OTA 2013 Posters

Scientific Poster #28 Geriatric OTA 2013

The Disutility of Preoperative Diagnostic Testing for Geriatric Hip Fractures

Joseph Bernstein, MD, MS; Francis O. Roberts; Samir Mehta, MD; Jaimo Ahn, MD, PhD;
University of Pennsylvania, Philadelphia, Pennsylvania, USA

Background/Purpose: Geriatric patients who undergo delayed surgery after presenting to the hospital with a low-energy hip fracture have an increased risk of mortality compared to patients who undergo earlier surgery. However, because of confounding, the assertion that delays to surgery cause increased mortality remains controversial. To an extent, common practice has come to accept that delays imposed to improve the patients' ability to tolerate the perioperative environment are admirable; however, delays resulting in limited optimization of the patient may be detrimental. Therefore, we ask, "Is preoperative testing associated with an increased interval between presentation and surgery itself?" Similarly, we ask, "Among those patients subjected to testing, how often were preoperative interventions performed as a result of the testing?"

Methods: Electronic medical records were reviewed (IRB approved) for 100 consecutive geriatric hip fractures admitted through the Emergency Department (ED) who underwent surgery at our institution. For each patient, the time of presentation to the ED and the time surgery was performed were recorded, from which the "time to surgery interval" or “interval” was derived. These 100 patients were then stratified according to whether or not a medical consultant requested further preoperative medical testing, and the interval for the two groups was calculated. Further, the results of the testing and the actions that followed were recorded.

Results: The mean “interval” for all 100 patients was 1.79 days. There were 77 patients for whom no specialized preoperative testing was performed. Their mean “interval” was 1.66. For the 23 patients who underwent testing (cardiac enzyme series, 1; ICD interrogation, 1; stress testing, 3; and echocardiography, 18), the mean “interval” was 2.22 (P = 0.016). In no instances were any specific preoperative interventions taken in response to the test results.

Conclusion: Preoperative testing for patients with low-energy hip fractures is associated with an increased time to surgery of more than one-half day and, on average, subjects these patients to an “interval” of greater than 2 days (a threshold previously linked to increased risk of mortality). Despite that investment of time, in none of the patients was any substantial clinical intervention undertaken directly in response to the test results. That zero rate of clinical intervention may be related, in part, to the relatively benign results obtained. We conclude that patient care may be improved by more rigorous criteria regarding testing—guided by results that would lead to treatment change—or by more expedited use of tests, all to prevent unnecessary surgical delay.

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.