The effect of traumatic head injuries on the outcome of middle-aged and geriatric orthopedic trauma patients.

BACKGROUND: The purpose of this study is to characterize the effects of head injuries amongst the middle-aged and geriatric populations on hospital quality measures, costs, and outcomes in an orthopedic trauma setting. METHODS: Patients with head and orthopedic injuries aged >55 treated at an academic medical center from October 2014-April 2021 were reviewed for their Abbreviated Injury Score for Head and Neck (AIS-H), baseline demographics, injury characteristics, hospital quality measures and outcomes. Univariate comparative analyses were conducted across AIS-H groups with additional regression analyses controlling for confounding variables. All statistical analyses were conducted with a Bonferroni adjusted alpha. RESULTS: A total of 1,051 patients were included. The mean age was 74 years, and median AIS-H score was 2 (range 1-6). While outcomes worsened and costs increased as AIS-H scores increased, the most drastic (and clinically relevant) rise occurs between scores 2-3. Patients who sustained a head injury warranting an AIS-H score of 3 experienced a significantly higher rate of major complications, need for ICU admission, inpatient and 1-year mortality with longer lengths of stay and higher total costs despite no differences in demographics or injury characteristics. Regression analysis found a higher AIS-H score was independently associated with greater mortality risk. CONCLUSION: AIS-H scores >2 correlate with significantly worse outcomes and higher hospital costs. Concomitant head injuries impact both outcomes and direct variable costs for middle-aged and geriatric orthopedic trauma patients. Clinicians, hospitals, and payers should consider the significant effect of head injuries on the hospitalization of these patients.

Diagnostic Accuracy of a Trauma Risk Assessment Tool Among Geriatric Patients With Crash Injuries.

ABSTRACT: The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a risk stratification tool. We evaluated the STTGMA's accuracy in predicting 30-day mortality and the odds of unfavorable clinical trajectories among crash-related trauma patients. This retrospective cohort study (n = 912) pooled adults aged 55 years and older from a single institutional trauma database. The data were split into training and test data sets (70:30 ratio) for the receiver operating curve analysis and internal validation, respectively. The outcome variables were 30-day mortality and measures of clinical trajectory. The predictor variable was the high-energy STTGMA score (STTGMAHE). We adjusted for the American Society of Anesthesiologists Physical Status. Using the training and test data sets, STTGMAHE exhibited 82% (95% CI: 65.5-98.3) and 96% (90.7-100.0) accuracies in predicting 30-day mortality, respectively. The STTGMA risk categories significantly stratified the proportions of orthopedic trauma patients who required intensive care unit (ICU) admissions, major and minor complications, and the length of stay (LOS). The odds of ICU admissions, major and minor complications, and the median difference in the LOS increased across the risk categories in a dose-response pattern. STTGMAHE exhibited an excellent level of accuracy in identifying middle-aged and geriatric trauma patients at risk of 30-day mortality and unfavorable clinical trajectories.

The Cost We Bear: Financial Implications for Hip Fracture Care Amidst the COVID-19 Pandemic.

INTRODUCTION: The purpose of this study was to assess the impact of COVID-19 on the cost of hip fracture care in the geriatric/middle-aged cohort, hypothesizing the cost of care increased during the pandemic, especially in COVID+ patients. METHODS: Between October 2014 and January 2022, 2,526 hip fracture patients older than 55 years were analyzed for demographics, injury details, COVID status on admission, hospital quality measures, and inpatient healthcare costs from the inpatient admission. Comparative analyses were conducted between: (1) All comers and high-risk patients in the prepandemic (October 2014 to January 2020) and pandemic (February 2020 to January 2022) cohorts and (2) COVID+ and COVID- patients during the pandemic. Subanalysis assessed the difference in cost breakdown for patients in the overall cohorts, the high-risk quartiles, and between the prevaccine and postvaccine pandemic cohorts. RESULTS: Although the total costs of admission for all patients, and specifically high-risk patients, were not notably higher during the pandemic, further breakdown showed higher costs for the emergency department, laboratory/pathology, radiology, and allied health services during the pandemic, which was offset by lower procedural costs. High-risk COVID+ patients had higher total costs than high-risk COVID- patients ( P < 0.001), most notably in room-and-board ( P = 0.032) and allied health ( P = 0.023) costs. Once the pandemic started, subgroup analysis demonstrated no change in the total cost in the prevaccine and postvaccine cohort. CONCLUSION: The overall inpatient cost of hip fracture care did not increase during the pandemic. Although individual subdivisions of cost signified increased resource utilization during the pandemic, this was offset by lower procedural costs. COVID+ patients, however, had notably higher total costs compared with COVID- patients driven primarily by increased room-and-board costs. The overall cost of care for high-risk patients did not decrease after the widespread administration of the COVID-19 vaccine. LEVEL OF EVIDENCE: III.

Home discharge location is safest following fracture of the hip.

PURPOSE: To determine the factors associated with discharge location in patients with hip fractures and whether home discharge was associated with a lower readmission and complication rate. METHODS: Hip fracture patients who presented to our academic medical center for operative management of a hip fracture were enrolled into an IRB-approved hip fracture database. Radiographs, demographics, and injury details were recorded at the time of presentation. Patients were grouped based upon discharge disposition: home (with or without home services), acute rehabilitation facility (ARF), or sub-acute rehabilitation facility (SAR). RESULTS: The cohorts differed in marital status, with a greater proportion of patients discharged to home being married (51.7% vs. 43.8% vs. 34.1%) (P < 0.05). Patients discharged to home were less likely to require an assistive device (P < 0.05). Patients discharged to home experienced fewer post-operative complications (P < 0.05) and had lower readmission rates (P < 0.05). Being married was associated with an increased likelihood of discharge to home (OR = 1.679, CI = 1.391-2.028, P < 0.001). Being enrolled in Medicare/Medicaid was associated with decreased odds of discharge to home (OR = 0.563, CI = 0.457-0.693, P < 0.001). Use of an assistive device was associated with decreased odds of discharge to home (OR = 0.398, CI = 0.326-0.468, P < 0.001). Increases in CCI (OR = 0.903, CI = 0.846-0.964, P = 0.002) and number of inpatient complications (OR = 0.708, CI = 0.532-0.943, P = 0.018) were associated with decreased odds of home discharge. CONCLUSION: Hip fracture patients discharged to home were healthier and more functional at baseline, and also less likely to have had a complicated hospital course. Those discharged to home also had lower rates of readmission and post-operative complications. LEVEL OF EVIDENCE: III.

Impact of Poorly Controlled Diabetes and Glycosylated Hemoglobin Values in Geriatric Hip Fracture Mortality Risk Assessment.

Introduction The presence of poorly-controlled diabetes in the setting of geriatric hip fractures has been shown to increase all-cause mortality and worsen outcomes. This study aimed to assess whether the addition of a patient's glycated hemoglobin (A1c) value to a validated geriatric inpatient risk tool improves the predictive capacity of the risk tool. Methods A cohort of 2430 patients >55 years old treated for low-energy mechanism hip fractures between October 2014 to November 2021 were reviewed for demographics (including diabetes diagnoses and their respective hemoglobin A1c values at the time of admission), injury details, hospital quality measures, and mortality. As past work demonstrated a hemoglobin A1c value above 8% to be the tipping point for worse outcomes, the baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for inpatient mortality in hip fractures (STTGMAHIP_FX_SCORE - Score for Trauma Triage in the Geriatric and Middle-Aged Hip Fracture Score) was modified to include a patient's hemoglobin A1c using an 8% cutoff (STTGMAHIP_8%A1c - Score for Trauma Triage in the Geriatric and Middle-Aged Hip 8% Hemoglobin A1c Cutoff Score). The new model's predictive ability (as measured by the area under the receiver operating curves (AUROCs)) for inpatient mortality was compared to the baseline tool using DeLong's test. Risk quartiles were generated for the new tool, and comparative analyses were conducted on hospital quality measures and outcomes.  Results Five hundred and sixty-five patients (23%) were noted to have diabetes mellitus, and 76 patients had an A1c above 8%. Patients with a hemoglobin A1c above 8% had a higher rate of inpatient complications and mortality through one year. The STTGMAHIP_8%A1c score significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.786 vs. 0.672, p=0.0456). Upon analysis of the risk quartiles, the highest risk cohort was found to have a longer length of stay (p<0.001), with higher rates of inpatient (p<0.001) and 30-day mortality (p<0.001) and need for admission to the intensive care unit (p<0.001) as compared to the minimal risk cohort. Patients in the lowest risk quartile were most likely to be discharged home (p<0.001). Conclusion Patients who present with a hemoglobin A1c above 8% experienced significantly worse outcomes than those below 8%. The inclusion of a patient's hemoglobin A1c as a cutoff score improves the STTGMAHIP_FX_SCORE tool to predict mortality and risk stratify patient outcomes. While diabetes presents another medical challenge to manage, providers may utilize this new variable to better highlight at-risk diabetic patients.

Increasing Diversity in Orthopaedics: The Problem, Strategies, and Solutions.

It is important to educate and equip the orthopaedic community with tools to address health care disparities and improve orthopaedic specialty recruitment for racial minorities. How patients and providers are affected by systemic racism in healthcare and what that means in orthopaedic surgery, methods to identify bias and improve access to orthopaedic care for racial minorities, and how to structure a program and department environment to encourage and promote diversity are important topics of discussion.

Adaptive Risk Modeling: Improving Risk Assessment of Geriatric Hip Fracture Patients Throughout their Hospitalization.

INTRODUCTION: The purpose of this study was twofold: 1. To assess how adaptive modeling, accounting for development of inpatient complications, affects the predictive capacity of the risk tool to predict inpatient mortality for a cohort of geriatric hip fracture patients. 2. To compare how risk triaging of secondary outcomes is affected by adaptive modeling. We hypothesize that adaptive modeling will improve the predictive capacity of the model and improve the ability to risk triage secondary outcomes. METHODS: Between October 2014-August 2021, 2421 patients >55 years old treated for hip fracture obtained through low-energy mechanisms were analyzed for demographics, injury details and hospital quality measures. The baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for hip fractures (STTGMAHIP) was calculated in the emergency department setting. A new mortality risk score (STTGMAHIP_ADPTV) was created including inpatient complications. Each models' predictive ability was compared using DeLong's test. Patients were grouped into quartiles based on their respective STTGMAHIP_ADPTV and comparative analyses were conducted. RESULTS: AUROC comparison demonstrated STTGMAHIP_ADPTV significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP (p < 0.01). STTGMAHIP_ADPTV correctly triaged 80% and 64% of high-risk patients with inpatient and 30-day mortality compared to 64% and 57% for STTGMAHIP. STTGMAHIP_ADPTV quartile stratification demonstrated that the highest risk cohort had the worst mortality outcomes and hospital quality measures. Patients whose risk classification changed from minimal risk using STTGMAHIP to high risk using STTGMAHIP_ADPTV experienced the highest rate of mortality, readmission, ICU admission, with longer lengths of stay and higher hospital costs. DISCUSSION: Adaptive modeling accounting for inpatient complications improves the predictive capacity and risk triaging of the STTGMAHIP tool. Real-time modulation of a patient's mortality risk profile can inform their requisite level of medical management to improve the quality and value of care as patients progress through their index hospitalization. STTGMAHIP_ADPTV can better identify patients at risk for developing complications whose mortality and readmission risk profile increase significantly, allowing their new risk classification to inform higher levels of care. While this may increase length of stay and total costs, it may improve outcomes in both the short and long-term. LEVEL OF EVIDENCE: III.

Assessment of Healthcare Delivery Systems in Orthopaedic Surgery: A Large Retrospective Cohort Evaluation.

INTRODUCTION: The purpose of this study was to assess how quality and volume of common orthopaedic care varies across private, municipal, and federal healthcare delivery systems (HDSs). METHODS: Hip and knee arthroplasty, knee and shoulder arthroscopy, and hip fracture repair were audited over a two-year period. Electronic medical records were reviewed for demographics, diagnosis, lengths of stay (LoSs), surgical wait times, inpatient complication, readmission, and revision surgery rates. Multivariate regression controlled for differences in age, sex, diagnosis, and Charlson Comorbidity Index to determine how HDS correlated with surgical wait time, length of stay, complication rates, readmission, and revision surgery. RESULTS: The 5,696 included patients comprise 87.4% private, 8.6% municipal, and 4.0% federal HDSs. Compared with private HDS for arthroplasty, federal surgical wait times were 18 days shorter (95% CI = 9 to 26 days, P < 0.001); federal LoS was 4 days longer (95% CI = 3.6 to 4.3 days, P < 0.001); municipal LoS was 1 day longer (95% CI = 0.8 to 1.4, P < 0.001); municipal 1-year revision surgery odds were increased (odds ratio [OR] = 2.8, 95% CI = 1.3 to 5.4, P = 0.045); and complication odds increased for municipal (OR = 12.2, 95% CI = 5.2 to 27.4, P < 0.001) and federal (OR = 12.0, 95% CI = 4.5 to 30.8, P < 0.001) HDSs. Compared with private HDS for arthroscopy, municipal wait times were 57 days longer (95% CI = 48 to 66 days, P < 0.001) and federal wait times were 34 days longer (95% CI = 21 to 47 days, P < 0.001). Compared with private HDS for fracture repair, municipal wait times were 0.6 days longer (95% CI = 0.2 to 1.0, P = 0.02); federal LoS was 7 days longer (95% CI = 3.6 to 9.4 days, P < 0.001); and municipal LoS was 4 days longer (95% CI = 2.4 to 4.8, P < 0.001). Only private HDS fracture repair patients received bone health consultations. DISCUSSION: The private HDS provided care for a markedly larger volume of patients seeking orthopaedic care. In addition, private HDS patients experienced reduced surgical wait times, LoSs, and complication odds for inpatient elective cases, with better referral patterns for nonsurgical orthopaedic care after hip fractures within the private HDS. These results may guide improvements for federal and municipal HDSs.

The Role of Smoking and Body Mass Index in Mortality Risk Assessment for Geriatric Hip Fracture Patients.

Background Smoking, obesity, and being below a healthy body weight are known to increase all-cause mortality rates and are considered modifiable risk factors. The purpose of this study is to assess whether adding these risk factors to a validated geriatric inpatient mortality risk tool will improve the predictive capacity for hip fracture patients. We hypothesize that the predictive capacity of the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool will improve. Methodology Between October 2014 and August 2021, 2,421 patients >55-years-old treated for hip fractures caused by low-energy mechanisms were analyzed for demographics, injury details, hospital quality measures, and mortality. Smoking status was recorded as a current every-day smoker, former smoker, or never smoker. Smokers (current and former) were compared to non-smokers (never smokers). Body mass index (BMI) was defined as underweight (<18.5 kg/m2), healthy weight (18.5-24.9 kg/m2), overweight (25.0-24.9 kg/m2), or obese (>30 kg/m2). The baseline STTGMA tool for hip fractures (STTGMAHIP_FX_SCORE) was modified to include patients' BMI and smoking status (STTGMA_MODIFIABLE), and new mortality risk scores were calculated. Each model's predictive ability was compared using DeLong's test by analyzing the area under the receiver operating curves (AUROCs). Comparative analyses were conducted on each risk quartile. Results A comparison of smokers versus non-smokers demonstrated that smokers experienced higher rates of inpatient (p = 0.025) and 30-day (p = 0.048) mortality, myocardial infarction (p < 0.01), acute respiratory failure (p < 0.01), and a longer length of stay (p = 0.014). Comparison among BMI cohorts demonstrated that underweight patients experienced higher rates of pneumonia (p = 0.033), decubitus ulcers (p = 0.046), and the need for an intensive care unit (ICU) (p < 0.01). AUROC comparison demonstrated that STTGMA_MODIFIABLE significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.792 vs. 0.672, p = 0.0445). Quartile stratification demonstrated the highest risk cohort had a longer length of stay (p < 0.01), higher rates of inpatient (p < 0.01) and 30-day mortality (p < 0.01), and need for an ICU (p < 0.01) compared to the minimal risk cohort. Patients in the lowest risk quartile were most likely to be discharged home (p < 0.01). Conclusions Smoking, obesity, and being below a healthy body weight increase the risk of perioperative complications and poor outcomes. Including smoking and BMI improves the STTGMAHIP_FX_SCORE tool to predict mortality and risk stratify patient outcomes. Because smoking, obesity, and being below a healthy body weight are modifiable patient factors, providers can counsel patients and implement lifestyle changes to potentially decrease their risk of longer-term poor outcomes, especially in the setting of another fracture. For patients who are former smokers, providers can use this information to encourage continued restraint and healthy choices.

Value-Based Care in Orthopedic Trauma.

The advent of value-based care as a component of the United States health care system is part of a broader paradigm shifting away from fee-for-service payment models in favor of alternative reimbursement incentives tied to quality and outcome metrics. Bundled care models, gainsharing agreements, and other cost containment measures, although promising, may induce unintended systemwide consequences for orthopedic trauma surgeons who often specialize in tending to costly multiply injured patients and marginalized populations. This article reviews facets of value-based care applicable to orthopedic trauma surgery with an emphasis on public health and ethical considerations for policymakers and orthopedic surgeons.

Orthopaedic Urgent Care Versus the Emergency Department: Cost Implications for Low-energy Fracture Care.

INTRODUCTION: This study compared costs, length of visit, and utilization trends for patients with fractures seen in an immediate care orthopaedic center (I-Care) versus the emergency department (ED) in a major metropolitan area. METHODS: A retrospective chart review of consecutive patients seen on an outpatient basis in the ED and I-Care over a 6-month period was conducted. Patient demographics, procedures done, care category, estimated costs, and disposition information were included for statistical analysis. Within the low-acuity fracture care group, a cost-comparison analysis was conducted. RESULTS: A total of 610 patients met inclusion criteria with 311 seen in I-Care and 299 in the ER. I-Care patients were more likely to have low-acuity injuries compared with ED patients (60.1% versus 18.1%, P < 0.001). The length of visit was longer for patients seen in the ED compared with I-Care (6.1 versus 1.43 hours, P value < 0.001). A cost analysis of low-acuity patients revealed that an estimated $62,150 USD could have been saved in healthcare costs by the initial diversion of low-acuity patients seen in the ER to I-Care during the study period. DISCUSSION: These results suggest that the I-Care orthopaedic urgent care model is a more cost-effective and more efficient alternative to the ED for patients with fractures requiring procedural treatment and low-acuity patients managed on an outpatient basis.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Distal Radius Fractures.

INTRODUCTION: Distal radius fractures are the second most common fracture in the elderly population. The incidence of these fractures has increased over time, and is projected to continue to do so. The aim of this study is to utilize a validated trauma risk prediction tool to stratify middle-aged and geriatric patients with operative distal radius fractures as well as compare hospital quality metrics and inpatient hospitalization costs among the risk groups. MATERIALS AND METHODS: Patients were prospectively enrolled in an orthopedic trauma registry. The Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) was calculated using patient demographics, injury severity, and functional status. Patients were then stratified into minimal-risk, moderate-risk, and high-risk cohorts based on their scores. Length of stay, need for escalation of care, complications, mortality, discharge location, 1-year patient reported outcomes, and index admission costs were evaluated. RESULTS: Ninety-two patients met inclusion criteria. Sixty-three (68.5%) patients were managed with outpatient surgery. The mean inpatient length of stay for the high-risk cohort was 2.9x and 2.2x higher than the minimal and moderate-risk cohorts, respectively (2.0 + 2.9 days vs. 0.7 + 0.9 and 0.9 + 1.1 days, P = .019). There were no complications or mortality in any of the risk groups. No patients required intensive care and all patients were discharged home. There was no difference in readmission rates, inpatient cost, or 1-year patient reported outcomes among the risk cohorts. DISCUSSION/CONCLUSIONS: The Score for Trauma Triage in Geriatric and Middle-Aged is able to risk-stratify patients that undergo operative intervention of distal radius fractures. Middle aged and elderly patients with isolated closed distal radius fractures can be safely managed on an outpatient basis regardless of risk. Standardized pathways can be created in the management of these injuries, thereby optimizing value-based care. LEVEL OF EVIDENCE: Prognostic Level III.

Can We Stratify Quality and Cost for Older Patients With Proximal and Midshaft Humerus Fractures?

INTRODUCTION: This study sought to investigate whether a validated trauma triage tool can stratify hospital quality measures and inpatient cost for middle-aged and geriatric trauma patients with isolated proximal and midshaft humerus fractures. MATERIALS AND METHODS: Patients aged 55 and older who sustained a proximal or midshaft humerus fracture and required inpatient treatment were included. Patient demographic, comorbidity, and injury severity information was used to calculate each patient's Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). Based on scores, patients were stratified to create minimal, low, moderate, and high risk groups. Outcomes included length of stay, complications, operative management, ICU/SDU-level care, discharge disposition, unplanned readmission, and index admission costs. RESULTS: Seventy-four patients with 74 humerus fractures met final inclusion criteria. Fifty-eight (78.4%) patients presented with proximal humerus and 16 (21.6%) with midshaft humerus fractures. Mean length of stay was 5.5 ± 3.4 days with a significant difference among risk groups (P = 0.029). Lower risk patients were more likely to undergo surgical management (P = 0.015) while higher risk patients required more ICU/SDU-level care (P < 0.001). Twenty-six (70.3%) minimal risk patients were discharged home compared to zero high risk patients (P = 0.001). Higher risk patients experienced higher total inpatient costs across operative and nonoperative treatment groups. CONCLUSION: The STTGMA tool is able to reliably predict hospital quality measures and cost outcomes that may allow hospitals and providers to improve value-based care and clinical decision-making for patients presenting with proximal and midshaft humerus fractures. LEVEL OF EVIDENCE: Prognostic Level III.

Declining Medicare Reimbursement in Orthopaedic Trauma Surgery: 2000-2020.

OBJECTIVES: To evaluate monetary trends in government (Medicare) reimbursement rates for 20 commonly used orthopedic trauma surgical procedures over a 20-year period. METHODS: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for the 20 common Current Procedural Terminology (CPT) codes in orthopaedic trauma, and reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars (USD) using changes to the US Consumer Price Index. Both the average annual and the total percentage change in reimbursement and in Relative Value Units were calculated for all included procedures. RESULTS: After adjusting for inflation, the average reimbursement for all procedures decreased by 30.0% from 2000 to 2020. Total Relative Value Units during this time increased by 4.4% on average. Procedures about the foot and ankle demonstrated the greatest decrease in the mean adjusted reimbursement at -42.6%, whereas procedures about the shoulder and upper extremity demonstrated the smallest mean decrease at 23.7% during the study period. From 2000 to 2020, the adjusted reimbursement rate for all included procedures decreased by an average of 1.5% each year. CONCLUSION: To the best of our knowledge, this is the first study to comprehensively evaluate trends in procedural Medicare reimbursement for orthopaedic trauma. When adjusted for inflation, Medicare reimbursement for included procedures has steadily decreased from 2000 to 2020. Increased awareness and consideration of these trends will be important for policy makers, hospitals, and surgeons to assure continued access to meaningful surgical orthopaedic trauma care in the United States.

Who Is the Geriatric Trauma Patient? An Analysis of Patient Characteristics, Hospital Quality Measures, and Inpatient Cost.

PURPOSE: The purpose of this study was 2-fold: 1) to investigate the age-related frequency, demographics and distribution of the middle-aged and geriatric orthopedic trauma population and 2) to describe the age-related frequency and distribution of hospital quality measure outcomes and inpatient cost. METHODS: All patients > 55 years of age who required orthopedic, trauma, or neurosurgery consults at 3 hospitals within an academic medical center from 2014 to 2017 were prospectively followed. On initial evaluation, each patient's demographics, injury severity, and functional status were collected. Patients were grouped into low and high-energy mechanism cohorts and divided into 5 groups based on age. Hospital quality measures including length of stay, complications, discharge location, and cost of care was compared between age groups. Data were analyzed using ANOVA and Chi-square tests. RESULTS: A total of 3965 patients were included in this study of which 3268 (82%) sustained low-energy trauma and 697 (18%) sustained high-energy trauma. With increasing age, more patients had more comorbidities, were less likely to be community ambulators, and more likely to use assistive devices (p < 0.05). Patients in older age groups had longer lengths of stay, more complications, were more likely to need ICU level care, and were less likely to be discharged home (p < 0.05). Rates of mortality were also greater in patients of more advanced age in both low and high-energy cohorts, and the calculated risk triage tool (STTGMA) score increased with each age bracket (p < 0.05). Total cost of care differed between age groups in the low-energy cohort (p = 0.003). CONCLUSION: This epidemiological study provides a clear picture of the frequency and distribution of demographic, physiologic characteristics, outcomes, and cost of care in a middle-aged and geriatric orthopedic trauma population as evaluated by the STTGMA risk tool. Risk profiling of geriatric trauma patients allows for the establishment of baseline norms.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Tibial Shaft and Plateau Fractures.

OBJECTIVES: To determine whether a validated trauma triage tool can identify the middle-aged and geriatric trauma patients with tibial shaft and plateau fractures who are at the risk for costly admissions and poorer hospital quality measures. DESIGN: Prospective cohort study. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Sixty-four patients older than 55 years hospitalized with isolated tibial shaft or plateau fractures. INTERVENTION: Patients with either isolated tibial plateau fractures or tibial shaft fractures over a 3-year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score. MAIN OUTCOME MEASURES: Length of stay, complications, discharge location, and direct variable costs. RESULTS: Sixty-four patients met inclusion criteria. Thirty-three patients (51.6%) presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (P < 0.001). Although 19 (90.5%) of the minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate- and high-risk patients were discharged home, respectively (P < 0.001). Higher-risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for intensive care unit-level care (P = 0.027 and P = 0.344, respectively). The total cost difference between the lowest- and highest-risk group was nearly 50% ($14,070 ± 8056 vs. $25,147 ± 14,471; mean difference, $11,077; P = 0.022). CONCLUSION: Application of the STTGMA triage tool allows for the prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Development of a Value-based Algorithm for Inpatient Triage of Elderly Hip Fracture Patients.

INTRODUCTION: The purpose of this study was to combine a validated middle-age and geriatric trauma risk assessment tool (STTGMA) with a novel cost-prediction tool to create an objective triage tool for elderly hip fractures that would guide value-based care initiatives. METHODS: From October 2014 to January 2018, all patients aged ≥55 years who were admitted with a primary diagnosis of hip fracture to a single level 1 trauma center were enrolled. Upon evaluation in the emergency department, demographics, injury severity, and functional status were recorded to calculate the trauma triage score (STTGMARisk). A model to predict high-cost hip fracture patients was created using similar variables (STTGMACost). RESULTS: Three hundred sixty-one consecutive operative hip fracture patients were enrolled. Inpatient mortalities were skewed toward STTGMARisk3 with 21.4% of patients in this high-risk group ultimately expiring during their hospitalization. High-cost patients were correctly skewed to the STTGMACost2 and STTGMACost3 groups with 88.9% of all high-cost operatively treated hip fracture correctly triaged to these cohorts. Statistically significant variations were found in cost within each STTGMARisk group. CONCLUSIONS: A simple risk score calculated upon admission (STTGMARisk and STTGMACost) was able to be used as a triage tool not only to differentiate increased mortality risk but also to predict high-cost patients based on resource utilization in hip fracture patients. LEVEL OF EVIDENCE: Prognostic, level II.

Using Trauma Triage Score to Risk-Stratify Inpatient Triage, Hospital Quality Measures, and Cost in Middle-Aged and Geriatric Orthopaedic Trauma Patients.

OBJECTIVES: To investigate the efficacy of a novel geriatric trauma risk assessment tool [Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA)] designed to predict inpatient mortality to risk-stratify measures of hospital quality and cost of care in middle-aged and geriatric orthopaedic trauma patients. DESIGN: Prospective cohort study. SETTING: Academic medical center. PATIENTS: One thousand five hundred ninety-two patients 55 years of age and older who were evaluated by orthopaedic surgery in the emergency department between October 1, 2014, and September 30, 2016. INTERVENTION: Calculation of the inpatient mortality risk score (STTGMA) using each patient's demographics, injury severity, and functional status. Patients were stratified into minimal-, low-, moderate-, and high-risk cohort groups based on risk of <0.9%, 0.9%-1.9%, 1.9%-5%, and >5%. MAIN OUTCOME MEASUREMENTS: Length of stay, complications, disposition, readmission, and cost. RESULTS: One thousand two hundred seventy-eight patients (80.3%) sustained low-energy injuries and 314 patients (19.7%) sustained high-energy injuries. The average age was 73.8 ± 11.8 years. The mean length of hospital stay was 5.2 days with a significant difference between the STTGMA risk groups. This risk stratification between groups was also seen in complication rate, need for Intensive Care Unit/Step Down Unit care, percentage of patients discharged, and readmission within 30-days. The mean total cost of admission for the minimal-risk group was less than one-third that of the high-risk cohort. CONCLUSIONS: The STTGMA tool is able to risk-stratify hospital quality outcome measures and cost. Thus, it is a valuable clinical tool for health care providers in identifying high-risk patients in efforts to continue to provide high-quality resource conscious care to orthopaedic trauma patients. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Ankle Fractures.

OBJECTIVES: To investigate the ability of a validated geriatric trauma risk prediction tool to stratify hospital quality metrics and inpatient cost for middle-aged and geriatric patients admitted from the emergency department for operative treatment of an ankle fracture. DESIGN: Prospective cohort study. SETTING: Single Academic Medical Center. PATIENTS: Patients 55 years of age and older who sustained a rotational ankle fracture and who were treated operatively during their index hospitalization. INTERVENTION: Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient demographics, injury severity, and functional status. Patients were stratified into groups based on scores to create a minimal-, low-, moderate-, and high-risk cohort. MAIN OUTCOME MEASUREMENTS: Length of stay, complications, need for intensive care unit-/step-down unit-level care, discharge location, and index admission costs. RESULTS: Fifty ankle fracture patients met inclusion criteria. The mean length of stay was 7.8 ± 5.2 days with a significant difference among the 4 risk groups (4.6-day difference between low and high risk). 73.1% of minimal-risk patients were discharged home compared with 0% of high-risk patients. There was no difference in complication rate or in need for intensive care unit-level care between groups. However, high-risk patients had a mean total inpatient cost 2 times greater than that of minimal-risk patients. CONCLUSION: The Score for Trauma Triage in Geriatric and Middle-Aged tool is able to meaningfully stratify older patients with ankle fracture who require operative fixation regarding hospital quality metrics and cost. This information may allow for efficient targeted reductions in costs while optimizing outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Age Alone Does Not Predict Complications, Length of Stay, and Cost for Patients Older Than 90 Years With Hip Fractures.

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 2019; 42(1):e51-e55.].