The clinical and economic impact of preoperative transthoracic echocardiography in elderly patients with hip fractures.
A Student's t-test was used to compare patients who underwent preoperative TTE to those who did not. Outcomes measured included time to surgery, overall length of stay, rate of cardiac intervention, in hospital mortality, and cost of patient care. Subgroup analysis was performed on patients who had an ASA score of 1 or 2, versus those with an ASA of 3 or 4. These groups were chosen in order to determine whether the patients' preoperative comorbidities had any effect on the value of preoperative TTE.
Cost analysis data was generated as actual cost of inpatient stay. A resource-based hospital accounting system (TSI Inc., Cambridge, MA) provided actual hospital cost data for each patient who underwent surgical treatment of a hip fracture during the time frame of the study.
Patients in the TTE group and non-TTE group were similar in age, gender, and preoperative comorbidities (Table 1). In the TTE group, 1/43 patients (2.4%) had a cardiac intervention (PTCA and stent placement). There were no cardiac interventions in the control group. Average time to OR was 1.5 days in the TTE group and 0.93 days in the control group (p < 0.001). Average length of stay was 7.2 days in the TTE group and 6.0 days in the control group (p = 0.04). In patients with a preoperative ASA score of 3 or 4, length of stay in the TTE group was 7.3 days and 6.3 days in the control group (p = 0.18). Inpatient mortality was 2.3% in the TTE group and 3% in the control group (p = 0.493). There was no correlation between findings on TTE and choice of anesthesia. A comparison of hospital costs for patients who underwent TTE and the control group demonstrated a significant difference in hospital cost between the groups (TTE $24,445 versus control $18,429, p = 0.02).
Forty-eight indications for TTE were cited in 43 patients based on medical documentation. The most common reasons for preoperative TTE was known coronary artery disease (CAD) (14/43); acute electrocardiographic changes (7/43); pre-existing conduction abnormalities, including atrial fibrillation and atrioventricular block (10/43); and pre-existing aortic valvular disease (4/43). Of the patients with acute EKG changes, four were presumed to have nonST segment elevation myocardial infarctions, and three had presumably new onset atrial fibrillation. One of the patients with presumed NSTEMI underwent preoperative diagnostic left heart catheterization with no intervention; one patient underwent postoperative heart catheterization and stent placement after developing ST elevations in the immediate postoperative period. The remainder of the indications cited for preoperative TTE included history of cerebrovascular accident (CVA) (3/43), clinical cardiac murmur (2/43), congestive heart failure (2/43), history of syncope related to injury (2/43), and multiple cardiac risk factors (hypertension, diabetes mellitus, hypercholesterolemia) in (4/43).
Care for patients with hip fractures is becoming an ever increasing burden to global health care. In the USA an estimated 340,000 hip fractures occur every year with an average annual cost estimated between 10 and 15 billion US dollars. With an aging population and escalating costs of health care, the administration of efficient and cost-effective health care in hip fracture patients is more important than ever. (1)
Hip fractures patients tend to be elderly, osteoporotic patients with a high rate of dementia and with multiple medical comorbidities. While determining whether the patient is fit for the operating room is important to minimize morbidity, there is also consistent evidence to suggest that significant delay between fracture and treatment has adverse outcomes on 30 day and 1 year mortality rates. Operative delay from 24 hours to 4 days has been used to define patient groups. Delay to the operating room also significantly increases the cost of treatment. (2-7)
One common reason for delay to the operating room is for preoperative evaluation of documented or suspected cardiac disease. Many hip fracture patients have pre-existing cardiac ischemia, conduction abnormalities, and valvular disease. Transthoracic echocardiogram (TTE) is a commonly used tool to assess cardiac pump function and valvular function. It is frequently ordered as part of the preoperative workup for patients with no cardiomyopathy and those who present with cardiac murmurs. There is recent evidence to suggest that the role of transthoracic echo in preoperative hip fractures may be of limited value. TTE rarely leads to preoperative cardiac intervention prior to hip fracture surgery but has shown consistently to delay the time to OR by 1 to 2 days. (8-10) At our institution, TTE is a commonly employed tool used by the medical staff to evaluate hip fracture patients with significant cardiac history, EKG abnormalities, or abnormal auscultation findings. We sought to determine what effect TTE had on patient outcomes and what economic impact it had on the treatment of our patients.
The annual cost of hip fracture care is rising at an alarming rate with current annual costs estimated at $10.3 billion to $15.2 billion. With an increasingly aging society, the number of hip fractures occurring yearly is projected to increase worldwide to 6.26 million annually by 2050. Therefore, cost containment is becoming an important issue. (10)
Our data suggests that current indications to obtain preoperative TTE increase time to surgery, hospital length of stay, and overall cost. There was an extremely low rate of preoperative TTE leading to cardiac intervention. Furthermore, there was no immediate difference in survival related to preoperative TTE. In an attempt to define whether the benefits of preoperative TTE would manifest itself with analysis of a subgroup of the most ill patients, we parsed out patients with ASA class III or IV comorbidities. In this group of patients, TTE still did not infer any significant benefit to improving mortality. Time to surgery and length of stay was also increased in the high comorbidity group; however, length of stay did not reach statistical significance. Overall, one patient did undergo postoperative cardiac catheterization with coronary intervention. The preoperative TTE showed well preserved ejection fraction with no significant wall motion abnormalities. The TTE had no effect on the perioperative course of the patient. In many instances, hip fracture patients have pre-existing cardiac disease that factor into the patient's treatment plan. In most instances, judicial fluid management and continuation of preoperative cardiac medications is all that is necessary to prevent significant cardiac related morbidity.
In a similar study by Ricci and coworkers, the benefit of preoperative cardiac testing in patients with hip fractures was evaluated. (9) Similar to our results, they found a significant delay to the operating room, increased cost, and no increase in preoperative cardiac intervention. They included patients that had nuclear stress tests, stress echocardiograms, and standard TTE. Economic data included the additional cost of performing the test, which amounted to $1,250 dollars per patient. (9) We attempted to further define the economic impact by assessing overall increase in cost, as the actual cost of the TTE is only a small portion of the additional costs accrued by this group of patients. Within our study population, preoperative TTE was associated with a $6,026 dollar increase in cost of hospitalization per patient.
Current health care trends are aimed at improving efficiency and controlling costs without compromising care. Minimizing inpatient length of stay, reducing unnecessary testing, and reducing complication rates all play a pivotal role in improving the quality, cost, and efficiency of health care. Our data suggests that preoperative TTE may provide little benefit in managing hip fracture patients. Furthermore, it appears to be related to surgical delay in fixation and significantly increased hospital costs. Patients with significant cardiac history are likely at increased risk of cardiac related complications after hip fracture. Determining what patient populations would have significant benefit from preoperative TTE has yet to be elucidated. It is also well known that delay to the operating room leads to significantly higher rates of mortality at 1 year. (11) Hip fracture patients tend to be comprised of the elderly, osteoporotic patients with multiple medical comorbidities. Time to surgery is an independent risk factor for serious complication and death. (4) For preoperative TTE to be of significant benefit, clear indications for its use need to be identified, and the information it provides should define a change in management in the preoperative, perioperative, or postoperative period. In order to assess whether TTE effects perioperative management, we reviewed the anesthesia records and spoke to the operative anesthesiologists. The consensus is that in relatively few instances, TTE results impacted the way anesthesiologists managed the patient; this is reflected by the nominal number of TTEs that were requested by the anesthesia team during their preoperative evaluations. Preoperative TTE for elderly patients with hip fractures is rarely indicated.
Richard Iorio, M.D., has or may receive payments or benefits, in any one year, an amount in excess of $10,000, from IMDS Co-Innovation and Kyocera Medical Corporation. None of the other authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony
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Andrew Marcantonio, D.O., M.B.A., Brandon Steen, M.D., Michael Kain, M.D., Kasey-Jean Bramlett, P.A.-C., John F. Tilzey, M.D., and Richard Iorio, M.D.
Andrew Marcantonio, D.O., Michael Kain, M.D., Kasey Jean Bramlett, P.A.-C., and John F. Tilzey, M.D., Department of Orthopaedic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts. Brandon Steen, M.D., Boston University Medical Center, Boston, Massachusetts. Richard Iorio, M.D., New York University Langone Medical Center, Hospital for Joint Diseases, New York, New York.
Correspondence: Andrew Marcantonio, D.O., M.B.A., Department of Orthopaedic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, Massachusetts 01805; Andrew.Marcantonio@lahey.org.
Table 1 Hip Fracture Patient Characteristics TTE group No TTE group P-value Number of Patients 43 152 Age 84.9 78.6 0.004 LOS 7.2 6.0 0.03 TTS 1.5 0.9 < 0.001 American Society of Anesthesiologists Physical Status Classification 3 and 4 patients. ASA 3 and 4 41 (95%) 111 (73%) Age ASA 3 and 4 group 84.5 80.1 0.03 LOS ASA 3 and 4 group 7.3 6.3 0.16 TTS ASA 3 and 4 group 1.5 0.9 < 0.001 LOS represents "length of stay," from admission through the ER until discharge from the hospital. TTS represents "time to surgery," measured as number of calendar days from admission until the patient had surgery.