where do we go from here? Commentary on an article by Andrew J Schoenfeld, MD, et al.: "Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program". J Bone Joint Surg Am. 2011;93(17):e101:(101-102). doi:10.2106/JBJS.K.00786.
33. Schilling PL, Hallstrom BR, Birkmeyer JD, Carpenter JE. Prioritizing perioperative quality improvement in orthopaedic surgery. J Bone Joint Surg Am. 2010;92(9):1884-1889. doi:10.2106/JBJS.I.00735.
34. Tsilimparis N, Perez S, Dayama A, Ricotta JJ 2nd. Age-stratified results from 20,095 aortoiliac aneurysm repairs: should we approach octogenarians and nonagenarians differently? J Am Coll Surg. 2012;215(5):690-701. doi:10.1016/j.jamcollsurg.2012.06.411.
35. ACS National Surgical Quality Improvement Program. American College of Surgeons Web site. https://www.facs.org/quality-programs/acs-nsqip?. Accessed March 14, 2013.
36. Henderson WG, Daley J. Design and statistical methodology of the National Surgical Quality Improvement Program: why is it what it is? Am J Surg. 2009;198(5 Suppl):S19-S27. doi:10.1016/j.amjsurg.2009.07.025.
37. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6-16. doi:10.1016/j.jamcollsurg.2009.09.031.
38. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692-697. doi:10.1016/j.injury.2009.01.010.
ABSTRACT
The morbidity and mortality after hip fracture in the elderly are influenced by non-modifiable comorbidities. Time-to-surgery is a modifiable factor that may play a role in postoperative morbidity. This study investigates the outcomes and complications in the elderly hip fracture surgery as a function of time-to-surgery.
Using the American College of Surgeons-National Surgical Quality Improvement Program data from 2011 to 2012, a study population was generated using the Current Procedural Terminology codes for percutaneous or open treatment of femoral neck fractures (27235, 27236) and fixation with a screw and side plate or intramedullary fixation (27244, 27245) for peritrochanteric fractures. Three time-to-surgery groups (<24 hours to surgical intervention, 24-48 hours, and >48 hours) were created and matched for surgery type, sex, age, and American Society of Anesthesiologists class. Time-to-surgery was then studied for its effect on the post-surgical outcomes using the adjusted regression modeling.
A study population of 6036 hip fractures was created, and 2012 patients were assigned to each matched time-to-surgery group. The unadjusted models showed that the earlier surgical intervention groups (<24 hours and 24-48 hours) exhibited a lower overall complication rate (P = .034) compared with the group waiting for surgery >48 hours. The unadjusted mortality rates increased with delay to surgical intervention (P = .039). Time-to-surgery caused no effect on the return to the operating room rate (P = .554) nor readmission rate (P = .285). Compared with other time-to-surgeries, the time-to-surgery of >48 hours was associated with prolonged total hospital length of stay (10.9 days) (P < .001) and a longer surgery-to-discharge time (hazard ratio, 95% confidence interval: 0.74, 0.69-0.79) (P < .001). Adjusted analyses showed no time-to-surgery related difference in complications (P = .143) but presented an increase in the total length of stay (P < .001) and surgery-to-discharge time (P < .001).
Timeliness of surgical intervention in a comorbidity-adjusted population of elderly hip fracture patients causes no effect on the overall complications, readmissions, nor 30-day mortality. However, time-to-surgery of >48 hours is associated with costly increase in the total length of stay, including an increased post-surgery-to-discharge time.
Continue to: Despite the best efforts to optimize surgical care...
Despite the best efforts to optimize surgical care and postoperative rehabilitation following hip fracture, elderly patients feature alarmingly high in-hospital and 1-year mortality rates of 4.35% to 9.2%1-4 and 36%,5 respectively. Those who survive are unlikely to return to independent living, with only 17% of the patients following hip fracture being able to walk independently 6 months postoperatively, and 12% being able to climb stairs6. Possibly, these poor outcomes reflect a preoperative medical comorbidity burden rather than a measure of medical or surgical quality. Given the absence of consensus regarding optimal time-to-surgery, treating physicians often opt to delay surgical intervention for the purposes of medically optimizing highly comorbid patients without significant data to suggest clinical benefit of such practice.
Numerous investigators have attempted to identify the modifiable risk factors for complication after surgical care of elderly hip fracture patients. However, consensus guidelines of care are missing. This condition is largely due to the difficulties in effectively modifying preoperative demographic and medical comorbidities on a semi-urgent basis. However, timeliness to surgery is one area for study that the care team can affect. Although time-to-surgery is dependent on multiple factors, including time of presentation, day of week of admission, difficulties with scheduling, and administrative delays, the care team plays a role in hastening or retarding time-to-surgery. Several studies have considered various time cut-offs (24, 48, 72, and 120 hours) to define early intervention, but none have defined a specific role for early or delayed surgery. Several investigators have discovered a positive association between delayed time-to-surgery and mortality;4,8-14 however, the most rigorously conducted studies that stringently control for preoperative comorbidities and demographics conclude that variance in time-to-surgery causes no effect on the in-hospital or 1-year mortality risk.1-3,15-18
Other investigators have shown that with early surgical intervention for hip fracture, patients experience shorter hospital stays,1,3,16,17,19-22 less days in pain,19 decreased risk of decubitus ulcers,15,17,19,22 and an increased likelihood of independence following fracture,22-25 regardless of preoperative medical status. Despite this evidence of improved outcomes with early surgery, 40% to 54% of hip fracture patients in the United States experience surgical delays of more than 24 to 48 hours. Additionally, with the recent (2013) national estimates of cost per day spent in the hospital falling between $1791 to $2289,26 minimizing the days spent in the hospital would likely lead to significant cost-savings, presuming no adverse effect on health-related outcomes. To this end, we hypothesize that the value (outcomes per associated cost)7 of hip fracture surgical care can be positively influenced by minimizing surgical wait-times. We assessed the effect of early surgical intervention, within 24 or 48 hours of presentation, on 30-day mortality, postoperative morbidity, hospital length of stay, and readmission rates in a comorbidity-adjusted population from a nationally representative cohort.
Continue to: METHODS AND MATERIALS...
METHODS AND MATERIALS
This study used the data from the American College of Surgeon-National Surgical Quality Improvement Program (ACS-NSQIP) database. With over 258 participating hospitals, this database has been widely used to identify national trends in various surgical specialties.27-34 The database includes information from participants in 43 states with hospitals ranging from rural community hospitals to large academic centers. Each site employs surgical clinical reviewers who are rigorously trained to collect data through chart review and discussion with the treating surgeon and/or patient,35 allowing for the use of robust and quality data with proven inter-rater reliability.36,37
Using the 2011 to 2012 NSQIP database, we used primary Current Procedural Terminology codes to identify all patients who underwent percutaneous (27235) or open (27236) fixation of femoral neck fractures; and fixation with a screw and side plate (27244) or intramedullary fixation (27245) for peritrochanteric fractures. The sample was divided into 3 time-to-surgery groups (<24 hours from presentation to surgery, 24-48 hours, and >48 hours) which were matched for fracture type (femoral neck or peritrochanteric), sex, age (under 75 years or ≥75 years), and American Society of Anesthesiologists (ASA) class used as a surrogate for severity of medical infirmary. The subjects were randomly matched 1:1:1 to create 3 statistically equivalent time-to-surgery groups using Proc SurveySelect (SAS version 9.2, SAS Institute).
Generalized linear models using logit link function for binary variables and identity link function for normally distributed characteristics were used to compare the 3 time-to-surgery groups. Descriptive statistics are presented as counts and percentages or least-square means with standard deviations. Preoperative lab values that were not normally distributed were log transformed and presented in their original scales with median values and 25th to 75th percentiles. Outcomes were similarly modeled.
Total hospital stay was modeled with a negative binomial distribution. Proportional hazards models were used to model the time from operating room (OR) to discharge, censoring patients who died before discharge, with results presented as hazard ratios (HR) and 95% confidence intervals (CI) (Figure). The assumption of the proportional hazards was tested using a Wald test. Using this model, a HR of <1 denotes a longer postoperative hospital stay, as a longer hospital stay decreases the “risk” for discharge.
All models were adjusted for confounders, including race, body mass index (BMI), hypertension, chronic obstructive pulmonary disease, cancer, bleeding disorders, transfusion within 72 hours before surgery, preoperative levels of creatinine, platelet count, white blood cells (WBCs), hematocrit anesthesia type, and wound infection. These covariates were selected based upon their observed relationship to the studied outcomes and time-to-surgery groups, and were evaluated across the models for all outcomes for consistency and clarity. All statistical analyses were run at a type I error rate of 5% and performed in SAS version 9.2 software.
Continue to: RESULTS...
RESULTS
A study population of 6036 hip fractures was identified and divided into 3 groups of 2012 subjects each based upon time-to-surgery. The groups were successfully matched for surgery type, age (≥75 years old), gender, and ASA class. In each group, 594 of the 2012 (29.5%) patients were male, 1525 (75.8%) were ≥75 years of age, 9 (.5%) were ASA Class I, 269 (13.4%) were ASA Class II, 1424 (70.8%) were ASA class III, and 309 (15.4%) were ASA class IV.
Significant differences in preoperative comorbidity burden and preoperative lab values were identified between the 3 cohorts. Increased time-to-surgery was associated with differences in race (P < .001), elevated BMI (P = .010), higher rates of congestive heart failure (P < .001), hypertension medication (P = .020), bleeding disorders (P < .001), blood transfusion within 72 hours of surgery (P < .001), and systemic sepsis (P = .001). Delay to surgery was also associated with lower preoperative sodium (P = .005), blood urea nitrogen (P = .013), serum WBC (P < .001), hematocrit (P < .001), and platelets (P < .001) (Table 1).
The unadjusted analyses revealed no association between time-to-surgery and return to OR (P = .554) nor readmission (P = .285). However, increasing time-to-surgery was associated with an increase in overall complications (P = .034), total length of hospital stay (P < .001), and 30-day mortality (P = .039) (Table 2).
Table 2. Estimated Event Rates from Matched Cohorts (Unadjusted)
| Time From Presentation to Definitive Fixation | |||
Outcomes | <24 hours | 24-48 hours | >48 hours | P-value |
Overall complication rate | 15.30% | 15.30% | 17.90% | 0.034 |
Total length of stay | 5.4 | 6.7 | 10.9 | <0.001 |
(mean days, 95% confidence interval) | (5.2, 5.7) | (6.5, 7.0) | (10.3, 11.5) | |
Time from OR to discharge | -ref- | 0.96 | 0.74 | <0.001 |
(Hazard ratio) | (0.90,1.02) | (0.69, 0.79) | ||
Return to OR | 2.40% | 2.40% | 2.00% | 0.554 |
Readmission | 9.60% | 8.40% | 8.30% | 0.285 |
30-day mortality rate | 5.80% | 5.30% | 7.20% | 0.039 |
Abbreviation: OR, operating room.
The adjusted analysis controlling for preoperative demographic and comorbidity variables revealed trends toward the increased overall complications and 30-day mortality with increased time-to-surgery; these trends showed no statistical significance (P = .143 and P = .08). No statistical relationship was observed between return to OR nor readmission and time-to-surgery. Increasing time-to-surgery remained significantly associated with the increased total length of hospital stay (P < .001). The adjusted analysis also revealed that the delay of >48 hours in time-to-surgery resulted in a longer surgery-to-discharge time (P < .001) (Table 3). No evidence of violation of the proportional hazards assumption was observed in the unadjusted nor adjusted clustered proportional hazards models (Wald test, P = .27 and P = .25, respectively).
Table 3. Estimated Event Rates from Matched Cohorts (Adjusteda)
| Time from Presentation to Definitive Fixation | |||
Outcomes | <24 hours | 24-48 hours | >48 hours | P-value |
Overall complication rate | 11.70% | 10.70% | 12.60% | 0.143 |
Total length of stay | 4.2 | 5.1 | 7.6 | <0.001 |
(mean days, 95% confidence interval) | (4.0, 4.5) | (4.8, 5.5) | (7.1, 8.3) | |
Time from OR to discharge | -ref- | 1.03 | 0.87 | <0.001 |
(Hazard ratio) | (0.97, 1.09) | (0.81, 0.92) | ||
Return to OR | 2.10% | 2.10% | 1.60% | 0.541 |
Readmission | 7.20% | 6.40% | 6.00% | 0.304 |
30-day mortality rate | 4.20% | 3.70% | 5.20% | 0.08 |
aModel adjusted for race, hypertension medication, cancer, bleeding disorders, transfusion within 72 hours before surgery, emergency status, wound infection, anesthesia type (general), body mass index (18.5-25), history of chronic obstructive pulmonary disease, and preoperative levels of creatinine, platelet count, white blood cell count, and hematocrit.
Continue to: DISCUSSION...
DISCUSSION
Previous research has demonstrated an association between age,3,4,25 comorbidity burden,1,3,25 gender,3,4 and ASA class4,18,21 with outcomes following hip fractures and serves as the basis of our matched analysis statistical methodology in assessing the effect of time-to-surgery on the outcome following hip fracture surgery. Prior investigators have also established the positive correlation between increased preoperative comorbidity burden and delay in time-to-surgery.10,15 This finding was confirmed in our unadjusted comparison of 3 time-to-surgery groups. However, prior investigations have not established a clear association between time-to-surgical intervention and postoperative morbidity and mortality.1,15,16,18,20,38 This study utilized a nationally representative dataset known for its data integrity and from which 6036 patients with surgically treated hip fractures, matched for surgery type, age, gender, and ASA class (a surrogate for severity of medical infirmary), were studied using adjusted regression modeling to afford an isolated statistical assessment of the effect of time-to-surgery on outcomes following hip fracture surgery.
Despite a large sample size and rigorous statistical methodology, for many outcome measures, our results show no support for the early or late operative intervention following hip fracture. We found no difference in 30-day mortality, readmission rate, nor total complication rate between the 3 time-to-surgery cohorts. This result indicates that the care of elderly patients following hip fracture is inherently complicated and that perioperative complication risk is probably only modestly modifiable by best medical practices, including optimizing time from clinical presentation to surgery.
As expected, patients who experienced longer delays from presentation to surgery were on average, more comorbid and more likely to yield abnormal preoperative lab values. However, in the adjusted analysis, delay in time-to-surgery, presumably for medical management, was not found to be associated with improved outcomes. In the same adjusted analysis, we uniquely identified that in the patients whose surgeries were delayed for more than 48 hours, the time from surgery-to-discharge was significantly increased. As a result, these patients spent extra days in the hospital both preoperatively and postoperatively, but without any corollary improvement in the outcomes.
Continue to: Recent estimates of the cost of hospital admission...
Recent estimates of the cost of hospital admission is approximated nationally at $2000/day.26 Although our data fail to support the formal cost-analysis of the effect of time-to-surgery in hip fracture care, a simple value-based analysis indicates that quality is preserved (no difference in outcome), whereas costly hospital days are eliminated with earlier surgery. The value in elderly hip fracture care. defined as the outcomes relative to the costs,7 is ultimately optimized by earlier time-to-surgery.
Although using a large, multi-institutional database is advantageous for finding population-based trends that are representative of a large cohort, using the ACS-NSQIP database features its limitations. Our analysis was limited to the defined scope of NSQIP and nature of the injury, whereas root cause for delay was not available for study. We were unable to identify which patients were delayed for administrative reasons or surgical convenience and which were delayed for medical optimization. Participation in the ACS-NSQIP database is voluntary, and no randomized hospital sampling was conducted. Participating hospitals were de-identified in the database. As expected, we were unable to identify the specific institution-based hip fracture protocols that may affect the outcomes following treatment for these fractures. Further, socioeconomic information and payer-status are unavailable for the study. Additionally, observations are limited to 30 days postoperative, and we cannot comment on longer-term outcomes. Finally, discharge disposition and functional outcome data are not represented, and we were unable to correlate time-to-surgery and functional recovery. However, previous studies have established that delay in time-to-surgery following hip fractures is negatively correlated with functional outcomes.22-25
Nevertheless, the ACS-NSQIP database remains one of the largest American surgical databases available, and includes care centers from nearly every state with variable demographics including rural, urban, and academic centers. The ACS performs broad-based inter-rater reliability audits on every participating site and has found an overall disagreement rate of only 1.8%. As such, although discrepancies exist between the complete patient chart and the data entered, the data found in the ACS-NSQIP database are reliable and considered a valid source of study.34,35 The large sample size, quality of data collection, wide geographic representation, and varied hospital types within the dataset possibly make our findings relevant in the majority of American healthcare settings.
CONCLUSION
This study demonstrates an associated increased length of hospital stay, including the increased time from surgery-to-discharge, in patients with hip fractures whose surgical intervention is delayed for >48 hours after presentation. Given the prior evidence that early surgical intervention improves the functional outcomes and the current evidence that surgical delay for any cause increases costly hospital length of stay without corollary improvement in the outcomes, a value-based assessment of hip fracture care argues for early surgical intervention whenever possible. Our findings should inform physician, institution, and policy maker value-based decision making regarding the best practices in geriatric hip fracture care.
ABSTRACT
The morbidity and mortality after hip fracture in the elderly are influenced by non-modifiable comorbidities. Time-to-surgery is a modifiable factor that may play a role in postoperative morbidity. This study investigates the outcomes and complications in the elderly hip fracture surgery as a function of time-to-surgery.
Using the American College of Surgeons-National Surgical Quality Improvement Program data from 2011 to 2012, a study population was generated using the Current Procedural Terminology codes for percutaneous or open treatment of femoral neck fractures (27235, 27236) and fixation with a screw and side plate or intramedullary fixation (27244, 27245) for peritrochanteric fractures. Three time-to-surgery groups (<24 hours to surgical intervention, 24-48 hours, and >48 hours) were created and matched for surgery type, sex, age, and American Society of Anesthesiologists class. Time-to-surgery was then studied for its effect on the post-surgical outcomes using the adjusted regression modeling.
A study population of 6036 hip fractures was created, and 2012 patients were assigned to each matched time-to-surgery group. The unadjusted models showed that the earlier surgical intervention groups (<24 hours and 24-48 hours) exhibited a lower overall complication rate (P = .034) compared with the group waiting for surgery >48 hours. The unadjusted mortality rates increased with delay to surgical intervention (P = .039). Time-to-surgery caused no effect on the return to the operating room rate (P = .554) nor readmission rate (P = .285). Compared with other time-to-surgeries, the time-to-surgery of >48 hours was associated with prolonged total hospital length of stay (10.9 days) (P < .001) and a longer surgery-to-discharge time (hazard ratio, 95% confidence interval: 0.74, 0.69-0.79) (P < .001). Adjusted analyses showed no time-to-surgery related difference in complications (P = .143) but presented an increase in the total length of stay (P < .001) and surgery-to-discharge time (P < .001).
Timeliness of surgical intervention in a comorbidity-adjusted population of elderly hip fracture patients causes no effect on the overall complications, readmissions, nor 30-day mortality. However, time-to-surgery of >48 hours is associated with costly increase in the total length of stay, including an increased post-surgery-to-discharge time.
Continue to: Despite the best efforts to optimize surgical care...
Despite the best efforts to optimize surgical care and postoperative rehabilitation following hip fracture, elderly patients feature alarmingly high in-hospital and 1-year mortality rates of 4.35% to 9.2%1-4 and 36%,5 respectively. Those who survive are unlikely to return to independent living, with only 17% of the patients following hip fracture being able to walk independently 6 months postoperatively, and 12% being able to climb stairs6. Possibly, these poor outcomes reflect a preoperative medical comorbidity burden rather than a measure of medical or surgical quality. Given the absence of consensus regarding optimal time-to-surgery, treating physicians often opt to delay surgical intervention for the purposes of medically optimizing highly comorbid patients without significant data to suggest clinical benefit of such practice.
Numerous investigators have attempted to identify the modifiable risk factors for complication after surgical care of elderly hip fracture patients. However, consensus guidelines of care are missing. This condition is largely due to the difficulties in effectively modifying preoperative demographic and medical comorbidities on a semi-urgent basis. However, timeliness to surgery is one area for study that the care team can affect. Although time-to-surgery is dependent on multiple factors, including time of presentation, day of week of admission, difficulties with scheduling, and administrative delays, the care team plays a role in hastening or retarding time-to-surgery. Several studies have considered various time cut-offs (24, 48, 72, and 120 hours) to define early intervention, but none have defined a specific role for early or delayed surgery. Several investigators have discovered a positive association between delayed time-to-surgery and mortality;4,8-14 however, the most rigorously conducted studies that stringently control for preoperative comorbidities and demographics conclude that variance in time-to-surgery causes no effect on the in-hospital or 1-year mortality risk.1-3,15-18
Other investigators have shown that with early surgical intervention for hip fracture, patients experience shorter hospital stays,1,3,16,17,19-22 less days in pain,19 decreased risk of decubitus ulcers,15,17,19,22 and an increased likelihood of independence following fracture,22-25 regardless of preoperative medical status. Despite this evidence of improved outcomes with early surgery, 40% to 54% of hip fracture patients in the United States experience surgical delays of more than 24 to 48 hours. Additionally, with the recent (2013) national estimates of cost per day spent in the hospital falling between $1791 to $2289,26 minimizing the days spent in the hospital would likely lead to significant cost-savings, presuming no adverse effect on health-related outcomes. To this end, we hypothesize that the value (outcomes per associated cost)7 of hip fracture surgical care can be positively influenced by minimizing surgical wait-times. We assessed the effect of early surgical intervention, within 24 or 48 hours of presentation, on 30-day mortality, postoperative morbidity, hospital length of stay, and readmission rates in a comorbidity-adjusted population from a nationally representative cohort.
Continue to: METHODS AND MATERIALS...
METHODS AND MATERIALS
This study used the data from the American College of Surgeon-National Surgical Quality Improvement Program (ACS-NSQIP) database. With over 258 participating hospitals, this database has been widely used to identify national trends in various surgical specialties.27-34 The database includes information from participants in 43 states with hospitals ranging from rural community hospitals to large academic centers. Each site employs surgical clinical reviewers who are rigorously trained to collect data through chart review and discussion with the treating surgeon and/or patient,35 allowing for the use of robust and quality data with proven inter-rater reliability.36,37
Using the 2011 to 2012 NSQIP database, we used primary Current Procedural Terminology codes to identify all patients who underwent percutaneous (27235) or open (27236) fixation of femoral neck fractures; and fixation with a screw and side plate (27244) or intramedullary fixation (27245) for peritrochanteric fractures. The sample was divided into 3 time-to-surgery groups (<24 hours from presentation to surgery, 24-48 hours, and >48 hours) which were matched for fracture type (femoral neck or peritrochanteric), sex, age (under 75 years or ≥75 years), and American Society of Anesthesiologists (ASA) class used as a surrogate for severity of medical infirmary. The subjects were randomly matched 1:1:1 to create 3 statistically equivalent time-to-surgery groups using Proc SurveySelect (SAS version 9.2, SAS Institute).
Generalized linear models using logit link function for binary variables and identity link function for normally distributed characteristics were used to compare the 3 time-to-surgery groups. Descriptive statistics are presented as counts and percentages or least-square means with standard deviations. Preoperative lab values that were not normally distributed were log transformed and presented in their original scales with median values and 25th to 75th percentiles. Outcomes were similarly modeled.
Total hospital stay was modeled with a negative binomial distribution. Proportional hazards models were used to model the time from operating room (OR) to discharge, censoring patients who died before discharge, with results presented as hazard ratios (HR) and 95% confidence intervals (CI) (Figure). The assumption of the proportional hazards was tested using a Wald test. Using this model, a HR of <1 denotes a longer postoperative hospital stay, as a longer hospital stay decreases the “risk” for discharge.
All models were adjusted for confounders, including race, body mass index (BMI), hypertension, chronic obstructive pulmonary disease, cancer, bleeding disorders, transfusion within 72 hours before surgery, preoperative levels of creatinine, platelet count, white blood cells (WBCs), hematocrit anesthesia type, and wound infection. These covariates were selected based upon their observed relationship to the studied outcomes and time-to-surgery groups, and were evaluated across the models for all outcomes for consistency and clarity. All statistical analyses were run at a type I error rate of 5% and performed in SAS version 9.2 software.
Continue to: RESULTS...
RESULTS
A study population of 6036 hip fractures was identified and divided into 3 groups of 2012 subjects each based upon time-to-surgery. The groups were successfully matched for surgery type, age (≥75 years old), gender, and ASA class. In each group, 594 of the 2012 (29.5%) patients were male, 1525 (75.8%) were ≥75 years of age, 9 (.5%) were ASA Class I, 269 (13.4%) were ASA Class II, 1424 (70.8%) were ASA class III, and 309 (15.4%) were ASA class IV.
Significant differences in preoperative comorbidity burden and preoperative lab values were identified between the 3 cohorts. Increased time-to-surgery was associated with differences in race (P < .001), elevated BMI (P = .010), higher rates of congestive heart failure (P < .001), hypertension medication (P = .020), bleeding disorders (P < .001), blood transfusion within 72 hours of surgery (P < .001), and systemic sepsis (P = .001). Delay to surgery was also associated with lower preoperative sodium (P = .005), blood urea nitrogen (P = .013), serum WBC (P < .001), hematocrit (P < .001), and platelets (P < .001) (Table 1).
The unadjusted analyses revealed no association between time-to-surgery and return to OR (P = .554) nor readmission (P = .285). However, increasing time-to-surgery was associated with an increase in overall complications (P = .034), total length of hospital stay (P < .001), and 30-day mortality (P = .039) (Table 2).
Table 2. Estimated Event Rates from Matched Cohorts (Unadjusted)
| Time From Presentation to Definitive Fixation | |||
Outcomes | <24 hours | 24-48 hours | >48 hours | P-value |
Overall complication rate | 15.30% | 15.30% | 17.90% | 0.034 |
Total length of stay | 5.4 | 6.7 | 10.9 | <0.001 |
(mean days, 95% confidence interval) | (5.2, 5.7) | (6.5, 7.0) | (10.3, 11.5) | |
Time from OR to discharge | -ref- | 0.96 | 0.74 | <0.001 |
(Hazard ratio) | (0.90,1.02) | (0.69, 0.79) | ||
Return to OR | 2.40% | 2.40% | 2.00% | 0.554 |
Readmission | 9.60% | 8.40% | 8.30% | 0.285 |
30-day mortality rate | 5.80% | 5.30% | 7.20% | 0.039 |
Abbreviation: OR, operating room.
The adjusted analysis controlling for preoperative demographic and comorbidity variables revealed trends toward the increased overall complications and 30-day mortality with increased time-to-surgery; these trends showed no statistical significance (P = .143 and P = .08). No statistical relationship was observed between return to OR nor readmission and time-to-surgery. Increasing time-to-surgery remained significantly associated with the increased total length of hospital stay (P < .001). The adjusted analysis also revealed that the delay of >48 hours in time-to-surgery resulted in a longer surgery-to-discharge time (P < .001) (Table 3). No evidence of violation of the proportional hazards assumption was observed in the unadjusted nor adjusted clustered proportional hazards models (Wald test, P = .27 and P = .25, respectively).
Table 3. Estimated Event Rates from Matched Cohorts (Adjusteda)
| Time from Presentation to Definitive Fixation | |||
Outcomes | <24 hours | 24-48 hours | >48 hours | P-value |
Overall complication rate | 11.70% | 10.70% | 12.60% | 0.143 |
Total length of stay | 4.2 | 5.1 | 7.6 | <0.001 |
(mean days, 95% confidence interval) | (4.0, 4.5) | (4.8, 5.5) | (7.1, 8.3) | |
Time from OR to discharge | -ref- | 1.03 | 0.87 | <0.001 |
(Hazard ratio) | (0.97, 1.09) | (0.81, 0.92) | ||
Return to OR | 2.10% | 2.10% | 1.60% | 0.541 |
Readmission | 7.20% | 6.40% | 6.00% | 0.304 |
30-day mortality rate | 4.20% | 3.70% | 5.20% | 0.08 |
aModel adjusted for race, hypertension medication, cancer, bleeding disorders, transfusion within 72 hours before surgery, emergency status, wound infection, anesthesia type (general), body mass index (18.5-25), history of chronic obstructive pulmonary disease, and preoperative levels of creatinine, platelet count, white blood cell count, and hematocrit.
Continue to: DISCUSSION...
DISCUSSION
Previous research has demonstrated an association between age,3,4,25 comorbidity burden,1,3,25 gender,3,4 and ASA class4,18,21 with outcomes following hip fractures and serves as the basis of our matched analysis statistical methodology in assessing the effect of time-to-surgery on the outcome following hip fracture surgery. Prior investigators have also established the positive correlation between increased preoperative comorbidity burden and delay in time-to-surgery.10,15 This finding was confirmed in our unadjusted comparison of 3 time-to-surgery groups. However, prior investigations have not established a clear association between time-to-surgical intervention and postoperative morbidity and mortality.1,15,16,18,20,38 This study utilized a nationally representative dataset known for its data integrity and from which 6036 patients with surgically treated hip fractures, matched for surgery type, age, gender, and ASA class (a surrogate for severity of medical infirmary), were studied using adjusted regression modeling to afford an isolated statistical assessment of the effect of time-to-surgery on outcomes following hip fracture surgery.
Despite a large sample size and rigorous statistical methodology, for many outcome measures, our results show no support for the early or late operative intervention following hip fracture. We found no difference in 30-day mortality, readmission rate, nor total complication rate between the 3 time-to-surgery cohorts. This result indicates that the care of elderly patients following hip fracture is inherently complicated and that perioperative complication risk is probably only modestly modifiable by best medical practices, including optimizing time from clinical presentation to surgery.
As expected, patients who experienced longer delays from presentation to surgery were on average, more comorbid and more likely to yield abnormal preoperative lab values. However, in the adjusted analysis, delay in time-to-surgery, presumably for medical management, was not found to be associated with improved outcomes. In the same adjusted analysis, we uniquely identified that in the patients whose surgeries were delayed for more than 48 hours, the time from surgery-to-discharge was significantly increased. As a result, these patients spent extra days in the hospital both preoperatively and postoperatively, but without any corollary improvement in the outcomes.
Continue to: Recent estimates of the cost of hospital admission...
Recent estimates of the cost of hospital admission is approximated nationally at $2000/day.26 Although our data fail to support the formal cost-analysis of the effect of time-to-surgery in hip fracture care, a simple value-based analysis indicates that quality is preserved (no difference in outcome), whereas costly hospital days are eliminated with earlier surgery. The value in elderly hip fracture care. defined as the outcomes relative to the costs,7 is ultimately optimized by earlier time-to-surgery.
Although using a large, multi-institutional database is advantageous for finding population-based trends that are representative of a large cohort, using the ACS-NSQIP database features its limitations. Our analysis was limited to the defined scope of NSQIP and nature of the injury, whereas root cause for delay was not available for study. We were unable to identify which patients were delayed for administrative reasons or surgical convenience and which were delayed for medical optimization. Participation in the ACS-NSQIP database is voluntary, and no randomized hospital sampling was conducted. Participating hospitals were de-identified in the database. As expected, we were unable to identify the specific institution-based hip fracture protocols that may affect the outcomes following treatment for these fractures. Further, socioeconomic information and payer-status are unavailable for the study. Additionally, observations are limited to 30 days postoperative, and we cannot comment on longer-term outcomes. Finally, discharge disposition and functional outcome data are not represented, and we were unable to correlate time-to-surgery and functional recovery. However, previous studies have established that delay in time-to-surgery following hip fractures is negatively correlated with functional outcomes.22-25
Nevertheless, the ACS-NSQIP database remains one of the largest American surgical databases available, and includes care centers from nearly every state with variable demographics including rural, urban, and academic centers. The ACS performs broad-based inter-rater reliability audits on every participating site and has found an overall disagreement rate of only 1.8%. As such, although discrepancies exist between the complete patient chart and the data entered, the data found in the ACS-NSQIP database are reliable and considered a valid source of study.34,35 The large sample size, quality of data collection, wide geographic representation, and varied hospital types within the dataset possibly make our findings relevant in the majority of American healthcare settings.
CONCLUSION
This study demonstrates an associated increased length of hospital stay, including the increased time from surgery-to-discharge, in patients with hip fractures whose surgical intervention is delayed for >48 hours after presentation. Given the prior evidence that early surgical intervention improves the functional outcomes and the current evidence that surgical delay for any cause increases costly hospital length of stay without corollary improvement in the outcomes, a value-based assessment of hip fracture care argues for early surgical intervention whenever possible. Our findings should inform physician, institution, and policy maker value-based decision making regarding the best practices in geriatric hip fracture care.
1. Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155(4):226-233. doi:10.7326/0003-4819-155-4-201108160-00006.
2. Verbeek DO, Ponsen KJ, Goslings JC, Heetveld MJ. Effect of surgical delay on outcome in hip fracture patients: a retrospective multivariate analysis of 192 patients. Int Orthop. 2008;32(1):13-18. doi:10.1007/s00264-006-0290-9.
3. Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009;91(7):922-927. doi:10.1302/0301-620X.91B7.22446.
4. Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury. 2013;44(6):726-729. doi:10.1016/j.injury.2012.08.025.
5. Zuckerman JD. Hip fracture. N Engl J Med. 1996;334(23):1519-1525. doi:10.1056/NEJM199606063342307.
6. Marottoli RA, Berkman LF, Cooney LM Jr. Decline in physical function following hip fracture. J Am Geriatr Soc. 1992;40(9):861-866. doi:10.1111/j.1532-5415.1992.tb01980.x.
7. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481. doi:10.1056/NEJMp1011024.
8. Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. 2008;90(1):34-42. doi:10.2106/JBJS.G.00065.
9. Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care. 2007;19(3):170-176. doi:10.1093/intqhc/mzm003.
10. Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br. 2005;87(3):361-366. doi:10.1302/0301-620X.87B3.15300.
11. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am. 2005;87(3):483-489. doi:10.2106/JBJS.D.01796.
12. Holt G, Smith R, Duncan K, McKeown DW. Does delay to theatre for medical reasons affect the peri-operative mortality in patients with a fracture of the hip? J Bone Joint Surg Br. 2010;92(6):835-841. doi:10.1302/0301-620X.92B6.24463.
13. Pioli G, Lauretani F, Davoli ML, et al. Older people with hip fracture and IADL disability require earlier surgery. J Gerontol A Biol Sci Med Sci. 2012;67(11):1272-1277. doi:10.1093/gerona/gls097.
14. Mackenzie DG, Wild S, Muir R. Mortality associated with delay in operation after hip fracture: Scottish data provide additional information. BMJ. 2006;332(7549):1093. doi:10.1136/bmj.332.7549.1093.
15. Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112(9):702-709. doi:10.1016/S0002-9343(02)01119-1.
16. Majumdar SR, Beaupre LA, Johnston DW, Dick DA, Cinats JG, Jiang HX. Lack of association between mortality and timing of surgical fixation in elderly patients with hip fracture: results of a retrospective population-based cohort study. Med Care. 2006;44(6):552-559. doi:10.1097/01.mlr.0000215812.13720.2e.
17. Hommel A, Ulander K, Bjorkelund KB, Norrman PO, Wingstrand H, Thorngren KG. Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year. Injury. 2008;39(10):1164-1174. doi:10.1016/j.injury.2008.01.048.
18. Rae HC, Harris IA, McEvoy L, Todorova T. Delay to surgery and mortality after hip fracture. ANZ J Surg. 2007;77(10):889-891. doi:10.1111/j.1445-2197.2007.04267.x.
19. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291(14):1738-1743. doi:10.1001/jama.291.14.1738.
20. Bergeron E, Lavoie A, Moore L, et al. Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems? J Trauma. 2006;60(4):753-757. doi:10.1097/01.ta.0000214649.53190.2a.
21. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005;87(8):1123-1126. doi:10.1302/0301-620X.87B8.16357.
22. Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am. 2008;90(7):1436-1442. doi:10.2106/JBJS.G.00890.
23. Hoenig H, Rubenstein LV, Sloane R, Horner R, Kahn K. What is the role of timing in the surgical and rehabilitative care of community-dwelling older persons with acute hip fracture? Arch Intern Med. 1997;157(5):513-520.
24. Doruk H, Mas MR, Yildiz C, Sonmez A, Kýrdemir V. The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly. Arch Gerontol Geriatr. 2004;39(2):179-185. doi:10.1016/j.archger.2004.03.004.
25. Yonezawa T, Yamazaki K, Atsumi T, Obara S. Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients. J Orthop Sci Off J Jpn Orthop Assoc. 2009;14(5):566-573. doi:10.1007/s00776-009-1380-5.
26. Henry J Kaiser Family Foundation. Hospital adjusted expenses per inpatient day by ownership. https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed March 14, 2013.
27. Belmont PJ Jr, Davey S, Orr JD, Ochoa LM, Bader JO, Schoenfeld AJ. Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program. J Am Coll Surg. 2011;213(3):370-378. doi:10.1016/j.jamcollsurg.2011.05.019.
28. Davis SS Jr, Husain FA, Lin E, Nandipati KC, Perez S, Sweeney JF. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg. 2013;216(1):96-104. doi:10.1016/j.jamcollsurg.2012.08.014.
29. Gart MS, Smetona JT, Hanwright PJ, et al. Autologous options for postmastectomy breast reconstruction: a comparison of outcomes based on the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2013;216(2):229-238. doi:10.1016/j.jamcollsurg.2012.11.003.
30. Greenblatt DY, Rajamanickam V, Pugely AJ, Heise CP, Foley EF, Kennedy GD. Short-term outcomes after laparoscopic-assisted proctectomy for rectal cancer: results from the ACS NSQIP. J Am Coll Surg. 2011;212(5):844-854. doi:10.1016/j.jamcollsurg.2011.01.005.
31. Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Callaghan JJ. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am. 2013;95(3):193-199. doi:10.2106/JBJS.K.01682.
32. Rao RD. Risk factors for complications and mortality after spine surgery assessed with the NSQIP database: where do we go from here? Commentary on an article by Andrew J Schoenfeld, MD, et al.: "Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program". J Bone Joint Surg Am. 2011;93(17):e101:(101-102). doi:10.2106/JBJS.K.00786.
33. Schilling PL, Hallstrom BR, Birkmeyer JD, Carpenter JE. Prioritizing perioperative quality improvement in orthopaedic surgery. J Bone Joint Surg Am. 2010;92(9):1884-1889. doi:10.2106/JBJS.I.00735.
34. Tsilimparis N, Perez S, Dayama A, Ricotta JJ 2nd. Age-stratified results from 20,095 aortoiliac aneurysm repairs: should we approach octogenarians and nonagenarians differently? J Am Coll Surg. 2012;215(5):690-701. doi:10.1016/j.jamcollsurg.2012.06.411.
35. ACS National Surgical Quality Improvement Program. American College of Surgeons Web site. https://www.facs.org/quality-programs/acs-nsqip?. Accessed March 14, 2013.
36. Henderson WG, Daley J. Design and statistical methodology of the National Surgical Quality Improvement Program: why is it what it is? Am J Surg. 2009;198(5 Suppl):S19-S27. doi:10.1016/j.amjsurg.2009.07.025.
37. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6-16. doi:10.1016/j.jamcollsurg.2009.09.031.
38. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692-697. doi:10.1016/j.injury.2009.01.010.
1. Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155(4):226-233. doi:10.7326/0003-4819-155-4-201108160-00006.
2. Verbeek DO, Ponsen KJ, Goslings JC, Heetveld MJ. Effect of surgical delay on outcome in hip fracture patients: a retrospective multivariate analysis of 192 patients. Int Orthop. 2008;32(1):13-18. doi:10.1007/s00264-006-0290-9.
3. Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009;91(7):922-927. doi:10.1302/0301-620X.91B7.22446.
4. Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury. 2013;44(6):726-729. doi:10.1016/j.injury.2012.08.025.
5. Zuckerman JD. Hip fracture. N Engl J Med. 1996;334(23):1519-1525. doi:10.1056/NEJM199606063342307.
6. Marottoli RA, Berkman LF, Cooney LM Jr. Decline in physical function following hip fracture. J Am Geriatr Soc. 1992;40(9):861-866. doi:10.1111/j.1532-5415.1992.tb01980.x.
7. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481. doi:10.1056/NEJMp1011024.
8. Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. 2008;90(1):34-42. doi:10.2106/JBJS.G.00065.
9. Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care. 2007;19(3):170-176. doi:10.1093/intqhc/mzm003.
10. Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br. 2005;87(3):361-366. doi:10.1302/0301-620X.87B3.15300.
11. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am. 2005;87(3):483-489. doi:10.2106/JBJS.D.01796.
12. Holt G, Smith R, Duncan K, McKeown DW. Does delay to theatre for medical reasons affect the peri-operative mortality in patients with a fracture of the hip? J Bone Joint Surg Br. 2010;92(6):835-841. doi:10.1302/0301-620X.92B6.24463.
13. Pioli G, Lauretani F, Davoli ML, et al. Older people with hip fracture and IADL disability require earlier surgery. J Gerontol A Biol Sci Med Sci. 2012;67(11):1272-1277. doi:10.1093/gerona/gls097.
14. Mackenzie DG, Wild S, Muir R. Mortality associated with delay in operation after hip fracture: Scottish data provide additional information. BMJ. 2006;332(7549):1093. doi:10.1136/bmj.332.7549.1093.
15. Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112(9):702-709. doi:10.1016/S0002-9343(02)01119-1.
16. Majumdar SR, Beaupre LA, Johnston DW, Dick DA, Cinats JG, Jiang HX. Lack of association between mortality and timing of surgical fixation in elderly patients with hip fracture: results of a retrospective population-based cohort study. Med Care. 2006;44(6):552-559. doi:10.1097/01.mlr.0000215812.13720.2e.
17. Hommel A, Ulander K, Bjorkelund KB, Norrman PO, Wingstrand H, Thorngren KG. Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year. Injury. 2008;39(10):1164-1174. doi:10.1016/j.injury.2008.01.048.
18. Rae HC, Harris IA, McEvoy L, Todorova T. Delay to surgery and mortality after hip fracture. ANZ J Surg. 2007;77(10):889-891. doi:10.1111/j.1445-2197.2007.04267.x.
19. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291(14):1738-1743. doi:10.1001/jama.291.14.1738.
20. Bergeron E, Lavoie A, Moore L, et al. Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems? J Trauma. 2006;60(4):753-757. doi:10.1097/01.ta.0000214649.53190.2a.
21. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005;87(8):1123-1126. doi:10.1302/0301-620X.87B8.16357.
22. Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am. 2008;90(7):1436-1442. doi:10.2106/JBJS.G.00890.
23. Hoenig H, Rubenstein LV, Sloane R, Horner R, Kahn K. What is the role of timing in the surgical and rehabilitative care of community-dwelling older persons with acute hip fracture? Arch Intern Med. 1997;157(5):513-520.
24. Doruk H, Mas MR, Yildiz C, Sonmez A, Kýrdemir V. The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly. Arch Gerontol Geriatr. 2004;39(2):179-185. doi:10.1016/j.archger.2004.03.004.
25. Yonezawa T, Yamazaki K, Atsumi T, Obara S. Influence of the timing of surgery on mortality and activity of hip fracture in elderly patients. J Orthop Sci Off J Jpn Orthop Assoc. 2009;14(5):566-573. doi:10.1007/s00776-009-1380-5.
26. Henry J Kaiser Family Foundation. Hospital adjusted expenses per inpatient day by ownership. https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed March 14, 2013.
27. Belmont PJ Jr, Davey S, Orr JD, Ochoa LM, Bader JO, Schoenfeld AJ. Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program. J Am Coll Surg. 2011;213(3):370-378. doi:10.1016/j.jamcollsurg.2011.05.019.
28. Davis SS Jr, Husain FA, Lin E, Nandipati KC, Perez S, Sweeney JF. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg. 2013;216(1):96-104. doi:10.1016/j.jamcollsurg.2012.08.014.
29. Gart MS, Smetona JT, Hanwright PJ, et al. Autologous options for postmastectomy breast reconstruction: a comparison of outcomes based on the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2013;216(2):229-238. doi:10.1016/j.jamcollsurg.2012.11.003.
30. Greenblatt DY, Rajamanickam V, Pugely AJ, Heise CP, Foley EF, Kennedy GD. Short-term outcomes after laparoscopic-assisted proctectomy for rectal cancer: results from the ACS NSQIP. J Am Coll Surg. 2011;212(5):844-854. doi:10.1016/j.jamcollsurg.2011.01.005.
31. Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Callaghan JJ. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am. 2013;95(3):193-199. doi:10.2106/JBJS.K.01682.
32. Rao RD. Risk factors for complications and mortality after spine surgery assessed with the NSQIP database: where do we go from here? Commentary on an article by Andrew J Schoenfeld, MD, et al.: "Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program". J Bone Joint Surg Am. 2011;93(17):e101:(101-102). doi:10.2106/JBJS.K.00786.
33. Schilling PL, Hallstrom BR, Birkmeyer JD, Carpenter JE. Prioritizing perioperative quality improvement in orthopaedic surgery. J Bone Joint Surg Am. 2010;92(9):1884-1889. doi:10.2106/JBJS.I.00735.
34. Tsilimparis N, Perez S, Dayama A, Ricotta JJ 2nd. Age-stratified results from 20,095 aortoiliac aneurysm repairs: should we approach octogenarians and nonagenarians differently? J Am Coll Surg. 2012;215(5):690-701. doi:10.1016/j.jamcollsurg.2012.06.411.
35. ACS National Surgical Quality Improvement Program. American College of Surgeons Web site. https://www.facs.org/quality-programs/acs-nsqip?. Accessed March 14, 2013.
36. Henderson WG, Daley J. Design and statistical methodology of the National Surgical Quality Improvement Program: why is it what it is? Am J Surg. 2009;198(5 Suppl):S19-S27. doi:10.1016/j.amjsurg.2009.07.025.
37. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6-16. doi:10.1016/j.jamcollsurg.2009.09.031.
38. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692-697. doi:10.1016/j.injury.2009.01.010.
TAKE-HOME POINTS
- Time-to-surgery for definitive fixation of hip fractures is a modifiable risk factor.
- This study fails to demonstrate a benefit in delaying surgery for medical optimization as there were no time-to-surgery related differences in complications (P = 1.43).
- Delay in definitive surgery results in an increase in the total length of stay (P < .001) and surgery-to-discharge time (P < .001) without an improvement in overall complications, readmission or 30-day mortality rates.
- Despite numerous investigations, there are no consensus guidelines to decrease complications and mortality rates following hip fracture surgery.
- ACS-NSQIP database is a reliable and validated database.
Recommendations to Improve Asthma Outcomes: Work Group Call to Action
Click here to read the supplement.
What can be done to address the burden of asthma beyond pharmacotherapy? A panel of experts discuss steps for addressing sensitization to allergens that trigger increased asthma burden.
Topics Include:
- Identifying Patients with Allergic Components of Asthma
- Identifying and Addressing Allergen Exposure in Daily Practice
- The Opportunity for Payers and Health Systems for Supporting Trigger Avoidance Education
Click here to read the supplement.
Click here to read the supplement.
What can be done to address the burden of asthma beyond pharmacotherapy? A panel of experts discuss steps for addressing sensitization to allergens that trigger increased asthma burden.
Topics Include:
- Identifying Patients with Allergic Components of Asthma
- Identifying and Addressing Allergen Exposure in Daily Practice
- The Opportunity for Payers and Health Systems for Supporting Trigger Avoidance Education
Click here to read the supplement.
Click here to read the supplement.
What can be done to address the burden of asthma beyond pharmacotherapy? A panel of experts discuss steps for addressing sensitization to allergens that trigger increased asthma burden.
Topics Include:
- Identifying Patients with Allergic Components of Asthma
- Identifying and Addressing Allergen Exposure in Daily Practice
- The Opportunity for Payers and Health Systems for Supporting Trigger Avoidance Education
Click here to read the supplement.
Glenn Close fights stigma; empty nesters share pleasures, pains
Glenn Close is infamous for her portrayal of a woman whose reactions to a one-night stand in “Fatal Attraction” become increasingly bizarre and hostile. Whether the character was in the throes of a mental disorder was never broached in the movie. But Ms. Close has real-life family experience; her sister has bipolar disorder and a nephew has schizophrenia.
“When I became an advocate, I realized that is a family affair for one in four of us. One in four is touched in some way by mental illness. So, it became obvious to me that we have to talk about it,” Ms. Close said in an interview on CBS Sunday Morning. In 2010, Ms. Close and her sister Jessie began Bring Change to Mind, a foundation that strives to move discussions about mental health into the mainstream.
Harm reduction and opioids
The “just say no” mantra to drug abstinence espoused by Nancy Reagan decades ago remains an option for some people today. However, according to an article in The Walrus, this approach does not cut it for many drug users. What may resonate is the harm they are inflicting on themselves and how they can lessen it by curbing drug use. In Ottawa, Canada, a program that features an individualized and flexible approach to opioid addiction, which continues to offer drugs while focusing on health instead of abstinence, is having a positive effect.
“I’m an opioid addict. That goes without saying if you’re in this program,” one participant says. “Struggling with addiction while being homeless creates a unique set of challenges ... the [program] provides not only freedom from drug addiction on the street but freedom from homelessness.”
Empty nesters’ new lives
The ritual of being a parent, for many, is the bittersweet day when the last or only child heads off to college or university. A recent segment on National Public Radio gauged the reactions of some parents. For some, the initial feeling is one of relief, with days that are quieter and perhaps encouraging of more personal exploration. “After 20 years of every moment being about the girls, it was once again just the two of us. Some things are really great – walking around the house naked, going to bed before it’s dark and not having children mock us, and having a tidy house,” says Michael Pusateri of South Pasadena, Calif.
“But, we do miss the girls,” he adds. “I miss the sound of them bumping around the house. And as corny as it sounds, I miss seeing them sleep.”
For others, the polar opposite prevails. “My job as a full-time, stay-at-home mom to four kids has finally come to an end after 31 years when our baby left for college last week. I’ve been dreading drop-off day for about a decade. The hardest part was walking back into the now empty house, feeling swallowed up by the silence. The tears flowed when I walked by her room for the first time knowing she won’t be saying goodnight, Mom, from behind that door every night. Saying goodbye to the last is especially difficult as I sit here in my empty nest, missing my daughter and wondering, now what?” relates Beth Smizlof of Saratoga Springs, N.Y.
“A hundred people will tell you how to raise your son, but very few will talk about how to let him go,” says Julie Stewart of Birmingham, Ala.
What is a hyperpolyglot?
An article in The New Yorker considers people whose linguistic mastery encompasses dozens of languages. To be a hyperpolyglot – defined as someone who can speak 11 or more languages – requires a lot of effort. And there may be a genetic predisposition, since there is evidence (which still requires confirmation) that “an extreme language learner has a more-than-random chance of being a gay, left-handed male on the autism spectrum, with an autoimmune disorder, such as asthma or allergies,” writes Judith Thurman.
A brain that is more apt to process the information needed to learn a new language may also be part of the picture.
Coffee and cancer warning
On Aug. 29, the Food and Drug Administration released a statement from Commissioner Scott Gottlieb, MD, that supports a proposal to exempt coffee from California’s cancer warning law. The action was prompted by a recent ruling by a California court that the state’s Proposition 65 could require labeling of coffee with a cancer warning, because of the presence of a chemical called acrylamide, which can form in many foods during frying, roasting, and baking.
“In coffee, acrylamide forms during the roasting of coffee beans. Although acrylamide at high doses has been linked to cancer in animals, and coffee contains acrylamide, current science indicates that consuming coffee poses no significant risk of cancer,” the statement reads in part.
Glenn Close is infamous for her portrayal of a woman whose reactions to a one-night stand in “Fatal Attraction” become increasingly bizarre and hostile. Whether the character was in the throes of a mental disorder was never broached in the movie. But Ms. Close has real-life family experience; her sister has bipolar disorder and a nephew has schizophrenia.
“When I became an advocate, I realized that is a family affair for one in four of us. One in four is touched in some way by mental illness. So, it became obvious to me that we have to talk about it,” Ms. Close said in an interview on CBS Sunday Morning. In 2010, Ms. Close and her sister Jessie began Bring Change to Mind, a foundation that strives to move discussions about mental health into the mainstream.
Harm reduction and opioids
The “just say no” mantra to drug abstinence espoused by Nancy Reagan decades ago remains an option for some people today. However, according to an article in The Walrus, this approach does not cut it for many drug users. What may resonate is the harm they are inflicting on themselves and how they can lessen it by curbing drug use. In Ottawa, Canada, a program that features an individualized and flexible approach to opioid addiction, which continues to offer drugs while focusing on health instead of abstinence, is having a positive effect.
“I’m an opioid addict. That goes without saying if you’re in this program,” one participant says. “Struggling with addiction while being homeless creates a unique set of challenges ... the [program] provides not only freedom from drug addiction on the street but freedom from homelessness.”
Empty nesters’ new lives
The ritual of being a parent, for many, is the bittersweet day when the last or only child heads off to college or university. A recent segment on National Public Radio gauged the reactions of some parents. For some, the initial feeling is one of relief, with days that are quieter and perhaps encouraging of more personal exploration. “After 20 years of every moment being about the girls, it was once again just the two of us. Some things are really great – walking around the house naked, going to bed before it’s dark and not having children mock us, and having a tidy house,” says Michael Pusateri of South Pasadena, Calif.
“But, we do miss the girls,” he adds. “I miss the sound of them bumping around the house. And as corny as it sounds, I miss seeing them sleep.”
For others, the polar opposite prevails. “My job as a full-time, stay-at-home mom to four kids has finally come to an end after 31 years when our baby left for college last week. I’ve been dreading drop-off day for about a decade. The hardest part was walking back into the now empty house, feeling swallowed up by the silence. The tears flowed when I walked by her room for the first time knowing she won’t be saying goodnight, Mom, from behind that door every night. Saying goodbye to the last is especially difficult as I sit here in my empty nest, missing my daughter and wondering, now what?” relates Beth Smizlof of Saratoga Springs, N.Y.
“A hundred people will tell you how to raise your son, but very few will talk about how to let him go,” says Julie Stewart of Birmingham, Ala.
What is a hyperpolyglot?
An article in The New Yorker considers people whose linguistic mastery encompasses dozens of languages. To be a hyperpolyglot – defined as someone who can speak 11 or more languages – requires a lot of effort. And there may be a genetic predisposition, since there is evidence (which still requires confirmation) that “an extreme language learner has a more-than-random chance of being a gay, left-handed male on the autism spectrum, with an autoimmune disorder, such as asthma or allergies,” writes Judith Thurman.
A brain that is more apt to process the information needed to learn a new language may also be part of the picture.
Coffee and cancer warning
On Aug. 29, the Food and Drug Administration released a statement from Commissioner Scott Gottlieb, MD, that supports a proposal to exempt coffee from California’s cancer warning law. The action was prompted by a recent ruling by a California court that the state’s Proposition 65 could require labeling of coffee with a cancer warning, because of the presence of a chemical called acrylamide, which can form in many foods during frying, roasting, and baking.
“In coffee, acrylamide forms during the roasting of coffee beans. Although acrylamide at high doses has been linked to cancer in animals, and coffee contains acrylamide, current science indicates that consuming coffee poses no significant risk of cancer,” the statement reads in part.
Glenn Close is infamous for her portrayal of a woman whose reactions to a one-night stand in “Fatal Attraction” become increasingly bizarre and hostile. Whether the character was in the throes of a mental disorder was never broached in the movie. But Ms. Close has real-life family experience; her sister has bipolar disorder and a nephew has schizophrenia.
“When I became an advocate, I realized that is a family affair for one in four of us. One in four is touched in some way by mental illness. So, it became obvious to me that we have to talk about it,” Ms. Close said in an interview on CBS Sunday Morning. In 2010, Ms. Close and her sister Jessie began Bring Change to Mind, a foundation that strives to move discussions about mental health into the mainstream.
Harm reduction and opioids
The “just say no” mantra to drug abstinence espoused by Nancy Reagan decades ago remains an option for some people today. However, according to an article in The Walrus, this approach does not cut it for many drug users. What may resonate is the harm they are inflicting on themselves and how they can lessen it by curbing drug use. In Ottawa, Canada, a program that features an individualized and flexible approach to opioid addiction, which continues to offer drugs while focusing on health instead of abstinence, is having a positive effect.
“I’m an opioid addict. That goes without saying if you’re in this program,” one participant says. “Struggling with addiction while being homeless creates a unique set of challenges ... the [program] provides not only freedom from drug addiction on the street but freedom from homelessness.”
Empty nesters’ new lives
The ritual of being a parent, for many, is the bittersweet day when the last or only child heads off to college or university. A recent segment on National Public Radio gauged the reactions of some parents. For some, the initial feeling is one of relief, with days that are quieter and perhaps encouraging of more personal exploration. “After 20 years of every moment being about the girls, it was once again just the two of us. Some things are really great – walking around the house naked, going to bed before it’s dark and not having children mock us, and having a tidy house,” says Michael Pusateri of South Pasadena, Calif.
“But, we do miss the girls,” he adds. “I miss the sound of them bumping around the house. And as corny as it sounds, I miss seeing them sleep.”
For others, the polar opposite prevails. “My job as a full-time, stay-at-home mom to four kids has finally come to an end after 31 years when our baby left for college last week. I’ve been dreading drop-off day for about a decade. The hardest part was walking back into the now empty house, feeling swallowed up by the silence. The tears flowed when I walked by her room for the first time knowing she won’t be saying goodnight, Mom, from behind that door every night. Saying goodbye to the last is especially difficult as I sit here in my empty nest, missing my daughter and wondering, now what?” relates Beth Smizlof of Saratoga Springs, N.Y.
“A hundred people will tell you how to raise your son, but very few will talk about how to let him go,” says Julie Stewart of Birmingham, Ala.
What is a hyperpolyglot?
An article in The New Yorker considers people whose linguistic mastery encompasses dozens of languages. To be a hyperpolyglot – defined as someone who can speak 11 or more languages – requires a lot of effort. And there may be a genetic predisposition, since there is evidence (which still requires confirmation) that “an extreme language learner has a more-than-random chance of being a gay, left-handed male on the autism spectrum, with an autoimmune disorder, such as asthma or allergies,” writes Judith Thurman.
A brain that is more apt to process the information needed to learn a new language may also be part of the picture.
Coffee and cancer warning
On Aug. 29, the Food and Drug Administration released a statement from Commissioner Scott Gottlieb, MD, that supports a proposal to exempt coffee from California’s cancer warning law. The action was prompted by a recent ruling by a California court that the state’s Proposition 65 could require labeling of coffee with a cancer warning, because of the presence of a chemical called acrylamide, which can form in many foods during frying, roasting, and baking.
“In coffee, acrylamide forms during the roasting of coffee beans. Although acrylamide at high doses has been linked to cancer in animals, and coffee contains acrylamide, current science indicates that consuming coffee poses no significant risk of cancer,” the statement reads in part.
Adults with autism, comorbid depression less likely to get talk therapy
Adults with autism spectrum disorders are less likely to receive individual talk therapy, but when they do, they make use of it more than adults without autism.
Using Medicaid data, Brenna B. Maddox, PhD, of the University of Pennsylvania, Philadelphia, and her colleagues presented the results of a study looking at treatment use by 268 adults with autism spectrum disorder (ASD) and 1,072 without, all of whom had depression or anxiety. They published their results in Research in Autism Spectrum Disorders.
Participants with ASD were less likely than those without ASD to receive either individual talk therapy (57.1% vs. 64.3%, P less than .05) or group talk therapy (0.7% vs. 2.9%, P less than .05). However, among those who did receive talk therapy, people with ASD had a significantly higher monthly mean number of visits than those without ASD (0.64 vs. 0.44, P less than .001).
“As predicted, adults with ASD and anxiety/depression were less likely to receive individual talk therapy, consistent with reports that they often experience difficulty accessing mental health services,” wrote Dr. Maddox and her colleagues.
The authors suggested the increased number of talk therapy visits by adults with ASD could reflect a need for more session time for those patients, compared with those without ASD. For example, cognitive-behavioral therapy programs are often adapted to ASD patients by increasing the number of sessions.
“An alternative explanation is that talk therapy in the community is less effective with adults with ASD, who therefore stay in therapy for a longer period in pursuit of greater symptom relief,” the authors wrote.
However, they also commented on the fact that both groups received less than one session a month and that it was unlikely that anxiety and depression symptoms would be well addressed with so few visits. “This finding highlights that the problem of limited access to mental health care is not exclusive to adults with ASD.”
Almost twice as many people with ASD used antipsychotics (39.6% vs. 21.5%, P less than .001) and stimulants (11.9% vs. 6.1%, P less than .001), compared with people without ASD. There were similar numbers of benzodiazepine and antidepressant users in both groups, but people with ASD were prescribed all medication types for a significantly higher number of days per month.
Those with ASD also were more likely to be prescribed different classes of medications at the same time. However, they also were less likely to show substance use.
Dr. Maddox and her colleagues cited several limitations. For example, the diagnosis of psychiatric and medical conditions was made using ICD-9 codes, and those conditions were not validated using clinical evaluation.
The study was supported by the National Institute of Mental Health. No conflicts of interest were declared.
SOURCE: Maddox BB et al. Res Autism Spectr Disord. 2018 Apr 11. doi: 10.1016/j.rasd.2018.03.009.
Adults with autism spectrum disorders are less likely to receive individual talk therapy, but when they do, they make use of it more than adults without autism.
Using Medicaid data, Brenna B. Maddox, PhD, of the University of Pennsylvania, Philadelphia, and her colleagues presented the results of a study looking at treatment use by 268 adults with autism spectrum disorder (ASD) and 1,072 without, all of whom had depression or anxiety. They published their results in Research in Autism Spectrum Disorders.
Participants with ASD were less likely than those without ASD to receive either individual talk therapy (57.1% vs. 64.3%, P less than .05) or group talk therapy (0.7% vs. 2.9%, P less than .05). However, among those who did receive talk therapy, people with ASD had a significantly higher monthly mean number of visits than those without ASD (0.64 vs. 0.44, P less than .001).
“As predicted, adults with ASD and anxiety/depression were less likely to receive individual talk therapy, consistent with reports that they often experience difficulty accessing mental health services,” wrote Dr. Maddox and her colleagues.
The authors suggested the increased number of talk therapy visits by adults with ASD could reflect a need for more session time for those patients, compared with those without ASD. For example, cognitive-behavioral therapy programs are often adapted to ASD patients by increasing the number of sessions.
“An alternative explanation is that talk therapy in the community is less effective with adults with ASD, who therefore stay in therapy for a longer period in pursuit of greater symptom relief,” the authors wrote.
However, they also commented on the fact that both groups received less than one session a month and that it was unlikely that anxiety and depression symptoms would be well addressed with so few visits. “This finding highlights that the problem of limited access to mental health care is not exclusive to adults with ASD.”
Almost twice as many people with ASD used antipsychotics (39.6% vs. 21.5%, P less than .001) and stimulants (11.9% vs. 6.1%, P less than .001), compared with people without ASD. There were similar numbers of benzodiazepine and antidepressant users in both groups, but people with ASD were prescribed all medication types for a significantly higher number of days per month.
Those with ASD also were more likely to be prescribed different classes of medications at the same time. However, they also were less likely to show substance use.
Dr. Maddox and her colleagues cited several limitations. For example, the diagnosis of psychiatric and medical conditions was made using ICD-9 codes, and those conditions were not validated using clinical evaluation.
The study was supported by the National Institute of Mental Health. No conflicts of interest were declared.
SOURCE: Maddox BB et al. Res Autism Spectr Disord. 2018 Apr 11. doi: 10.1016/j.rasd.2018.03.009.
Adults with autism spectrum disorders are less likely to receive individual talk therapy, but when they do, they make use of it more than adults without autism.
Using Medicaid data, Brenna B. Maddox, PhD, of the University of Pennsylvania, Philadelphia, and her colleagues presented the results of a study looking at treatment use by 268 adults with autism spectrum disorder (ASD) and 1,072 without, all of whom had depression or anxiety. They published their results in Research in Autism Spectrum Disorders.
Participants with ASD were less likely than those without ASD to receive either individual talk therapy (57.1% vs. 64.3%, P less than .05) or group talk therapy (0.7% vs. 2.9%, P less than .05). However, among those who did receive talk therapy, people with ASD had a significantly higher monthly mean number of visits than those without ASD (0.64 vs. 0.44, P less than .001).
“As predicted, adults with ASD and anxiety/depression were less likely to receive individual talk therapy, consistent with reports that they often experience difficulty accessing mental health services,” wrote Dr. Maddox and her colleagues.
The authors suggested the increased number of talk therapy visits by adults with ASD could reflect a need for more session time for those patients, compared with those without ASD. For example, cognitive-behavioral therapy programs are often adapted to ASD patients by increasing the number of sessions.
“An alternative explanation is that talk therapy in the community is less effective with adults with ASD, who therefore stay in therapy for a longer period in pursuit of greater symptom relief,” the authors wrote.
However, they also commented on the fact that both groups received less than one session a month and that it was unlikely that anxiety and depression symptoms would be well addressed with so few visits. “This finding highlights that the problem of limited access to mental health care is not exclusive to adults with ASD.”
Almost twice as many people with ASD used antipsychotics (39.6% vs. 21.5%, P less than .001) and stimulants (11.9% vs. 6.1%, P less than .001), compared with people without ASD. There were similar numbers of benzodiazepine and antidepressant users in both groups, but people with ASD were prescribed all medication types for a significantly higher number of days per month.
Those with ASD also were more likely to be prescribed different classes of medications at the same time. However, they also were less likely to show substance use.
Dr. Maddox and her colleagues cited several limitations. For example, the diagnosis of psychiatric and medical conditions was made using ICD-9 codes, and those conditions were not validated using clinical evaluation.
The study was supported by the National Institute of Mental Health. No conflicts of interest were declared.
SOURCE: Maddox BB et al. Res Autism Spectr Disord. 2018 Apr 11. doi: 10.1016/j.rasd.2018.03.009.
FROM RESEARCH IN AUTISM SPECTRUM DISORDERS
Key clinical point: Therapists may need more session time for adults with autism spectrum disorder.
Major finding: Among adults with autism who experience anxiety and depression, 57.1% received talk therapy, compared with 64.3% of those without autism.
Study details: A study of Medicaid claims data for 268 adults with autism and 1,072 without.
Disclosures: The study was supported by the National Institute of Mental Health. No conflicts of interest were declared.
Source: Maddox BB et al. Res Autism Spectr Disord. 2018 Apr 11. doi: 10.1016/j.rasd.2018.03.009.
AD severity linked to S. aureus clonal complex types
A new study offers insight into the over time.
The research “suggests that different CC types might harbor different virulence factors and that the patient’s immune system needs to adjust to this,” concluded the authors of the study, published in the British Journal of Dermatology.
There is a strong association between disease severity and colonization with S. aureus in patients with AD, and as many as 90% are colonized with the microbe but, the authors pointed out, it’s not entirely clear how S. aureus affects the development of AD.
They added that there’s been little research into the possible effects of changes in S. aureus clonal types over time. Still, “new studies indicate that specific clonal types could be linked to specific host phenotypes, illustrating that host-microbe interactions might be important for colonization of AD skin,” they said.
The authors, led by Maja-Lisa Clausen, MD, of the department of dermatology at the University of Copenhagen, tracked 63 adult patients with AD at Denmark’s Bispebjerg Hospital from 2013-2015 to a 2016-2017 follow-up period. Their mean age was 36 years.
They analyzed bacterial swabs taken from the nose, lesional skin, and nonlesional skin. Of the 63 participants, 47 (75%) were colonized with S. aureus in at least one location when the study began, and 27 of those (57%) were still colonized at follow-up. Of the 16 patients not colonized at baseline, 7 patients (44%) had become colonized by follow-up.
Of the 27 patients who were colonized at both time points, 14 (52%) had no change in CC type.
Those who were colonized at follow-up in at least one of the three sites sampled had more severe disease, with a mean SCORAD – or disease severity score – of 37, compared with those who were not colonized at that time, with a mean SCORAD of 28 (P = .067).
There was a much bigger gap in mean SCORAD score between the 14 patients who had the same CC type at both baseline and follow-up (a mean score of 30), compared with the 11 patients with different CC types at follow-up (a mean score of 47), a statistically significant difference (P = .03). Mean severity scores went up in those who changed CC types and down in those whose CC types remained the same.
The findings “illustrate that colonization changes over time, and also probably reflect the relapsing course of this disease, as colonization likely occurs in relation to worsening of the eczema,” the study authors wrote. They cautioned that “other factors should be taken into considerations as these are known to influence AD severity, including change in treatment regimens, climate, or other disease.”
Novo Nordisk Foundation funded the study. No relevant disclosures were reported.
SOURCE: Clausen, ML et al. Br J Dermatol. 2018 Aug 2. doi: 10.1111/bjd.17033.
A new study offers insight into the over time.
The research “suggests that different CC types might harbor different virulence factors and that the patient’s immune system needs to adjust to this,” concluded the authors of the study, published in the British Journal of Dermatology.
There is a strong association between disease severity and colonization with S. aureus in patients with AD, and as many as 90% are colonized with the microbe but, the authors pointed out, it’s not entirely clear how S. aureus affects the development of AD.
They added that there’s been little research into the possible effects of changes in S. aureus clonal types over time. Still, “new studies indicate that specific clonal types could be linked to specific host phenotypes, illustrating that host-microbe interactions might be important for colonization of AD skin,” they said.
The authors, led by Maja-Lisa Clausen, MD, of the department of dermatology at the University of Copenhagen, tracked 63 adult patients with AD at Denmark’s Bispebjerg Hospital from 2013-2015 to a 2016-2017 follow-up period. Their mean age was 36 years.
They analyzed bacterial swabs taken from the nose, lesional skin, and nonlesional skin. Of the 63 participants, 47 (75%) were colonized with S. aureus in at least one location when the study began, and 27 of those (57%) were still colonized at follow-up. Of the 16 patients not colonized at baseline, 7 patients (44%) had become colonized by follow-up.
Of the 27 patients who were colonized at both time points, 14 (52%) had no change in CC type.
Those who were colonized at follow-up in at least one of the three sites sampled had more severe disease, with a mean SCORAD – or disease severity score – of 37, compared with those who were not colonized at that time, with a mean SCORAD of 28 (P = .067).
There was a much bigger gap in mean SCORAD score between the 14 patients who had the same CC type at both baseline and follow-up (a mean score of 30), compared with the 11 patients with different CC types at follow-up (a mean score of 47), a statistically significant difference (P = .03). Mean severity scores went up in those who changed CC types and down in those whose CC types remained the same.
The findings “illustrate that colonization changes over time, and also probably reflect the relapsing course of this disease, as colonization likely occurs in relation to worsening of the eczema,” the study authors wrote. They cautioned that “other factors should be taken into considerations as these are known to influence AD severity, including change in treatment regimens, climate, or other disease.”
Novo Nordisk Foundation funded the study. No relevant disclosures were reported.
SOURCE: Clausen, ML et al. Br J Dermatol. 2018 Aug 2. doi: 10.1111/bjd.17033.
A new study offers insight into the over time.
The research “suggests that different CC types might harbor different virulence factors and that the patient’s immune system needs to adjust to this,” concluded the authors of the study, published in the British Journal of Dermatology.
There is a strong association between disease severity and colonization with S. aureus in patients with AD, and as many as 90% are colonized with the microbe but, the authors pointed out, it’s not entirely clear how S. aureus affects the development of AD.
They added that there’s been little research into the possible effects of changes in S. aureus clonal types over time. Still, “new studies indicate that specific clonal types could be linked to specific host phenotypes, illustrating that host-microbe interactions might be important for colonization of AD skin,” they said.
The authors, led by Maja-Lisa Clausen, MD, of the department of dermatology at the University of Copenhagen, tracked 63 adult patients with AD at Denmark’s Bispebjerg Hospital from 2013-2015 to a 2016-2017 follow-up period. Their mean age was 36 years.
They analyzed bacterial swabs taken from the nose, lesional skin, and nonlesional skin. Of the 63 participants, 47 (75%) were colonized with S. aureus in at least one location when the study began, and 27 of those (57%) were still colonized at follow-up. Of the 16 patients not colonized at baseline, 7 patients (44%) had become colonized by follow-up.
Of the 27 patients who were colonized at both time points, 14 (52%) had no change in CC type.
Those who were colonized at follow-up in at least one of the three sites sampled had more severe disease, with a mean SCORAD – or disease severity score – of 37, compared with those who were not colonized at that time, with a mean SCORAD of 28 (P = .067).
There was a much bigger gap in mean SCORAD score between the 14 patients who had the same CC type at both baseline and follow-up (a mean score of 30), compared with the 11 patients with different CC types at follow-up (a mean score of 47), a statistically significant difference (P = .03). Mean severity scores went up in those who changed CC types and down in those whose CC types remained the same.
The findings “illustrate that colonization changes over time, and also probably reflect the relapsing course of this disease, as colonization likely occurs in relation to worsening of the eczema,” the study authors wrote. They cautioned that “other factors should be taken into considerations as these are known to influence AD severity, including change in treatment regimens, climate, or other disease.”
Novo Nordisk Foundation funded the study. No relevant disclosures were reported.
SOURCE: Clausen, ML et al. Br J Dermatol. 2018 Aug 2. doi: 10.1111/bjd.17033.
FROM BRITISH JOURNAL OF DERMATOLOGY
Key clinical point: Changes in skin colonization of Staphylococcus aureus clonal complex (CC) types in patients with atopic dermatitis (AD) over time may be related to relapses.
Major finding: Mean SCORAD among the 14 participants with the same CC type at baseline and follow-up was 30, vs. 47 in the 11 patients with different CC types at follow-up (P = .03).
Study details: The study of 63 adults with AD compared the association of disease severity and colonization with S. aureus, and changes in S. aureus clonal complex types over time.
Disclosures: Novo Nordisk Foundation funded the study. No relevant disclosures were reported.
Source: Clausen ML et al. Br J Dermatol. 2018 Aug 2. doi: 10.1111/bjd.17033.
HIV intervention for drug users also benefits injection partners
A combination intervention that included standard of care antiretroviral therapy (ART), systems navigation, and psychosocial counseling showed success in HIV-infected people who inject drugs (PWID), according to the results of a randomized study in the Lancet.
The intervention patients showed an increase in both the use of ART and medication-assisted treatment (MAT) for drug use. In addition, they showed a reduced mortality, compared with standard-of-care controls. The study was carried out in one community site in the Ukraine and two health center sites in Vietnam.
A unique aspect of the study was that each HIV-positive PWID recruited one or more HIV-negative injection partners who were followed throughout the study to determine any change in their HIV status, according to a report by William C. Miller, MD, PhD, of the Ohio State University, Columbus, and his colleagues.
The study included 502 eligible and enrolled HIV-positive PWID along with 806 eligible and enrolled injection partners. The subjects comprised 85% men, with 65% of the participants between the ages of 30-39 years at time of enrollment. Patients were randomized to the intervention group (25%) or the standard of care–only group (75%).
At 1 year, self-reported ART use was higher among the index participants in the intervention group than in the standard of care group (probability ratio,1.7; 95% confidence interval, 1.4-1.9) and viral suppression also was higher with the intervention group than with standard of care (PR 1.7; 95% CI, 1.3-2.2). In addition, MAT use was higher with the intervention than with standard of care (PR, 1.7; 95% CI, 1.3-2.2). Seven HIV infections occurred during the study, all in the injection partners of the standard of care group, with none in the intervention group partners, but the study was not powered to determine if this was a significant difference.
Mortality was lower in the intervention group than in the standard of care group with 5.6 deaths/100 person-years (95% CI, 2.6-10.6) in the intervention group vs. 12.1 deaths/100 person-years (95% CI, 9.1-15.6) in the standard of care group (hazard ratio, 0.47; 95% CI 0.22-0.90). Similarly, mortality also was lower among injection partners in the intervention group than in the standard of care group (0.46 deaths/100 person-years; 95% CI, 0.01-2.6 vs. 2.6 deaths/100 person-years; 95% CI, 1.5-4.1, respectively (HR, 0.17; 95% CI, 0.01-0.84).
“This vanguard study provides evidence that a flexible, scalable intervention increases ART and MAT use and reduced mortality among PWID,” according to the authors. “The intervention might have reduced HIV incidence, but incidence was low in both groups of uninfected partners. This low incidence presents a challenge for any similar future trial assessing transmission and precludes a future randomized controlled trial,” they concluded.
The study was funded by the National Institutes of Health and the authors reported no conflicts of interest within the scope of the study.
SOURCE: Miller WC et al. Lancet 2018;392:747-59.
Although the study had unexpectedly low incidences of HIV infection in the standard of care population controls, which made it not powered to find a statistically significant difference in HIV incidence in the two groups, given the results, standard of care may be considered substandard in trials such as these, according to Don C. Des Jarlais, MD, and Huong Thi Duong, MD.
Because of this, “we propose that, when an incident case of HIV is identified, ART [antiretroviral therapy] and MAT [medication-assisted therapy] should be offered immediately, and all reasonable attempts should be made to identify potential sources of transmission and people who might have been infected within the person’s injecting and sexual networks,” in any future trials, “even if supplying ethically acceptable standard of care might make the study extremely expensive,” Dr. Des Jarlais and Dr. Duong wrote.
They pointed out that, because combined prevention and care have ended HIV epidemics among people who inject drugs (PWID) in high-income countries, the same should be the case for low- and middle-income settings, especially as MAT has been shown to be quite effective among these latter groups as well.
“Governments and community-based organizations should now unambiguously commit to the goal of using evidence-based interventions to end HIV epidemics among PWID globally,” Dr. Jarlais and Dr. Duong concluded.
Dr. Des Jarlais of the Icahn School of Medicine at Mount Sinai, N.Y., and Dr. Duong of Hai Phong (Vietnam) University of Medicine and Pharmacy made their comments in an accompanying editorial (Lancet 2018;392:714-6) .
Although the study had unexpectedly low incidences of HIV infection in the standard of care population controls, which made it not powered to find a statistically significant difference in HIV incidence in the two groups, given the results, standard of care may be considered substandard in trials such as these, according to Don C. Des Jarlais, MD, and Huong Thi Duong, MD.
Because of this, “we propose that, when an incident case of HIV is identified, ART [antiretroviral therapy] and MAT [medication-assisted therapy] should be offered immediately, and all reasonable attempts should be made to identify potential sources of transmission and people who might have been infected within the person’s injecting and sexual networks,” in any future trials, “even if supplying ethically acceptable standard of care might make the study extremely expensive,” Dr. Des Jarlais and Dr. Duong wrote.
They pointed out that, because combined prevention and care have ended HIV epidemics among people who inject drugs (PWID) in high-income countries, the same should be the case for low- and middle-income settings, especially as MAT has been shown to be quite effective among these latter groups as well.
“Governments and community-based organizations should now unambiguously commit to the goal of using evidence-based interventions to end HIV epidemics among PWID globally,” Dr. Jarlais and Dr. Duong concluded.
Dr. Des Jarlais of the Icahn School of Medicine at Mount Sinai, N.Y., and Dr. Duong of Hai Phong (Vietnam) University of Medicine and Pharmacy made their comments in an accompanying editorial (Lancet 2018;392:714-6) .
Although the study had unexpectedly low incidences of HIV infection in the standard of care population controls, which made it not powered to find a statistically significant difference in HIV incidence in the two groups, given the results, standard of care may be considered substandard in trials such as these, according to Don C. Des Jarlais, MD, and Huong Thi Duong, MD.
Because of this, “we propose that, when an incident case of HIV is identified, ART [antiretroviral therapy] and MAT [medication-assisted therapy] should be offered immediately, and all reasonable attempts should be made to identify potential sources of transmission and people who might have been infected within the person’s injecting and sexual networks,” in any future trials, “even if supplying ethically acceptable standard of care might make the study extremely expensive,” Dr. Des Jarlais and Dr. Duong wrote.
They pointed out that, because combined prevention and care have ended HIV epidemics among people who inject drugs (PWID) in high-income countries, the same should be the case for low- and middle-income settings, especially as MAT has been shown to be quite effective among these latter groups as well.
“Governments and community-based organizations should now unambiguously commit to the goal of using evidence-based interventions to end HIV epidemics among PWID globally,” Dr. Jarlais and Dr. Duong concluded.
Dr. Des Jarlais of the Icahn School of Medicine at Mount Sinai, N.Y., and Dr. Duong of Hai Phong (Vietnam) University of Medicine and Pharmacy made their comments in an accompanying editorial (Lancet 2018;392:714-6) .
A combination intervention that included standard of care antiretroviral therapy (ART), systems navigation, and psychosocial counseling showed success in HIV-infected people who inject drugs (PWID), according to the results of a randomized study in the Lancet.
The intervention patients showed an increase in both the use of ART and medication-assisted treatment (MAT) for drug use. In addition, they showed a reduced mortality, compared with standard-of-care controls. The study was carried out in one community site in the Ukraine and two health center sites in Vietnam.
A unique aspect of the study was that each HIV-positive PWID recruited one or more HIV-negative injection partners who were followed throughout the study to determine any change in their HIV status, according to a report by William C. Miller, MD, PhD, of the Ohio State University, Columbus, and his colleagues.
The study included 502 eligible and enrolled HIV-positive PWID along with 806 eligible and enrolled injection partners. The subjects comprised 85% men, with 65% of the participants between the ages of 30-39 years at time of enrollment. Patients were randomized to the intervention group (25%) or the standard of care–only group (75%).
At 1 year, self-reported ART use was higher among the index participants in the intervention group than in the standard of care group (probability ratio,1.7; 95% confidence interval, 1.4-1.9) and viral suppression also was higher with the intervention group than with standard of care (PR 1.7; 95% CI, 1.3-2.2). In addition, MAT use was higher with the intervention than with standard of care (PR, 1.7; 95% CI, 1.3-2.2). Seven HIV infections occurred during the study, all in the injection partners of the standard of care group, with none in the intervention group partners, but the study was not powered to determine if this was a significant difference.
Mortality was lower in the intervention group than in the standard of care group with 5.6 deaths/100 person-years (95% CI, 2.6-10.6) in the intervention group vs. 12.1 deaths/100 person-years (95% CI, 9.1-15.6) in the standard of care group (hazard ratio, 0.47; 95% CI 0.22-0.90). Similarly, mortality also was lower among injection partners in the intervention group than in the standard of care group (0.46 deaths/100 person-years; 95% CI, 0.01-2.6 vs. 2.6 deaths/100 person-years; 95% CI, 1.5-4.1, respectively (HR, 0.17; 95% CI, 0.01-0.84).
“This vanguard study provides evidence that a flexible, scalable intervention increases ART and MAT use and reduced mortality among PWID,” according to the authors. “The intervention might have reduced HIV incidence, but incidence was low in both groups of uninfected partners. This low incidence presents a challenge for any similar future trial assessing transmission and precludes a future randomized controlled trial,” they concluded.
The study was funded by the National Institutes of Health and the authors reported no conflicts of interest within the scope of the study.
SOURCE: Miller WC et al. Lancet 2018;392:747-59.
A combination intervention that included standard of care antiretroviral therapy (ART), systems navigation, and psychosocial counseling showed success in HIV-infected people who inject drugs (PWID), according to the results of a randomized study in the Lancet.
The intervention patients showed an increase in both the use of ART and medication-assisted treatment (MAT) for drug use. In addition, they showed a reduced mortality, compared with standard-of-care controls. The study was carried out in one community site in the Ukraine and two health center sites in Vietnam.
A unique aspect of the study was that each HIV-positive PWID recruited one or more HIV-negative injection partners who were followed throughout the study to determine any change in their HIV status, according to a report by William C. Miller, MD, PhD, of the Ohio State University, Columbus, and his colleagues.
The study included 502 eligible and enrolled HIV-positive PWID along with 806 eligible and enrolled injection partners. The subjects comprised 85% men, with 65% of the participants between the ages of 30-39 years at time of enrollment. Patients were randomized to the intervention group (25%) or the standard of care–only group (75%).
At 1 year, self-reported ART use was higher among the index participants in the intervention group than in the standard of care group (probability ratio,1.7; 95% confidence interval, 1.4-1.9) and viral suppression also was higher with the intervention group than with standard of care (PR 1.7; 95% CI, 1.3-2.2). In addition, MAT use was higher with the intervention than with standard of care (PR, 1.7; 95% CI, 1.3-2.2). Seven HIV infections occurred during the study, all in the injection partners of the standard of care group, with none in the intervention group partners, but the study was not powered to determine if this was a significant difference.
Mortality was lower in the intervention group than in the standard of care group with 5.6 deaths/100 person-years (95% CI, 2.6-10.6) in the intervention group vs. 12.1 deaths/100 person-years (95% CI, 9.1-15.6) in the standard of care group (hazard ratio, 0.47; 95% CI 0.22-0.90). Similarly, mortality also was lower among injection partners in the intervention group than in the standard of care group (0.46 deaths/100 person-years; 95% CI, 0.01-2.6 vs. 2.6 deaths/100 person-years; 95% CI, 1.5-4.1, respectively (HR, 0.17; 95% CI, 0.01-0.84).
“This vanguard study provides evidence that a flexible, scalable intervention increases ART and MAT use and reduced mortality among PWID,” according to the authors. “The intervention might have reduced HIV incidence, but incidence was low in both groups of uninfected partners. This low incidence presents a challenge for any similar future trial assessing transmission and precludes a future randomized controlled trial,” they concluded.
The study was funded by the National Institutes of Health and the authors reported no conflicts of interest within the scope of the study.
SOURCE: Miller WC et al. Lancet 2018;392:747-59.
FROM THE LANCET
Key clinical point: Mortality was lower in the intervention group and among their injection partners, compared with the standard of care group.
Major finding: Seven HIV infections occurred in injection partners of the standard-of-care group, with none in those of the intervention group, although this result was underpowered to detect significance.
Study details: Randomized, controlled vanguard study in 502 index HIV-infected participants and 806 uninfected injection partners in one Ukraine community site and two Vietnam health center sites.
Disclosures: The study was funded by the National Institutes of Health, and the authors reported no conflicts of interest within the scope of the study.
Source: Miller WC et al. Lancet 2018;392:747-59.