12891-017-1768-X

Chen et al. BMC Musculoskeletal Disorders (2017) 18:410 DOI 10.1186/s12891-017-1768-x RESEARCHARTICLE Open Access The relationship between preoperative American Society of Anesthesiologists Physical Status Classification scores and functional recovery following hip-fracture surgery Li-Huan Chen1,2, Jersey Liang3,4, Min-Chi Chen5, Chi-Chuan Wu6, Huey-Shinn Cheng7, Hsiu-Ho Wang1 and Yea-Ing Lotus Shyu6,8,9,10* Abstract Background: Little is known about the relationship of the American Society of Anesthesiologists Physical Status Classification scores (ASA scores) on patient outcomes following hip fracture surgery in Asian countries. Therefore, this study explored the association of patients’ preoperative ASA scores on trajectories of recovery in physical functioning and health outcomes during the first year following postoperative discharge for older adults with hip-fracture surgery in Taiwan. Methods: The data for this study was generated from three prior studies. Participants (N = 226) were older hip-fracture patients from an observational study (n = 86) and two clinical trials (n =61andn = 79). Participants were recruited from the trauma wards of one medical center in northern Taiwan and data was collected prior to discharge and at 1, 3, 6, and 12 months after hospital discharge. Participants were grouped as ASA class 1–2 (50.5%; ASA Class 1, n =7;ASA Class 2, n = 107) and ASA class 3 (49.5%, n = 112). Measures for mortality, service utilization, activities of daily living (ADL), measured by the Chinese Barthel Index, and health related quality of life, measured by Medical Outcomes Study Short Form-36, were assessed for the two groups. Generalized estimating equations (GEE) were used to analyze the changes over time for the two groups. Results: During the first year following hip-fracture surgery, ASA class 1–2 participants had significantly fewer rehospitalizations (6%, p = .02) and better scores for mental health (mean = 70.29, standard deviation = 19.03) at 6- and 12-months following discharge than those classified as ASA 3. In addition, recovery of walking ability (70%, p = .001) and general health (adjusted mean = 58.31, p = .003) was also significantly better than ASA 3 participants. Conclusions: There was a significant association of hip-fracture patients classified as ASA 1–2 with better recovery and service utilization during the first year following surgery. Interventions for hip fractured patients with high ASA scores should be developed to improve recovery and quality of life. Keywords: American Society of Anesthesiologists scores, Asa, Health-related quality of life, Hip-fractured adults, Mortality, Physical function recovery, Service utilization * Correspondence: [email protected] 6Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, 5 Fu-Hsing Street, Guishan District, Taoyuan 33305, Taiwan 8School of Nursing, College of Medicine, and Healthy Aging Research Center, Chang Gung University, 259 Wenhua 1st Road, Guishan District, Taoyuan 33302, Taiwan Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Chen et al. BMC Musculoskeletal Disorders (2017) 18:410 Page 2 of 9 Background Methods The worldwide incidence of hip fracture in 2000 was 1.6 Data source and participants million and is expected to rise dramatically as of 2050 to This was a secondary analysis of data from three previ- approximately 6.3 million, due to the ongoing aging of ously published studies of 285 participants recruited from the world’s population [1]; an estimated 50% of those the trauma wards of a medical center in northern Taiwan. hip fractures are expected to occur in Asian populations We excluded 59 of the participants due to incomplete data [2]. Hip fracture affects the life expectancy and mortality relevant to this study. The hip-fracture participants for of persons aged 65 years and older [3]. The mortality this analysis (N = 226) were from an observational study rate for elderly patients with hip fracture has been esti- (n = 86 [13]), and control groups were non-interventional mated to be between 21.5% to 27.3% within 1 year of participants from two clinical trials (n =61[14]and fracture [3, 4]. In a previous study the 1-year mortality n = 79 [15]). The Chang Gung Memorial Hospital Re- rate of elderly Taiwanese persons with hip fracture was search Ethics Board approved these studies (NHRI-EX92- found to be 15.5%, with only 56.1% recovering their pre- 9023PL: CMRP819, 89–25, and 94-422c) and written in- vious performance of activities of daily living (ADL) and formed consent was obtained for each participant. Data 37.9% recovering their instrumental ADL (IADL) 1 year for these three studies were collected at baseline (prior to following hip fracture [5]. hospital discharge) and at 1-, 3-, 6-, and 12-month post- One widely used measure of preoperative function is discharge. For all three studies, the inclusion criteria for the American Society of Anesthesiologists Physical Sta- hip-fracture patients were as follows: 1) age ≥ 60 years, 2) tus Classification (ASA class), which has been found to hospitalization resulting from a hip fracture that was sub- predict patient outcomes after hip fracture. For example, sequently treated with internal fixation or arthroplasty, 3) patients with an ASA class of 1 or 2 (healthy or with a place of residence located in northern Taiwan, and 4) a mild systemic illness, respectively) were more likely to lack of any severe cognitive impairment as determined by be living at home 1 year after hip fracture [6, 7]. Simi- a physician or by a score of ≥10 on the Chinese Mini- larly, 1-year mortality following surgery for hip fracture Mental State Examination (CMMSE) [16]. Because data was almost 9-times higher for patients with an ASA was collected from self-report measures, patients found to class of 3 or 4 (severe systemic illness) than patients with have severe cognitive impairment were excluded if they an ASA class 1 or 2 [8]. In addition, higher ASA grades were unable to complete the measures. were associated with poorer 30-day outcomes, which in- cluded higher mortality, number of comorbidities, and Measures number of inpatient readmissions [9, 10]. Higher ASA ASA score scores have also been associated with greater pain, less An anesthesiologist, aware of the study, assessed partici- distance walked and poorer movement [11]. pants’ ASA scores, which was determined by the partici- Currently, there is little knowledge regarding the correl- pant’s medical history. In Taiwan, ASA scores are divided ation between preoperative ASA classes of hip fracture for into six classes: a completely healthy patient is given a persons in Asian countries and patient outcomes. Although class 1 ASA score; a patient with mild systemic disease is the ASA score has been correlated with several factors re- considered class 2; a patient with a severe but not incap- garding patient outcomes [2, 12] no studies have explored acitating systemic disease is class 3 ASA; a patient with an the association between ASA scores and the trajectory of incapacitating disease that is also life-threatening is class 4 recovery or longitudinal changes in health outcomes fol- ASA; and a moribund patient not expected to live for 24 h lowing hip fracture surgery in Taiwan [13]. Therefore, the with or without surgery is class 5. A class 5 ASA score is aim of the present study was to determine the association, also taken to indicate a need for emergency surgery. A if any, of the preoperative ASA classes of a sample of older class 6 ASA score is provided to patients classified as hip fracture patients in Taiwan on recovery trajectories as brain-dead and eligible to be designated as organ donors. measured by physical functioning and health outcomes The validity of using ASA scores to indicate a patient’s over the course of the first year following hospital dis- long-term mortality and complications following total hip charge. We hypothesized that during the first year after sur- arthroplasty [6, 17] and hip-fracture surgery [8] has been gical treatment for hip fracture, older patients with severe well established. ASA scores are routinely used in Taiwan preoperative systemic disease (ASA score 3 and 4) would to assess for anesthesia and surgery risk. have higher mortality as well as increased service utilization, emergency room visits, and institutionalization. Activities of daily living (ADL) In addition, we hypothesized these patients would have The Chinese Barthel Index (CBI) was used to measure poorer recovery in walking ability, performance of ADLs, each patient’s ability to perform ADL. The CBI exhibits and health-related quality of life than those with mild sys- satisfactory reliability and validity when used as an assess- temic disease (ASA grade 1 and 2) or healthy patients. ment tool for assessing Taiwanese older adults with hip Chen et al. BMC Musculoskeletal Disorders (2017) 18:410 Page 3 of 9 fracture [18]. Specifically, the CBI is used to measure the Covariates level of dependency of a patient with regard to each of the In the analysis for predictors of outcome variables, we following activities: bathing, grooming, dressing, eating, controlled for covariates of time, gender, age, type of using the toilet, transferring, climbing stairs, and bowel/ surgery (internal fixation or arthroplasty), pre-fracture bladder control.

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