Validation of a prospective mortality prediction score for hip fracture patients

Abstract

Purpose Although mortality prediction tools are the subject of significant interest as components of comprehensive hip fracture protocols, few have been applied or validated to prospectively inform ongoing patient management. Five regional hospitals are currently generating real-time mortality risk scores for all adults at the time of admission using available laboratory and comorbidity data (Cowen et al. J Hosp Med 9(11):720-726, 2014). Although results for aggregated conditions have been published, the primary aim of this study is to determine how well prospectively calculated scores predict mortality for hip fracture patients specifically. Methods Using a five-hospital database, 1376 patients who were prospectively scored on admission were identified from January 2013 to April 2017, cross-referencing ICD9/10 diagnosis and procedure codes for AO/OTA 31A1 through 31B3 fractures. Prospective mortality scores have been previously divided into 5 risk categories to facilitate ease of clinical use. Vital status was determined from hospital data, Social Security and Michigan Death Indices. Results Prospective scores demonstrated good mortality prediction, with AUCs of 0.80, 0.73, 0.74 and 0.74 for in hospital, 30-, 60-and 90-day mortality, respectively. Patients in the top 2 mortality risk categories represented 30% (410/1376) of the cohort and accounted for 78% (25/32) of the inpatient and 59% (57/97) of the 30 day deaths. Conclusions Implementation of this real-time mortality risk tool is feasible and valid for the prediction of short-to mediumterm mortality risk for hip fracture patients, and potentially offers valuable information to guide ongoing patient management decisions such as admitting service or level of care.

Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study

“…Patients are stratified by calculated risk scores according to the health systems' proprietary scoring system. 10 Patients in high-risk categories are admitted to a medicine service, and those in low-risk categories are admitted to the orthopaedic service with medicine consult. Case management and social work are consulted on admission.…”

A Tool to Estimate Risk of 30-day Mortality and Complications After Hip Fracture Surgery: Accurate Enough for Some but Not All Purposes? A Study From the ACS-NSQIP Database

“…The 30-day postoperative mortality for surgical hip fracture repair is high, ranging on average from 5.0% to 13.3% [9,10]. But those percentages are averages; the actual risk for an individual patient may be lower or higher than the average, depending on factors such as frailty, comorbidities, and prefracture functioning [6,11]. The risk-reward calculus for most patients with hip fractures favors surgical repair [6,11].…”

“…But those percentages are averages; the actual risk for an individual patient may be lower or higher than the average, depending on factors such as frailty, comorbidities, and prefracture functioning [6,11]. The risk-reward calculus for most patients with hip fractures favors surgical repair [6,11]. However, some patients have low prefracture functioning and/or very high risk of postoperative mortality, making the choice between surgical and nonsurgical management more difficult.…”

“…In addition to improving the quality of personalized informed consent for all patients, perhaps one of the primary values of risk prediction in the context of hip fracture is to identify accurately those patients who are unlikely to survive 30 days after surgery [6,11]. Patients who are very likely to die within 30 days may benefit from personalized information about the risk of surgery within a shared decision-making process and may wish to consider nonoperative management or palliative care rather than surgery [6,20].…”

“…Although studies and meta-analyses have identified factors associated with mortality and major complications after surgical repair of hip fractures [1,3,15,29], these studies were not designed to estimate the risks of experiencing adverse events for individual patients. Existing models and tools for predicting postoperative mortality and complications have several limitations; some come only from a single institution [4,27], others have not been internally or externally validated [27], have low overall accuracy [4], have low accuracy for subgroups of patients [9], are limited to in-hospital mortality [28], or include laboratory values that are frequently missing or need additional testing [11,25,28]. Some of the most promising existing tools for predicting 30-mortality and complications are the models reported by Pugely et al [25]; in that study, the authors developed and internally validated reasonably accurate and well-calibrated models of 30-day mortality (C-index 0.70) and major complications (C-index 0.69).…”