The Dudley Grid: An evidence-based audit/research tool to investigate mortality risk following a displaced intracapsular hip

fracture. How can it be applied in practice?

Mr Maulik J Gandhi (ST6 T&O) Mr Jan Herman Kuiper

Ms Swati Bhasin Mr David J Ford

Mr Alastair Marsh Mr Sohail Quraishi

Introduction Aims

• Identify patient factors that influence mortality risk

• Make a clinically useful tool that may help in the management of hip fracture patients

• Objectively assess risk of mortality • Objectively assess the likely use of

prosthesis

• Current practice is subjective risk assessment.

• 1990: 1.26 million hip fractures worldwide • 2050: 4.5 million hip fractures worldwide

projected

• Important to identify factors that contribute to higher mortality

• Pre-, intra-, post-op phases

• Plan Management • Use the prosthesis which best serve

the needs of the patient.

Our patients

Methods

Inclusions • Patients admitted to Russell Hall Hospital (Dudley, West Midlands)

with intracapsular hip fracture between August 2008 and July 2012 Exclusions • Follow-up less than a year 562 patients entered into study Hip fracture database reviewed for patients factors • Retrospectively scored using Nottingham Hip Fracture Score • Walking ability outdoors • Walking ability indoors

Nottingham Hip Fracture Score (NHFS)

Mortality risk scoring system validated at 30 days and 1 year

Maxwell, Moran, Moppett. Development and validation of a preoperative scoring system to predict 30 day mortality in patients undergoing hip fracture surgery. British Journal of Anaesthesia. 101 (4): 511-17 (2008)

Outdoor mobility categories Independently predicts mortality risk

NHFD outdoor mobility

category

Outdoor mobility

category

Consolidated outdoor

mobility category

Mobilise without aids M1 A

Mobilise with 1 aid M2

Mobilise with 2 aids/frame M3 B

Wheelchair/Bedbound M4

Results

Kaplan Meier Survival Curve (outdoors)

Kaplan Meier Survival Curve (indoors)

© 2012 Dudley Group NHS Foundation Trust. All rights reserved. Authored by Mr Maulik J Gandhi

Mortality

NICE guidance

• Perform replacement arthroplasty in patients with a displaced intracapsular fracture.

• Offer THR to patients with a displaced intracapsular fracture who: • were able to walk independently out of doors with no more than

the use of a stick and • are not cognitively impaired and • are medically fit for anaesthesia and the operation.

• Use a proven femoral stem design rather than Austin Moore or Thompson stems for arthroplasties

• Use cemented implants in patients undergoing surgery with arthroplasty

Is this appropriate management?

Influence of cement on mortality risk . It was observed there is a significant increase in mortality risk when no

cement is used when all the patients are being analysed with a cox proportional hazard

Number

of cases P value

All 478

Is this appropriate management?

Is this appropriate?

Maulik J Gandhi mj@gandhi.org.uk

Is this appropriate?

Is this appropriate?

Is this appropriate management?

Outdoor mobility groups

NHFS A B

M1 M2 M3 M4

0 THR THR Uncemented/IF Uncemented/IF

1 THR THR Uncemented/IF Uncemented/IF

2 THR THR Uncemented/IF Uncemented/IF

3 THR THR Uncemented/IF Uncemented/IF

4 THR THR Uncemented/IF Uncemented/IF

5 Cemented Cemented Uncemented/IF Uncemented/IF

6 Cemented Cemented Uncemented/IF Uncemented/IF

7 Cemented Cemented Uncemented/IF Uncemented/IF

8 Cemented Cemented Uncemented/IF Uncemented/IF

9 Cemented Cemented ? conservative ? conservative

10 Cemented Cemented ? conservative ? conservative

Dilemmas

High risk patients who were immobile prior to admission 1. Should they get an operation?

1. Hemiarthroplasty versus internal fixation? 2. Which implant? 3. Use of cement?

2. If managed conservatively? 1. What management plan? 2. Role of an intra-articular local anaesthetic injection

We can now design studies looking into the influence of these strategies, whilst standardising patients • Look at patients within one grid box/column/row

Would this be useful to know…

Mortality – understand local factors and counsel patient/family Incidence – help organize rehabilitation and social services Research – standardize patients for better quality studies Management – objective tool to guide treatment

Maulik J Gandhi mj@gandhi.org.uk

Our patients

THANK YOU

Questions?

Incidence

0 1 2 3 4 5 6 7 8 9 10M1 0 0.9 2.3 1.6 2.7 16.5 16.2 3.6 0 0 0M2 0 0 0.7 0.4 0.5 7.7 12.1 3.2 0.7 0 0M3 0 0 0.2 0 0.4 2 4.4 2.1 0.5 0 0M4 0 0 0.9 0.2 0.4 5.3 9.8 4.3 0.5 0 0

0

2

4

6

8

10

12

14

16

18

% o

f pat

ient

s

Incidence

0 1 2 3 4 5 6 7 8 9 10A 0 0.9 3 2 3.2 24.2 28.3 6.8 0.7 0 0B 0 0 1.1 0.2 0.8 7.3 14.2 6.4 1 0 0

0

5

10

15

20

25

30%

of p

atie

nts

Incidence Grid

Help plan inpatient and outpatient services

• 69% in outdoor mobility group A • Majority should have rehabilitation potential identify rehab bed • The remaining should have post hospital care identified e.g. residential/nursing

home rather than rely on rehab bed

Can you enhance the NHFS?

Demographics and observational data

Missing values for a factor were managed using a technique described by Tabachnick and Fidell

Analysis

Primary outcome - patient mortality

Cox hazard ratios for each independent factor p

Cox Hazard Ratios higher mortality risk. In CI, if value >1 it increases mortality risk.

Number

of

cases

P value Lower

CI 0.95

Upper

CI 0.95 C

NHFS 562

Why not another scoring system?

• ASA Shown to lack intra- and inter-observer reliability . (Aronson et al. 2003)

• NHFS shown to predict mortality (review article Vitale 2012) • RISK-VAS, POSSUM and Charlston index predicted ambulation NOT

mortality at 3 months (Burgos et al. 2008) • Other scoring systems compared

• The American Society of Anesthesiologists classification, • The Barthel index, • The Goldman index, • The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity

(POSSUM) scoring system, • The Charlson index and the • Visual Analogue Scale for Risk (RISK-VAS)

Maulik J Gandhi mj@gandhi.org.uk

They can do it…

Maulik J Gandhi mj@gandhi.org.uk

How they do it

Compare an outcome of interest - £ of car insurance Standardise the risk – driver details Standardise the “at risk” item – car details

Maulik J Gandhi mj@gandhi.org.uk

How we should do it

Compare an outcome of interest – mortality, length of stay, etc Standardise the risk – management plan Standardise the “at risk” item – Dudley Grid box

Maulik J Gandhi mj@gandhi.org.uk

Maulik J Gandhi mj@gandhi.org.uk

The Dudley Grid: An evidence-based audit/research tool to investigate mortality risk following a displaced intracapsular hip fracture. How can it be applied in practice?Introduction AimsOur patientsMethodsNottingham Hip Fracture Score (NHFS)Outdoor mobility categories�Independently predicts mortality risk�ResultsKaplan Meier Survival Curve (outdoors)Kaplan Meier Survival Curve (indoors)Slide Number 10MortalityNICE guidanceIs this appropriate management?Influence of cement on mortality risk�. It was observed there is a significant increase in mortality risk when no cement is used when all the patients are being analysed with a cox proportional hazard �Is this appropriate management?Is this appropriate?Is this appropriate?Is this appropriate?Is this appropriate management?DilemmasWould this be useful to know…Our patientsTHANK YOU IncidenceIncidenceIncidence GridCan you enhance the NHFS?Demographics and observational data �Missing values for a factor were managed using a technique described by Tabachnick and Fidell AnalysisCox Hazard Ratios �higher mortality risk. In CI, if value >1 it increases mortality risk.Why not another scoring system?Slide Number 32They can do it…How they do itHow we should do itSlide Number 36