Clinical Practice Guidelines Decrease Unnecessary Echocardiograms Before Hip Fracture Surgery

Adair, Chris MD1; Swart, Eric MD1; Seymour, Rachel PhD1; Patt, Joshua MD, MPH1; Karunakar, Madhav A. MD1,a

Journal of Bone & Joint Surgery - American Volume: 19 April 2017 - Volume 99 - Issue 8 - p 676–680
doi: 10.2106/JBJS.16.01108
Scientific Articles

Background: Preoperative assessment of geriatric patients with a hip fracture may include transthoracic echocardiography (TTE), which increases resource utilization and cost and may delay surgery. The purpose of this study was to evaluate preoperative TTE utilization at a single institution in order to determine (1) how often TTE is ordered in accordance with clinical practice guidelines (CPGs), (2) how frequently TTE reveals cardiac disease that may alter medical or anesthesia management, and (3) whether following CPGs reduces unnecessary TTE utilization without potentially missing important disease.

Methods: A retrospective review of data on 100 geriatric patients with a hip fracture who had undergone preoperative TTE was performed. Charts were reviewed to evaluate if TTE had been obtained in accordance with the published CPGs from the American College of Cardiology/American Heart Association (ACC/AHA). TTE reports were reviewed for the presence of disease that was important enough to cause modifications in anesthesia or perioperative management, including new left ventricular systolic or diastolic dysfunction, moderate or severe valvular disease, and pulmonary hypertension. Finally, the sensitivity and specificity of accordance with the ACC/AHA CPGs for predicting which patients would have TTE that identified important disease were calculated.

Results: The TTE was ordered in accordance with the published ACC/AHA CPGs for 66% of the patients. TTE revealed disease with the potential to modify anesthesia or medical management in 14% of the patients—for all of whom the TTE had been indicated according to ACC/AHA guidelines (i.e., the guidelines were 100% sensitive). In this study population, following the ACC/AHA guidelines could have prevented the performance of TTE in 34% of the patients without missing any disease (40% specificity).

Conclusions: Preoperative TTE for patients with a hip fracture is frequently obtained outside the recommendations of established CPGs. Utilization of CPGs such as the ACC/AHA guidelines should be considered, as it may decrease variability in care and reduce unnecessary resource utilization without adversely affecting patient outcomes.

1Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina

E-mail address for M.A. Karunakar:

Article Outline

Approximately 300,000 hip fractures occur yearly in the United States1, the incidence of hip fractures is increasing as the geriatric population increases2, and hip fractures frequently occur in patients with multiple medical comorbidities3,4. As a result, orthopaedic surgeons usually work in conjunction with internal medicine physicians and anesthesiologists to formulate a management plan, including preoperative evaluation, operative timing, and perioperative medical management5-8.

Early operative treatment is generally advocated for patients with a hip fracture to minimize the potential morbidity associated with bed rest and also for pain control, to decrease the need for narcotics9. In general, surgical treatment within 24 to 48 hours is encouraged10-12. However, surgical expediency should not take precedence over adequate preoperative assessment, and surgery may need to be delayed if there are acute medical issues that must be addressed prior to surgery to minimize perioperative risk.

One important consideration is whether elderly patients should undergo transthoracic echocardiography (TTE). TTE can provide critical information about cardiac function, which can directly affect (1) the need for additional preoperative cardiac interventions, (2) intraoperative anesthesia care, and (3) postoperative fluid management13,14. However, TTE also requires specialized staff (including technologists to perform the study and physicians to review the results) that may not be available overnight at all medical centers. As a result, there is concern that, in addition to the resource requirement of acquiring TTE, “clearance” for surgery may be delayed because of logistic issues in performing the study on an urgent basis7,15-17.

To provide objective guidance for perioperative assessment, several clinical practice guidelines (CPGs) have been developed to aid physicians in preoperative evaluation and risk stratification18-21. One example is the American College of Cardiology and American Heart Association (ACC/AHA) Guideline on Perioperative Cardiovascular Evaluation, generated via high-level literature review and expert consensus, which was most recently updated in 201422. The guidelines provide specific indications for performing preoperative TTE, with the goal of acting as a screening mechanism to identify patients who have a high likelihood of demonstrating disease on TTE without missing any patients with important disease. These guidelines were derived to consolidate evidence-based information about perioperative cardiovascular risk for use by care teams as well as to foster discussion between medical and surgical teams regarding “optimal location and timing of surgery.”22 In an outpatient preoperative medical evaluation setting, the ACC/AHA guidelines were shown to improve appropriate use of cardiac testing without increasing the rate of cardiac complications23. Their appropriateness in the immediate evaluation of acute hip fractures in geriatric patients is not well established.

The purpose of this study was to evaluate preoperative TTE utilization at a single institution in order to determine (1) how often TTE is ordered in accordance with current ACC/AHA CPGs, (2) how frequently TTE reveals cardiac disease that may alter medical or anesthesia management, and (3) whether the use of CPGs to indicate preoperative TTE could reduce unnecessary utilization without potentially missing important disease. We hypothesized that TTE is overutilized and that the use of TTE outside of the CPGs infrequently identifies new disease.

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Materials and Methods

In this retrospective study, based on chart review and conducted with institutional review board approval, the records on patients >55 years old who had received TTE before hip fracture surgery were reviewed. Demographic and medical comorbidity data were obtained from a prospectively created registry used to track the outcomes of hip fractures in geriatric patients at our institution. The charts of all patients admitted between May 2009 and November 2012 with an osteoporotic hip fracture, including femoral neck, intertrochanteric, and subtrochanteric patterns, were reviewed to determine whether they had undergone TTE for preoperative risk assessment. A full chart review was then performed to retrospectively evaluate the factors listed below.

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Adherence to CPGs

For each patient, present illness, review of systems, medical and surgical history, and findings documented in the preoperative examination by the medical team were reviewed for criteria that would meet the indications for TTE outlined by the ACC/AHA CPGs. These assessments were made by a single reviewer blinded to the later results of the TTE. The ACC/AHA indications for TTE included (1) dyspnea of unknown origin, (2) worsening of known signs or symptoms of heart failure, (3) known history of valvular dysfunction or heart failure without TTE in the last year or worsened symptoms, and (4) suspicion of moderate or greater valvular stenosis or regurgitation18. The indication for the TTE described by the ordering physician was also obtained from the clearance documentation. Electrocardiograms and previous TTE findings were also reviewed when available. When ≥1 of the ACC/AHA criteria were met, it was determined that the TTE had been ordered in accordance with the guidelines.

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Delay in Operative Treatment

The number of patients who experienced a clinically important delay between admission and the definitive operation was determined. Delay cutoffs of both >24 hours and >48 hours were calculated as meta-analysis has shown those delays to be associated with worse outcomes10-12. A Student 2-tailed t test was used to compare the delay for patients who received TTE with that for patients who did not receive TTE.

The charts of patients who had had both a delay in operative treatment and TTE were reviewed to determine if the TTE was the major source of the delay. Our criteria for defining this included (1) an orthopaedic note documenting a plan for operative treatment pending medical clearance, and (2) a medical clearance note documenting that all other medical factors had resolved with the exception of TTE.

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Potential to Change Management

The formal TTE study report for each patient was assessed by a reviewer, blinded to whether the CPGs had been followed, to identify cardiac conditions likely to change perioperative management by either the medical team or the anesthesia team. These conditions included a left ventricular ejection fraction diminished by <25% (affects fluid management and anesthetic dosing), right ventricular systolic pressure elevated to >55 mm Hg (as a proxy for pulmonary hypertension), and “moderate” or “severe” valvular disease13,14. The information was considered to change management if the results from the TTE (1) were abnormal and (2) represented a change from baseline (when known).

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Statistical Analysis

Sensitivity and specificity analyses are used to test potential diagnostic screening tools and highlight their accuracy in identifying patients with and without disease24,25. The performance of the ACC/AHA CPGs as a screening tool was evaluated by calculating their sensitivity and specificity for identifying patients in whom TTE would reveal novel disease that would change management. The patients were considered “test positive” when they met the ACC/AHA criteria for ordering TTE and “test negative” when they did not meet those criteria. They were considered “disease positive” when the TTE revealed disease with a potential to change perioperative management and “disease negative” when the TTE showed no such new disease. Sensitivity was calculated as true positive/(true positive + false negative), and specificity was calculated as true negative/(false positive + true negative).

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Over the 3.5-year study period, 538 patients were treated for an osteoporotic hip fracture, and 121 (22%) of them underwent preoperative TTE prior to fracture fixation. Of those 121 patients, 21 had the TTE performed for reasons other than preoperative clearance (e.g., as part of a resuscitation/code, stroke evaluation, etc.), leaving 100 patients to be analyzed. The average age of the patients who received TTE was 82.3 years (standard deviation [SD] = 10.5 years) compared with 78.5 years (SD = 10.5 years) for those who did not receive TTE, which was a significant difference (p < 0.001). Medical conditions and comorbidities for the patients who received and those who did not receive preoperative TTE are shown in Table I. The average Charlson Comorbidity Index was 2.8 (SD = 2.2) for the group that received TTE and 2.3 (SD = 2.0) for those who did not receive TTE, which was also a significant difference (p = 0.03).

The rate of adherence to the CPGs published by the ACC/AHA was 66%. The primary indications for the TTE performed in adherence to the guidelines were known heart disease and >1 year since the last TTE (26 patients), heart murmur (21), known heart disease with worsened symptoms (12), and new signs/symptoms of heart disease (7). The most common documented reasons for ordering the TTE outside the CPGs were dementia preventing evaluation of the preoperative cardiac symptoms (8 of the 34 patients) and generic “evaluation of cardiac function” although the patient had no history, physical examination findings, or recent studies that suggested any heart disease (11 of the 34). Nine of the 34 patients had no documented reason for TTE in the initial medical evaluation.

The average time between admission and surgery was 31 hours (median, 23 hours) for the patients who did not receive TTE and 45 hours (median, 35 hours) for those who did, which was a significant difference (p < 0.0001). The TTE was performed at an average of 18 hours (median, 16 hours) after admission and 28 hours (median, 21 hours) before surgery. The delay before operative treatment was >24 hours for 68% of the patients who received TTE and >48 hours for 29%. However, TTE was identified as the major reason for the delay in only 7 cases (10%) with a >24-hour delay and none of the cases with a >48-hour delay.

Fourteen percent of the patients were identified by the TTE as having disease with the potential to alter perioperative management, including new or worsened valvular disease (6 patients), new or worsened pulmonary hypertension (5 patients), substantial decline in ejection fraction (1 patient), a new left ventricular outflow tract obstruction (1 patient), and a new diagnosis of hypertrophic cardiomyopathy (1 patient). No important disease was identified in any of the 34 patients who underwent TTE that had not been indicated by ACC/AHA criteria, whereas important disease was identified in 14 (21%) of the 66 patients for whom TTE was indicated by ACC/AHA criteria. This corresponds to a calculated sensitivity of 100% and a specificity of 40% (Table II).

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Hip fractures are common in the geriatric population. The incidence will continue to rise as the population ages, and these hip fractures will be associated with a growing social and economic burden. In light of this increasing demand, it is important to have evidence-based algorithms for the care of patients with fragility fracture. This involves an organized effort among orthopaedic surgeons, internal medicine physicians and/or geriatricians, and anesthesiologists. Previous work has shown that a formal, coordinated fragility fracture program can improve outcomes, decrease complications and mortality, reduce length of hospital stay, and lower costs8,26-28. Also, multiple meta-analyses have suggested that the time to operative treatment may play a role in perioperative mortality and patient outcomes10-12 and that dedicating resources to expediting preoperative work-up may be cost-effective7. Thus, an objective algorithm to determine which patients need additional cardiac evaluation (such as TTE) that could be integrated into care pathways could be extremely valuable.

The results of this study show that ACC/AHA CPGs provide a reasonable framework for the decision of whether to perform TTE for geriatric patients with a hip fracture. The CPGs were 100% sensitive for identifying patients who may benefit from TTE (i.e., no patient who did not meet CPG criteria for TTE had important disease detected by TTE) and relatively specific (40%), highlighting their utility as a screening tool.

These guidelines also appear effective for evaluating other types of cardiac evaluation. Recently, Stitgen et al. found that only 29% of geriatric patients with hip fracture who received a cardiology consultation had met the ACC/AHA guidelines for such a consultation29. In our study, 34% of the patients who had received TTE preoperatively had not met the ACC/AHA CPGs, and the TTE did not show disease with a potential to change management in any of those patients.

These data suggest that integration of CPGs into a perioperative protocol has the potential to improve the efficiency of preoperative evaluation, reduce resource utilization, and reduce the time to surgery without sacrificing patient safety. In our series, use of CPGs would have reduced unnecessary TTE by 34% without missing any important disease. It is also worth noting that, in addition to decreasing cost, following CPGs may help expedite surgery, as TTE was associated with an increased time until surgery in our study population and investigators from other institutions have also reported surgical delays associated with waiting for TTE to be performed15-17. We think that the ACC/AHA guidelines represent clear, objective, evidence-based criteria for triaging which patients need more advanced cardiac evaluation, creating direct cost-savings by eliminating unnecessary testing without affecting patient outcomes.

There are several limitations to this study. Although we used data from a prospectively collected registry, the study was inherently retrospective and thus subject to biases frequently encountered in retrospective studies. We were able to evaluate TTE results only for disease that might change management on the basis of cardiac factors shown to affect anesthesia and perioperative care in the literature. However, even with a relatively liberal definition of these diagnoses, we still found that actionable information is infrequently provided by TTE (for 14% of the patients in this study). Another study limitation is that the charts were assessed by a single observer, which introduces the potential for bias. However, we based our analysis on objective parameters (e.g., documented history of heart failure, newly identified valvular disease, etc.), which hopefully minimized the potential for interobserver variability. Finally, although we did note an association between TTE and increased time to operative treatment, the patients who underwent TTE were also more medically frail, as seen by a difference in the Charlson Comorbidity Index and increased age. Therefore, we cannot definitively conclude that the delay in operative treatment resulted solely from the performance of TTE. Despite these limitations, we believe that this analysis provides valuable information by establishing a quantitative basis for utilization of the ACC/AHA preoperative guidelines in the geriatric hip fracture population. The utility of the guidelines for patients with dementia is still an open question. In our cohort, 8 of the 34 patients for whom TTE was performed outside of the ACC/AHA guidelines had dementia that limited their ability to provide a complete medical history. While the TTE of these patients did not yield important findings, the number of patients with dementia was small. Thus future studies specifically investigating preoperative evaluation of demented patients and the applicability of CPGs are warranted.

At our institution, preoperative TTE of patients with hip fracture was frequently ordered outside established ACC/AHA CPGs. Our study showed that TTE revealed disease likely to change management in 14% of the patients and suggested that following published CPGs would have reduced unnecessary TTE utilization by 34% without an increased risk of missed disease. Specifically, these CPGs were 100% sensitive and 40% specific for identifying patients who would have evidence of disease on TTE. We believe that these findings are translatable to any inpatient facility caring for patients with hip fracture and provide a useful algorithm to improve the efficiency of preoperative evaluation by reducing costs and avoiding unnecessary delays without adversely affecting patient outcomes.

Investigation performed at the Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina

Disclosure: There was no external funding source for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

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