Original Article Geriatric Orthopaedic Surgery & Rehabilitation 1-6 Predictors of Mortality in Elder Patients ª The Author(s) 2017 Reprints and permission: With Proximal Humeral Fracture sagepub.com/journalsPermissions.nav DOI: 10.1177/2151458517728155 journals.sagepub.com/home/gos Chad M. Myeroff, MD1, Jeffrey P. Anderson, ScD, MPH2, Daniel S. Sveom, MD1, and Julie A. Switzer, MD1,3 Abstract Background: Known possible consequences of proximal humerus fractures include impaired shoulder function, decreased independence, and increased risk for mortality. The purpose of this report is to describe the survival and independence of elderly patients with fractures of the proximal humerus, treated in our institution, relative to patient characteristics and treatment method. Methods: Retrospective cohort study from 2006 to 2012. Setting: Community-based hospital with level 1 designation. Patients/Participants: Three hundred nineteen patients 60 years who presented to the emergency department with an isolated fracture of the proximal humerus were either admitted to the inpatient ward for the organization and provision of immediate definitive care or discharged with the expectation of coordination of their care as an outpatient. Treatment was nonoperative or operative. Outcome Measures: One- and 2-year mortality. Results: Significant predictors of mortality at 1 year included Charlson Comorbidity Index (CCI; continuous, hazard ratio [HR] ¼ 1.40; 95% confidence interval [CI]: 1.06-1.86), body mass index (BMI; <25 vs 25; HR ¼ 3.43; 95% CI: 1.45-8.14), and American Society of Anesthesiologists (ASA) disease severity score (3-4 vs 1-2; HR ¼ 4.48; 95% CI: 1.21-16.55). In addition to CCI and BMI, reliance on a cane/walker/wheelchair at the time of fracture predicted mortality at 2 years (vs unassisted ambulation; HR ¼ 3.13; 95% CI: 1.59-5.88). Although the Neer classification of fracture severity significantly correlated with inpatient admission (P < .001), it was not significantly associated with mortality or with loss of living or ambulatory independence. Among admitted patients, 64% were discharged to a facility with a higher level of care than their prefracture living facility. Twenty percent of study patients experienced a loss in ambulatory status by at least 1 level at 1 year postfracture. Conclusion: In a cohort of elderly patients with fractures of the proximal humerus, patient characteristics including comorbidities, ASA classification, and lower BMI were associated with increased mortality. Specifically, those admitted at the time of fracture and treated nonoperatively had the highest mortality rate and, likely, represent the frailest cohort. Those initially treated as outpatients and later treated operatively had the lowest mortality and, likely, represent the healthiest cohort. These data are inherently biased by prefracture comorbidities but help stratify our patients’ mortality risk at the time of injury. Keywords geriatric trauma, trauma surgery, upper extremity surgery, fragility fractures, osteoporosis, mortality, proximal humerus fracture, hospital admission Submitted May 23, 2017. Revised July 22, 2017. Accepted July 22, 2017. Introduction bearing, surgical repair within 48 hours, and the stratification of risk relative to age and comorbidities.5-10 In contrast to this Proximal humerus fractures are the third most common fracture work in hip fracture care, relatively little analogous data exist in patients over the age of 65.1 Historically, these patients have been considered to be more robust than patients with hip frac- 2-3 tures but frailer than patients with distal radius fractures. 1 Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Although the incidence of these fractures is rising, only sparse MN, USA literature addresses the significance of this injury in elderly 2 HealthPartners Institute, Bloomington, MN, USA individuals, especially in frail elderly individuals.4 3 Department of Orthopaedic Surgery, Regions Hospital, St Paul, MN, USA During previous decades, the implication of hip fractures on Corresponding Author: morbidity and mortality has been well studied and has also Julie A. Switzer, Department of Orthopaedic Surgery, Regions Hospital, 640 driven care. Examples of this effect include the development Jackson St, MS11503L, St Paul, MN 55101, USA. of hip fracture protocols that prescribe immediate full weight Email: [email protected] Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Geriatric Orthopaedic Surgery & Rehabilitation Figure 1. Illustration of ambulatory status and living independence levels. to help counsel elderly patients regarding survival or living independence following a fracture of the proximal humerus. The primary aim of this study was to identify risk factors for Figure 2. Study sample and clinical management. mortality in elderly patients with proximal humeral fracture. Secondarily, we investigated correlates in patient characteris- classification schemes.11,12 Mortality was captured from the tics and patient outcomes. Specifically, we examined mortality EMRs when documented or from Ancestry.com, if date of death in elderly patients with isolated fractures of the proximal was not recorded in the EMRs or if clinical activity was not humerusinrelationtopatientfactors including comorbid documented beyond 2 years of fracture. Those not identified as conditions, body mass index (BMI), hospital admission deceased at 1-year or 2-year postinjury by the EMRs or Ances status, treatment method, level of discharge facility, and level try.com were assumed to be alive at that point. 13,14 of prefracture patient independence. Statistical Methods Patients and Methods Descriptive statistics were used to summarize the patient The research was performed at a community-based hospital with population as well as changes in living and ambulatory status level 1 trauma center designation. By searching Current Proce- pre- and postfracture. Cox proportional hazards regression dural Terminology and International Classification of Diseases, analysis evaluated 1-year and 2-year mortality in relation to Ninth Revision codes, we identified 648 patients aged 60 years patient factors with results reported as hazard ratios (HRs) with with fractures of the proximal humerus, treated between 95% confidence intervals (CIs). For all other outcomes, we 2006 and 2012. Eligible study patients were 60 years old with constructed multivariable generalized linear regression models an isolated and unilateral fracture of the proximal humerus. to calculate b estimates (continuous outcomes) or odds ratios Exclusion criteria included polytrauma patients, bilateral (ORs; binary outcomes). Independent variables for final fractures, shoulder dislocations, and pathologic fractures. adjusted models were chosen from a pool of a priori defined Admission, at the discretion of the emergency department covariates using a stepwise selection algorithm. All statistical (ED), orthopaedic, or medical attending physician, was typically analyses were carried out with SAS (v9.4) software. secondary either to a degree of social or medical dependence or to plans for early operative intervention. Fracture care was at the discretion of the treating senior author (JAS). Results Three hundred nineteen patients aged 60 and over with A total of 319 patients, who were treated for fracture of the isolated fractures of the proximal humerus met the inclusion proximal humerus between January 2006 and April 2012, met criteria. Data were collected retrospectively from the electronic study inclusion criteria. One hundred twenty-one (38%) were medical records (EMRs). The information obtained included gen- admitted as inpatients from the ED, while the remaining 198 eral patient demographics, admission status, treatment method, were discharged from the ED. Patients in both groups were length of stay, discharge facility, prefracture level of indepen- treated operatively and nonoperatively for their isolated prox- dence, residence at 1-year postinjury, ambulatory status at 1-year imal humerus fracture, as shown in Figure 2. postinjury, and mortality at 1-year and 2-year postinjury. Comor- The average age of the study cohort was 75 years (range: 60- bidities were captured using the Charlson Comorbidity Index 97), and 76% were female. The majority of the patients (n ¼ 196, (CCI) and American Society of Anesthesiologists (ASA) score. 63%) were fully ambulatory (without assistance) prior to fracture Changes in living and ambulatory status were ranked as “worse” and 72% (n ¼ 227) lived independently in private homes without or “same or better” (Figure 1). Fractures were classified accord- assistance. According to Neer classification, 35% of these ing to both Neer and Orthopedic Trauma Association (OTA) patients were type 1, 52% were type 2, 9% were type 3, and 4% Myeroff et al 3 Table 1. Patient Demographics and 1-Year Mortality Stratified by Patient Characteristics. Admitted From ED Discharged From ED Nonoperative Operative Nonoperative Operative Variable Total, N (%) n Deaths (%) n Deaths (%) n Deaths (%) n Deaths (%) Total 319 (100) 60 9