Journal Logo

Original Article

Unnecessary Preoperative Cardiology Evaluation and Transthoracic Echocardiogram Delays Time to Surgery for Geriatric Hip Fractures

Hoehmann, Christopher L. DOa; Thompson, Jeffrey DOa; Long, Mitchell DOa; DiVella, Michael DOa; Munnangi, Swapna PhDb; Ruotolo, Charles MDa; Galos, David K. MDa

Author Information
Journal of Orthopaedic Trauma: April 2021 - Volume 35 - Issue 4 - p 205-210
doi: 10.1097/BOT.0000000000001941
  • Free

Abstract

INTRODUCTION

The incidence of geriatric hip fracture is increasing with approximately 300,000 occurring each year in the United States alone.1 The geriatric population frequently has many medical comorbidities, often including cardiac disease, and therefore a multidisciplinary approach is essential.2–5 A synchronized fragility fracture program has been shown to improve outcomes, lower costs, reduce lengths of hospital stay, and decrease both complications and mortality.2–4 Because of the diversity of this team effort, it is not uncommon for there to be different opinions on patient care, and it is therefore important for there to be an evidence based protocol for management and preoperative optimization.3,4

Hip fractures are associated with a high mortality rate as up to one-third of patients will die within 1 year and an even larger percentage will be hindered in the postoperative ambulatory status.2,6–10 The most recent evidence supports expeditious surgery to mitigate poor outcomes.6–8,10,11 Time greater than 24 hours to surgery is associated with increased complications secondary to immobilization, such as pneumonia and venous thromboembolism.11 In addition, hip fracture surgery delayed greater than 48 hours has been associated with elevated risk of 30 days and 1 year mortality.8,10,11

Minimizing the time between admission and surgery is a major goal for the multidisciplinary team caring for patients with hip fracture, but medical optimization of the comorbid conditions of elderly patients makes this challenging. Because heart disease remains the most frequent cause of postoperative mortality in the elderly population,5 those at increased cardiac risk are evaluated by cardiologists and may benefit from additional testing, such as a transthoracic echocardiogram (TTE).12 However, additional work-up sacrifices time to surgery and is financially costly.13,14 Therefore, advanced workup should be performed judiciously when it is likely that management or perioperative monitoring will be changed.15–17 It is difficult to identify which patients are at an increased risk, and therefore, the American College of Cardiology (ACC) and the American Heart Association (AHA) have created clinical practice guidelines (CPG) to assist this process.18 Recent studies however have reported a poor adherence to these guidelines.13–16,19–22 Safety net institutions with limited resources must pay special attention to increased costs associated with unnecessary testing and workup.

The purpose of this study was to evaluate adherence to the AHA and ACC CPG in regards to both cardiology consultation and TTE and what affect this has on time to the operating room. Despite data acquisition from a safety net institution, we hypothesized that both cardiology consultation and TTE are over used causing unnecessary delays to the operating room.

MATERIALS AND METHODS

After approval from the institutional review board, a retrospective review was performed of all patients 65 years of age or older admitted with hip fractures to an academic safety-net level 1 trauma center with a standardized hip fracture protocol between the years of 2016 and 2019. Hip fractures were classified per the OTA/AO Classification 31-A and 31-B. A prospectively generated registry created for patients meeting the hip fracture protocol was referenced to select patients for chart review and used for assortment of data. Once selected, a full chart review was performed for each patient to verify inclusion and exclusion criteria from the study and to record and verify data for statistical analysis.

Hip Fracture Protocol

Patients with a hip fracture 65 years of age or older are admitted to the surgical intensive care unit under care of the trauma surgery service. A multidisciplinary approach is used within 1 hour of hip fracture diagnosis. Along with comanagement of medical comorbidities, the medicine team is charged with determining preoperative risk stratification and making recommendations for preoperative optimization. These adjunctive entities can involve TTE or cardiology evaluation per the CPG created by the AHA and ACC (Table 1); however, they can operate outside of these guidelines.

TABLE 1. - Active Cardiac Conditions Should Undergo Cardiology Assessment.
Condition Example
Severe valvular disease Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or heart failure)
Severe aortic stenosis (mean pressure gradient 0.40 mm Hg, aortic valve area, 1.0 cm2, or symptomatic)
Significant arrhythmias Supraventricular tachycardia with uncontrolled ventricular rate (>100 bpm at rest)
Newly recognized symptomatic ventricular tachycardia arrhythmia
High degree atrioventricular block (Mobitz II and third degree heart block)
Symptomatic sinus bradycardia and/or sick sinus syndrome
Symptomatic bradycardia
Heart failure Decompensated heart failure NYHA functional class IV
Worsening or new-onset heart failure
Unstable coronary syndromes Acute coronary syndrome and/or myocardial infarct
Unstable angina
Recent myocardial infarction (<1 mo)
Adapted from the AHA/ACC guidelines used by other studies.15,18,24

Inclusion/Exclusion Criteria

Patients 65 years of age and older with fracture of the proximal femur (OTA/AO 31-A and 31-B)23 from 2016 to 2019 were selected from the hospital's prospectively generated trauma registry, then a full chart review was performed. Patients were excluded if they did not have surgery; which may be due to hospital transfer, death, contraindication to surgery, or refusal by family and patient. Patients were also excluded if they were younger than 65 years, did not have a femoral neck, intertrochanteric, or subtrochanteric hip fracture, if the fracture was periprosthetic, or if they were not admitted to the surgical intensive care unit or trauma surgery service.

Data Collection

Patients were selected from the prospectively generated hospital registry of hip fractures; then, all data were verified by a full-chart review of the electronic medical record (EMR). A full-chart review was performed by a resident physician specializing in orthopaedic surgery. Admission date and time was recorded from the emergency department triage note. Time and date of medicine consult was obtained from the time of the EMR order. Similarly, if a cardiology consult was placed, the time and date was obtained from the EMR. The time of surgery was obtained from the EMR operative logs. These times were used to calculate the difference in duration between admission and surgery. Charts were reviewed for indications per the AHA and ACC guidelines that would recommend a cardiology consultation (Table 1). Per the same guidelines, TTE is indicated for worsening known signs or symptoms of heart failure, known history of heart failure or valvular disease without TTE in the past year or worsening symptoms, dyspnea of unknown origin, or suspicion of moderate or greater valvular regurgitation or stenosis.21

Statistical Analysis

Statistical analysis was performed using SAS 9.4 (SAS Institute, Cary NC). Continuous variables were presented as mean ± SD. Frequency and percentages were used to present categorical variables. Differences in continuous variables were examined using student t test or Mann–Whitney U test as per the distribution. The Pearson χ2 test or Fisher exact test was used to examine the association of categorical variables with outcomes of interest. Logistic regression analysis was used to identify the risk factors associated with an unindicated cardiology consult in the adjusted model. Characteristics that were significantly associated with an unindicated cardiology consult in the unadjusted model were selected for inclusion as covariates in the adjusted model. A P-value <0.05 was considered statistically significant.

RESULTS

A total of 412 patients were retrieved from the prospective hip fracture registry from 2016 to 2019, but 51 were excluded leaving a total of 361 patients included in the analysis. Of those excluded, 10 transferred to another hospital, 7 expired before surgery, 2 were treated nonoperatively because of poor medical condition and nonambulatory status, and all others excluded did not fit the study's hip fracture criteria (eg, isolated greater trochanteric hip fracture without intertrochanteric extension and periprosthetic hip fracture). Demographic and clinical characteristic profiles were assembled (Table 2).

TABLE 2. - Demographic and Clinical Characteristics
Variable All (n = 361)
Age (y) 84.50 ± 8.17
Sex
 Male 270 (74.79%)
 Female 91 (25.21%)
Mechanism of injury
 Low 340 (94.18%)
 High 21 (5.82%)
Optimization
 Low 148 (41.00%)
 Moderate 49 (13.57%)
 High 164 (45.43%)
Comorbidities
 Hypertension 259 (71.75%)
 Congestive heart failure 58 (16.07%)
 Hyperlipidemia 142 (39.34%)
 Diabetes Mellitus 69 (19.11%)
 Osteoporosis 13 (3.60%)
 History of cardiac arrest 57 (15.79%)
 Depression 25 (6.93%)
 Chronic obstructive pulmonary disease 39 (10.80%)
 Cerebrovascular accident 41 (11.36%)
 Gastroesophageal reflux disease 43 (11.91%)
 End stage renal disease 13 (3.60%)
 Previous fragility fracture 5 (1.39%)
Anticoagulant use
 Home aspirin 89 (24.65%)
 Apixaban 12 (3.32%)
 Coumadin 33 (9.14%)
 Other 46 (12.74%)
Hospital disposition
 ALC (alternate level of care) 1 (0.28%)
 Acute rehabilitation 182 (50.42%)
 Died 9 (2.49%)
 Home 14 (3.88%)
 SAR (subacute rehab) 139 (38.50%)
 SNF 5 (1.39%)
 Others 11 (3.05%)
Complications 17 (14.71%)
Hospital length of stay (d) 5.42 ± 3.51
Injury severity score 9.67 ± 2.03
Time to operating room (hours) 21.99 ± 14.42
Fracture type
 Femoral neck 145 (40.17%)
 Intertrochanteric 209 (57.89%)
 Subtrochanteric 7 (1.94%)

Of the 361 total patients analyzed, 160 (44.4%) received cardiology consultation despite only 64 (17.7%) meeting criteria. Of the group of patients that received cardiology consultation, only 61 (38%) met criteria. Furthermore, 143 (89.4%) patients who received cardiology consultation also received a TTE, despite only 54 (33.8%) being indicated. The most common indication for cardiology consultation was a suspicion of severe valvular disease.

Time to surgery in hours (Table 3) was found to be significantly longer in the group receiving cardiology consultation (25.42 ± 14.54 vs. 19.27 ± 13.76, P-value <0.001). Time to surgery was significantly longer for those patients receiving preoperative TTE (26.00 ± 15.33 vs. 18.94 ± 12.92, P-value <0.001). No patient in any group received advanced interventions, such as cardiac catheterization or cardiac vessel or valvular surgery, before hip fracture surgery.

TABLE 3. - Cardiology Consultation Information
Variable Cardiology Consult Placed (n = 160; 44.32%) Cardiology Consult Indicated (n = 64; 17.73%)
TTE performed 143 (89.38%) 56 (87.50%)
Indicated cardiology consult 61 (38.13%) 64 (100%)
Unstable coronary syndrome 10 (6.25%) 9 (14.06%)
Decompensated CHF (congestive heart failure) 7 (4.38%) 7 (10.94%)
Significant arrhythmias 14 (8.75%) 16 (25%)
Severe valvular disease 42 (26.25%) 43 (67.19%)
Dyspnea of unknown origin 3 (1.88%) 3 (4.69%)
Worsening of known symptoms of HF 7 (4.38%) 7 (10.94%)
Known history of valve dysfunction 28 (17.50%) 22 (34.38%)
Suspicion of moderate or greater valve disease 38 (23.75%) 32 (50.00%)
TTE indicated (per AHA/ACC CPG) 54 (33.75%) 42 (65.63%)

Further analysis was performed to determine risk factors for those who received an unindicated cardiology consultation (Table 4). The most likely factor for receiving an unindicated cardiology consultation was the home medication apixaban (odds ratio 5.6). Other anticoagulants also tended to prompt unnecessary cardiology consults, as did patients with a history of osteoporosis, hypertension, and congestive heart failure.

TABLE 4. - Length of Stay and Time to Surgery
Cardio Consult No Cardio Consult P TTE No TTE P
Length of stay (d) 5.80 ± 4.66 5.12 ± 3.32 0.0738 5.65 ± 3.10 5.24 ± 3.79 0.2682
Time to surgery (hours) 25.42 ± 14.54 19.27 ± 13.76 <0.001* 26.00 ± 15.33 18.94 ± 12.92 <0.001*
*Indicates statistically significant value.

DISCUSSION

The results of this study demonstrate the AHA/ACC CPG to be a reasonable starting point for assessing the appropriateness of preoperative cardiology consultation in patients with hip fracture. All 64 patients who were indicated for preoperative cardiology consultation received one. Most patients indicated for cardiology consultation were indicated because of a suspicion of valvular disease (67.2%), with significant arrhythmias being the second most common indication (25%). Moreover, these data show that most patients indicated for cardiology consultation were also indicated for TTE per the same guidelines (65.6%). This demonstrates the CPG's efficacy as a screening tool.

The results of this study also show that most cardiology consultations and TTE's are placed without indications supported by the AHA/ACC CPG. In total, 60% (96/160) of cardiology consultations placed in this sample did not meet accepted criteria for doing so. Similarly, only 48% (96/199) of performed TTE's met indications. These numbers are slightly favorable to the available literature. Stitgen et al15 demonstrated only 29% of their sample receiving cardiac consultations in geriatric hip fractures met the same AHA/ACC indications. Adair et al showed that only 34% of preoperative TTE's performed for geriatric hip fracture met the same guidelines.15,21 It seems that providers frequently go outside of the AHA/ACC CPG when indicating patients with geriatric hip fracture for preoperative cardiology assessment and TTE. It is not surprising that this study indicates fewer unnecessary cardiology consultations and TTE's than others being that it were performed at a safety-net hospital with limited resources; however, it is still unfortunate and perhaps wasteful that most of these measures are performed without approved indications.

Unindicated preoperative cardiology consultation and TTE is costly because these data show a delayed time to surgery associated with both. On average, patients not receiving either of these added steps went to the operating room under 24 hours whereas the others, on average, did not. Adair et al demonstrated similar findings with an increase in time to the operating room in those receiving cardiology consultations; however, their increase was much larger in this group at 20.8 hours compared with 6.2 hours in this study. They also demonstrated an increase in length of stay by 2.6 days for those receiving preoperative cardiology assessment; however, this study only demonstrated a trend toward increased hospital length of stay but was not statistically significant.21

Risk factor analysis demonstrated increased age, hypertension, congestive heart failure, osteoporosis, and home anticoagulant usage were all associated with a statistically significant increased odds ratio for unindicated cardiology consult (Table 4). The largest factor drawing unindicated cardiology consultation was the presence of home medication apixaban. The reason for this could be multifactorial. There is no reversal agent for this anticoagulant and a delayed operating time is to be expected, therefore cardiology can be consulted in the interim. In addition, despite meeting the AHA/ACC CPG for cardiology consult, a hospitalist may consider a patient on apixaban to be at increased risk and warrant cardiology evaluation. Despite investigation of these risk factors, it is unclear why so many unindicated cardiology consultations are requested (Table 5).

TABLE 5. - Unadjusted and Adjusted Risk Factor Analysis of Receiving an Unindicated Cardiology Consult
Risk Factor Unadjusted Adjusted
OR (95% CI; P-value) OR (95% CI; P-value)
Age 1.06 (1.027–1.094; 0.0003*) 1.060 (1.025–1.096; 0.0007*)
Sex female (reference male) 0.862 (0.510–1.456; 0.5788)
Mechanism of injury low (reference high) 0.941 (0.355–2.499; 0.9033)
Hypertension 2.124 (1.198–3.766; 0.0100*) 1.460 (0.792–2.695; 0.2255)
Congestive heart failure 2.146 (1.197–3.848; 0.0104*) 1.640 (0.875–3.073; 0.1224)
Hyperlipidemia 0.841 (0.521–1.356; 0.4777)
Diabetes mellitus 1.674 (0.959–2.923; 0.0699)
Osteoporosis 3.246 (1.063–9.911; 0.0387*) 3.679 (1.106–12.240; 0.0337*)
History of cardiac arrest 0.665 (0.336–1.318; 0.2476)
Depression 1.032 (0.417–2.551; 0.9463)
Chronic obstructive pulmonary disease 1.201 (0.583–2.474; 0.6240)
Cerebrovascular accident 1.828 (0.930–3.592; 0.0800)
Gastroesophageal reflux disease 0.671 (0.309–1.455; 0.3120)
End stage renal disease 2.351 (0.770–7.716; 0.1330)
Previous fragility fracture 0.658 (0.073–5.962; 0.7101)
Home aspirin 2.101 (1.266–3.505; 0.0041*) 1.814 (1.226–16.257; 0.324*)
Apixaban 5.670 (1.668–19.278; 0.0055*)
Coumadin 1.168 (0.535–2.550; 0.6975)
Other anticoagulants 2.833 (1.054–5.336; 0.0013*) 2.218 (1.122–4.383; 0.0219*)
*P < 0.05.
OR, odds ratio; CI, confidence interval.

Attempts to understand the delays to surgery for geriatric hip fractures have been a topic of great interest to many investigators. Ricci et al14 found additional cardiac testing did not change management before surgery but was associated with longer time to surgery. Data from that study was extrapolated to estimate preoperative cardiac testing costing $47,000,000 annually if only 15% of patients undergo testing, which is a lower rate than the 55% demonstrated in our study or other similar studies.14 O'hEireamhoin et al further supports this notion, finding that preoperative testing may sometimes produce medication changes but no increased intervention in the form of angiography or surgery at the cost of significant delays to surgery.19 Cluett et al20 found patients who received advanced cardiac testing also had worse postoperative mobility in addition to significant delays to surgery. Several other studies have also identified unnecessary over screening when using the AHA/ACC CPG for preoperative assessment.13,15,20,21

There is an estimated $240 billion annual cost for treating hip fractures by the year 2040.14 Additional consideration should be made when optimizing geriatric hip fracture patients for surgery at a safety net hospital. The results of this study extend the unfortunately high rate of unindicated cardiology consultation to a safety-net hospital where funds are increasingly limited. The approximate cost of preoperative cardiac testing has been estimated to be $1250 per patient but also noted that this underestimates a variety of factors that cannot be quantified.14 Every effort possible should be made to reduce waste and spend funds appropriately, while also optimizing patient care.

In this study, most advanced cardiology assessment and testing was performed despite not meeting indications recommended by the AHA/ACC CPG for patients with geriatric hip fracture. The effectiveness of CPG indicating TTE is unclear. These data also showed both advanced cardiology assessment and TTE to be associated with delays to surgery, which is associated with increased morbidity and mortality. Furthermore, in our cost-constrained safety net hospital, we found similarly high rates of poor CPG compliance despite the costliness associated with these adjunctive tests and evaluations. Cardiology consultation and TTE are frequently performed outside of AHA/ACC CPG by every study known to these authors. We propose that either the guidelines should be re-evaluated or the hospital systems scrutinize their own practices to achieve better compliance. The authors believe that the findings of this study are relevant for any institution that treats patients with geriatric hip fracture intending to improve performance and be more cost efficient.

ACKNOWLEDGMENTS

The authors thank Maksim Vaysman for his assistance with data collection. The authors also thank Sara Cardoza-Stolberg for her wisdom in navigating the trauma registry and obtaining data from our institution's records.

REFERENCES

1. Brauer CA, Coca-Perraillon M, Cutler DM, et al. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573–1579.
2. Swart E, Vasudeva E, Makhni EC, et al. Dedicated perioperative hip fracture comanagement programs are cost-effective in high-volume centers: an economic analysis. Clin Orthop Relat Res. 2016;474:222–233.
3. Kates SL, Mendelson DA, Friedman SM. The value of an organized fracture program for the elderly: early results. J Orthop Trauma. 2011;25:5.
4. Friedman SM. Impact of a comanaged geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med. 2009;169:1712.
5. Roche JJW, Wenn RT, Sahota O, et al. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ. 2005;331:1374.
6. Goldacre MJ. Mortality after admission to hospital with fractured neck of femur: database study. BMJ. 2002;325:868–869.
7. Miller C. Survival and ambulation following hip fracture. J Bone Joint Surg Am. 1978;60:930–934.
8. Roberts SE. Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study. BMJ. 2003;327:771–775.
9. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ. 2000;11:651.
10. Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization, and functional status: a prospective study. Am J Public Health. 1997;87:398–403.
11. Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anesth. 2008;55:146–154.
12. Canty DJ, Royse CF, Kilpatrick D, et al. The impact of pre-operative focused transthoracic echocardiography in emergency non-cardiac surgery patients with known or risk of cardiac disease: pre-operative echocardiography in emergency surgery. Anaesthesia. 2012;67:714–720.
13. Alibhai M, Fawdington R, Sharma A, et al. Does pre-operative echocardiography delay hip fracture surgery? Indian J Anaesth. 2013;57:408.
14. Ricci WM, Rocca GJD, Combs C, et al. The medical and economic impact of preoperative cardiac testing in elderly patients with hip fractures. Injury. 2007;38:49–52.
15. Stitgen A, Poludnianyk K, Dulaney-Cripe E, et al. Adherence to preoperative cardiac clearance guidelines in hip fracture patients. J Orthop Trauma. 2015;29:500–503.
16. Bernstein J, Roberts FO, Wiesel BB, et al. Preoperative testing for hip fracture patients delays surgery, prolongs hospital stays, and rarely dictates care. J Orthop Trauma. 2016;30:78–80.
17. Kalem M, Kocaoğlu H, Şahin E, et al. Impact of echocardiography on one-month and one-year mortality of intertrochanteric fracture patients. Acta Orthop Traumatol Turc. 2018;52:97–100.
18. Fleisher LA, Fleischmann KE, Auerbach AD, et al. ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol. 2014;64:e77–e137.
19. O'hEireamhoin S, Beyer T, Ahmed M, et al. The role of preoperative cardiac investigation in emergency hip surgery. J Trauma. 2011;71:1345–1347.
20. Cluett J, Caplan J, Yu W. Preoperative cardiac evaluation of patients with acute hip fracture. Am J Orthop (Belle Mead NJ). 2008;37:32–36.
21. Adair C, Swart E, Seymour R, et al. Clinical practice guidelines decrease unnecessary echocardiograms before hip fracture surgery. J Bone Joint Surg Am. 2017;99:676–680.
22. Smeets SJM, Poeze M, Verbruggen JPAM. Preoperative cardiac evaluation of geriatric patients with hip fracture. Injury. 2012;43:2146–2151.
23. Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018;32:S1–S170.
24. Siu CW, Sun NCH, Lau TW, et al. Preoperative cardiac risk assessment in geriatric patients with hip fractures: an orthopedic surgeons' perspective. Osteoporos Int. 2010;21:587–591.
Keywords:

geriatric hip fractures; transthoracic echocardiogram; cardiology clearance; delay to surgery

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.