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A retrospective study suggests mortality and morbidity might be lower with surgical repair. A common dilemma is whether to repair hip fractures in nursing home patients with severe dementia. To explore this issue, investigators used a Medicare dataset to identify 3083 nursing home patients (mean age, 84) with advanced dementia and hip fractures; 15% were managed without surgery. Patients with directives that prohibited hospitalization were excluded. One third of all patients died within 6 months; mean survival for surgical patients was 1.4 years compared with 0.4 years for nonsurgical patients. In analyses adjusted for a wide range of demographic and clinical factors that might influence management decisions, all-cause mortality was about 12% lower among surgical patients. In analyses stratified by whether patients were ambulatory before their hip fractures (28% were ambulatory), results were the same. A large proportion of patients who were ambulatory at the time of hip fracture were treated surgically, but of those who were alive at 6 months, only about 10% remained ambulatory. Also at 6 months, surgical patients experienced less pain (22% less likely) and fewer pressure ulcers (36% less likely). |
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COMMENT
Despite statistical adjustment, these results still might be confounded by underlying differences between patients who were selected for surgery and those who were not. Although the mortality data favored surgical patients, the pain and pressure ulcer outcomes, labelled as “secondary” by the authors, might be equally important. The high rate of death within 6 months, regardless of management choice, and the high likelihood of becoming nonambulatory despite surgical repair, also should be noted.